Author’s Response to Letter to the Editor

To the Editor, We appreciate the interest of Drs. Hassall and Owen in our article and are happy to clarify their concerns regarding our report [1]. The questions put forth are made based on their personal observations in management of patients. Gastroesophageal reflux disease (GERD) and Helicobacter pylori (Hp) are two major research topics of interest to us, hence we routinely evaluate all gastric biopsies for the presence of inflammation, parietal cell hyperplasia and enterochromaffin-cell-like cell (ECL) hyperplasia, Hp density of colonization, and other relevant findings [2]. Stomach biopsies were routinely reviewed by experienced pathologists at Children’s Hospital of Michigan (CHM). When asked specifically about ECL hyperplasia, the Chief of Pathology assured me that it is possible to evaluate for the presence of this finding on routine stains and that special stains are performed for further evaluation if needed. We respect their judgment and expertise regarding this evaluation for ECL hyperplasia. We have also confirmed this approach for detection of ECL hyperplasia with the Chief of Pathology at Providence Hospital, who is in agreement with this observation [3] (personal communication, Dr. Barry Herschman). We perform two biopsies each from body and antrum regularly for histology and then perform additional biopsies as indicated based on endoscopic findings and clinical setting. Additional drugs potentially used by the patients in our report were not mentioned as the majority of patients were not on any other medications. Since vitamin B12 levels were in the normal range in all patients on whom they were obtained, this is not an issue. None of the patients were simultaneously on histamine 2 receptor antagonists (H2RAs) in this cohort of patients. We had a huge patient population at CHM, and the cohort identified for this study was, as strictly defined, on proton pump inhibitors (PPIs) as an acid-suppressing medication continuously for at least 1 year before being evaluated by repeat endoscopy and for laboratory tests mentioned in our report. Other patients in the author’s practice who were on different medications or had a different management profile were not included in this data set. The abstract cited is from an entirely different set of patients [4]. The current study involved performing some of the tests for monitoring after parents expressed concern about the safety of continuous use of PPIs when we were not able to withdraw the medication or minimize the dose. In our experience, otherwise normal patients with GERD may be well for a few days to few weeks after discontinuing PPIs; however, the majority relapse and require reinstitution of treatment. We have seen patients and parents report symptoms even within a few hours after missing a dose. For the majority of patients, the same PPI was given. We were able to do that by writing to insurance carriers about justifying their need. So concern about different PPIs is irrelevant in our cohort. The maximum dose on each patient was reported in our paper. The efficacy of pharmacological management of GERD is variable. GERD is a dynamic, multifactorial condition that varies from day to day and different times of the day in the same patient. In the majority of circumstances, dietary indiscretions accounted for temporary increase in symptoms. We are aware of the ways to increase doses, monitor for medication efficacy by performing intra-esophageal and intragastric pH monitoring, as well as the impedance V. Tolia (&) Department of Pediatrics, Providence Hospital, Michigan State University, Southfield, MI 48075, USA e-mail: vasu.tolia@gmail.com