The brain–esophagus axis in subjects with and without obesity assessed by esophageal acid perfusion and functional brain imaging

Authors Marcelo Ribeiro, Cassiano Mateus Forcelini, Jose Carlos Tomiozzo Jr., Ricardo Bernardi Soder, Fernando Fornari, Marcelo Ribeiro.


Background Gastroesophageal reflux disease (GERD) has a complex pathophysiology and a heterogeneous symptom profile. The brain–esophageal axis in GERD has been studied with functional brain imaging during the last decades, but data from obese patients was just recently reported. A comparison of such a group with non-obese subjects is lacking in the literature. This study aimed to evaluate heartburn perception and brain connectivity responses during esophageal acid stimulation in subjects with and without obesity, controlling for the presence of typical reflux symptoms.

Methods In this cross-sectional study, 25 patients with obesity (body mass index ≥30 kg/m2) and 46 subjects without obesity underwent functional magnetic resonance imaging (fMRI) of the brain with esophageal water and acid perfusion. The fMRI paradigm and connectivity were assessed.

Results About two-thirds of the participants had reflux symptoms. Heartburn perception during fMRI did not differ between subjects with and without obesity. The presence of reflux symptoms was associated with lower activation in frontal brain regions during acid perfusion compared to water perfusion. Compared to subjects without obesity, patients with obesity presented significantly lower connectivity within the anterior salience network. Corrected clusters included left caudate, left putamen and left anterior cingulate gyrus.

Conclusions The brain–esophagus axis showed differences between subjects with and without obesity. Even without symptomatic differences following esophageal acid perfusion, patients with reflux symptoms showed less brain activation in frontal areas, while obese individuals presented lower connectivity within the anterior salience network.

Keywords Functional magnetic resonance imaging, brain activation, heartburn perception, gastroesophageal reflux disease

Ann Gastroenterol 2023; 36 (5): 504-510

Original Articles