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Significance of this study
What is already known about this subject?
After food intake, gastric acid floats on top of the ingested food; this is also referred to as the gastric acid pocket.
The acid pocket functions as a reservoir from which acid refluxes into the oesophagus.
The position of the acid pocket relative to the crural diaphragm is an important determinant of the acidity of the refluxate.
The position of the acid pocket is largely determined by the presence of a hiatus hernia.
What are the new findings?
Azithromycin (Azi) reduces acid reflux episodes and oesophageal acid exposure in patients with gastro-oesophageal reflux disease (GORD).
A reduction in hiatal hernia size results in a more distal position of the acid pocket relative to the diaphragm, probably explaining the reduction in acid reflux. This effect is mainly seen in patients with a small hiatal hernia.
Azi significantly reduces hiatal hernia size, providing evidence for a new potential explanation of the effect of prokinetics on acid exposure.
How might it impact on clinical practice in the foreseeable future?
These data indicate that modulation of the position of the acid pocket has an impact on the acidity of the refluxate, further confirming that the acid pocket is a potential target in GORD treatment.
Introduction
Gastro-oesophageal reflux is a physiological phenomenon in which gastric contents flow back into the oesophagus. When reflux causes symptoms such as heartburn or regurgitation and/or oesophageal damage, it is referred to as gastro-oesophageal reflux disease (GORD), a common chronic condition affecting 10-20% of the adult population. 1 2
Most reflux episodes occur after a meal, when the stomach is filled with ingested food. In contrast to the belief that meal ingestion buffers gastric acid, acid reflux episodes occur even in the early postprandial period. 3 Fletcher et al elegantly showed that gastric acid floats on top of the meal, acting as a reservoir from which acid can enter the oesophagus during episodes of opening of the oesophago-gastric junction. This unbuffered pool of gastric acid is referred to as the gastric acid pocket. 4
The position of the acid pocket relative to the crural diaphragm is an important determinant of the acidity of the refluxate. We previously showed that 74-85% of reflux episodes...