Carbonated Beverages and Upper GI Disorders

What Is the Evidence?

Ronnie Fass, MD.

Professor of Medicine

University of Arizona

Changes in Intraesophageal pH During Ingestion of Carbonated

Beverage (A) and Coffee (B)

Agrawal A et al. Dig Dis Sci 2005;50(10):1916-1920

Comparison of Percentage of Time of pH < 4.0 for Test and Drink Periods

Shoenut J P et al. Dig Dis Sci 1998;43(4):834-839

Total time of pH <4.0 (%)

Time during drink of pH <4.0 (%)

Water (N=32) 9.2 9.6 17 40

Coffee/tea N=35) 5.9 7.3 17 68

Juice (N=29) 9.0 11.4 51 57

Coke (N=34) 6.5 5.2 63 47

Beer (N=12) 7.7 6.4 17 17

Comparison of Minutes of pH <4.0, 10 Minutes Before and After Drink

Shoenut J P et al. Dig Dis Sci 1998;43(4):834-839

10 min priorto drink

10 minfollowing drink

Water (N=32) 0.86 1.74 0.87 2.60

Coffee/tea N=35) 0.41 1.70 0.82 2.30

Juice (N=29) 0.16 0.40 0.43 1.20

Coke (N=34) 0.48 1.00 0.83 1.63

Beer (N=12) 0.65 1.30 4.21 11.00

Number of Total Gastroesophageal Refluxes Recorded by pH Impedance 1 H Before and 4 H After Meal (N = 15)

B1 = Still water B2 = Sprite© without CO2 B3 = Sprite © with CO2

P < 0.05 vs basal level

Cuomo et al. Neurogastroenterol Motil 2008;20:780-789

Diet, Lifestyle and Gender in Gastroesophageal Reflux Disease

Dore MP et al. Dig Dis Sci 2007 Nov 22. [Epub ahead of print]

Assessment of risk factors associated among 3,000 patients presenting with GERD versus 200 controls

Positive:

Being female OR = 2.1

Lack of college education OR = 2.1

Obesity OR = 1.8

Not associated:

Soda consumption

Level of Evidence

Kaltenbach T et al. Arch Intern Med 2006;166:965-971

Evidence A One or more well-designed randomized controlled clinical trials with consistent evidence

Evidence B Cohort or case-control trials, nonrandomized or uncontrolled clinical trials

Evidence C Case reports, flawed clinical trials, population studies

Evidence D Expert or investigator opinion

Evidence E Insufficient evidence or trials with significantly conflicting data

Summary of Physiologic Evidence for Gastroesophageal Reflux

Kaltenbach T et al. Arch Intern Med 2006;166:965-971

Factor Trials, No.

Lowered LESP

Worsened pH

Worsened Symptoms

Tobacco 12 B B B

Alcohol 16 No effect (B) B B

Obesity 24 E E E

Coffee and caffeine 14 E E No effect (C)

Chocolate 2 B B E

Spicy foods 2 E E C

Citrus 3 No effect (B) E C

Carbonated beverages 2 B E C

Fatty foods 9 D B E

Mint 1 D E E

Recumbent position 1 E B B

RLD position 3 B B E

Late-evening meal 3 E No effect (B) E

– For esophageal adenocarcinoma – OR = 0.71 (95% CI = 0.49-1.03)

– For esophageal adenocarcinoma (after adjustment for risk factors) – OR = 0.47 (95% CI = 0.29-0.76)

– For noncardia adenocarcinoma – OR = 0.65 (95% CI = 0.4-0.98)

• Overall, high carbonated soft drink consumption was associated with reduced risk of esophageal adenocarcinoma in men and women.

High Carbonated Soft Drink Consumption and Risk for Upper GI Cancer

Mayne S et al. J Natl Cancer Inst 2006; 98(1):72-75

Distribution of 304 Squamous Cell Esophageal Cancer Case Patients and Corresponding 743 Control Subjects, According to Consumption of Carbonated Soft Drinks (CSD), Italy 1992-1997

CSD Regular Drinkers( 1 glass/day)

All CSD drinkers( 1 glass/mo)

Characteristic Case/Controls OR (95% CI) Case/Controls OR (95% CI)

Sex Men Women

41/984/22

0.80 (0.49-1.29)0.70 (0.15-3.19)

92/22010/48

0.82 (0.57-1.18)1.11 (0.38-3.27)

Age, y <60 60

27/6318/57

0.94 (0.50-1.78)0.86 (0.44-1.69)

61/3741/131

1.09 (0.67-1.78)0.69 (0.43-1.12)

Gallus S et al. J Natl Cancer Inst 2006;98(9):645-646

Total Stomach Emptying of Liquid Component of Mixed Solid/Liquid Meal with Sparkling versus Still Water

Pouderoux et al. Dig Dis Sci 1997;42(1):34-39

P < 0.05 sparkling water versus still water

N = 8

Total Stomach Emptying of Solid Component of Mixed Solid/Liquid Meal with Sparkling versus Still Water

Pouderoux et al. Dig Dis Sci 1997;42(1):34-39

P < 0.05 sparkling water versus still water

N = 8

Mean Visual Analogue Scale of (a) Hunger, (b) Fullness, (c) Desire to Eat and (d) Thirst Before Carbonated Beverage Preload Until 18

Minutes Post Consumption for Women (N=15)

Moorhead et al. Br J Nutr 2008;99:1362-1369

Half Gastric Emptying Time and Percent of Gallbladder Emptying Contraction with 3 Beverages (N = 15)

Cuomo et al. Neurogastroenterol Motil 2008;20:780-789

B1 = Still water

B2 = Sprite© without CO2

B3 = Sprite © with CO2

Dashed line = Mean

P = all NS

Predictive Factors for Peptic Ulcer Disease in Greece (N=295)

• Predictive– Family history– Smoking– Alcohol consumption– H pylori infection

• Not predictive– Education level– Area of residence– Cola drink consumption

Archimandritis A et al. Ann Med Interne (Paris) 1995:146:299-303

Dyspepsia Scores Before and After Each Water Treatment

Before After Before After

Means are indicated by a short horizontal line in each column of data.

Cuomo R et al. Eur J Gastroenterol Hepatol 2002, 14:991-999

Constipation Scores Before and After Each Water Treatment

Cuomo R et al. Eur J Gastroenterol Hepatol 2002, 14:991-999

Means are indicated by a short horizontal line in each column of data.

Colonic Transit Time and Gastric Emptying Parameters in the Two Treatment Groups

Cuomo R et al. Eur J Gastroenterol Hepatol 2002, 14:991-999

Carbonated Water Group Tap Water Group

Before After Before After

Colonic transit time (total transit; h)

40.8 18.0 35.6 10.2 56.4 38.2 53.6 30.6

Gastric emptying (half time; min)

76.6 12.6 68.4 16.1 94.8 22.4 78.9 21.4

Rate (% per min) 0.64 0.14 0.70 0.16 0.57 0.14 0.64 0.14

Lag time (min.) 19.9 7.7 16.2 7.0 21.1 13.9 16.2 12.7

Therapeutic Usage of Carbonated Beverages such as Cola in Gastroenterology

1. Oral hydration for diarrhea (acute and chronic)

2. Declogging feeding tubes

3. Cleaning barium prior to upper endoscopy

4. Bezoar removal

5. Clearance of esophageal food impaction