Ambulatory 24-hour Esophageal pH Monitoring Research Articles

Prevalencia de enfermedad por reflujo gastroesofágico por pHmetría en recién nacidos prematuros con síntomas sugestivos

Introducción: el reflujo gastroesofágico (RGE), fenómeno fisiológico común en recién nacidos pretérminos (RNPreT), se diagnostica frecuentemente en neonatos, convirtiéndose en un importante fenómeno clínico en pretérminos.
 Objetivo: determinar la prevalencia y los síntomas de enfermedad por RGE (ERGE) por pH-metría intraesofágica ambulatoria de 24 horas (pHm) en pretérminos.
 Metodología: estudio de prevalencia en pretérminos de una unidad de cuidados intensivos neonatales de Cali, Colombia a quienes, por sospecha clínica de ERGE, se les solicitó una pHm, teniendo en cuenta variables sociodemográficas y clínicas. La estadística incluyó un análisis univariado por medio de medidas de tendencia central y análisis bivariado con la prueba de chi cuadrado (χ2) y la t de student, siendo significativa una p <0,05.
 Resultados: se analizaron 20 RNPreT de 36,5 + 27,6 días de edad postnatal; de 31,6 + 3,8 semanas de edad gestacional; 12 masculinos. 11 RNPreT (55,0 %) presentaron una pHm anormal. La presencia de residuos y cardiopatía estuvieron asociados con pHm anormal.
 Conclusión: La ERGE por pHm en los RNPreT estudiados tiene una prevalencia relativamente alta en comparación con la literatura mundial, sin encontrar una franca asociación con los síntomas analizados, a excepción de cardiopatía y residuos gástricos.

Foods Inducing Typical Gastroesophageal Reflux Disease Symptoms in Korea.

Background/AimsSeveral specific foods are known to precipitate gastroesophageal reflux disease (GERD) symptoms and GERD patients are usually advised to avoid such foods. However, foods consumed daily are quite variable according to regions, cultures, etc. This study was done to elucidate the food items which induce typical GERD symptoms in Korean patients.MethodsOne hundred and twenty-six Korean patients with weekly typical GERD symptoms were asked to mark all food items that induced typical GERD symptoms from a list containing 152 typical foods consumed daily in Korea. All patients underwent upper gastrointestinal endoscopy followed by 24-hour ambulatory esophageal pH monitoring. The definition of “GERD” was if either of the 2 studies revealed evidence of GERD, and “possible GERD” if both studies were negative.ResultsOne hundred and twenty-six cases (51 GERD and 75 possible GERD) were enrolled. In 19 (37.3%) of 51 GERD cases and in 17 (22.7%) of 75 possible GERD cases, foods inducing typical GERD symptoms were identified. In the GERD group (n = 19), frequent symptom-inducers were hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki. In the possible GERD group (n = 17), frequent symptom-inducers were hot spicy stews, fried foods, doughnuts, breads, ramen noodles, coffee, pizza, topokki, rice cakes, champon noodles, and hotdogs.ConclusionsIn one-third of GERD patients, foods inducing typical symptoms were identified. Hot spicy stews, rice cakes, ramen noodles, fried foods, and topokki were the foods frequently inducing typical symptoms in Korea. The list of foods frequently inducing typical GERD symptoms needs to be modified based on their own local experiences.

Research on Gastroesophageal Reflux Disease Based on Dynamic Features of Ambulatory 24-Hour Esophageal pH Monitoring.

Ambulatory 24-hour esophageal pH monitoring has been considered as the gold standard for diagnosing gastroesophageal reflux disease (GERD), and in clinical application, static parameters are widely used, such as DeMeester score. However, a shortcoming of these static variables is their relatively high false negative rate and long recording time required. They may be falsely labeled as nonrefluxers and not appropriately treated. Therefore, it is necessary to seek more accurate and objective parameters to detect and quantify GERD. This paper first describes a new effort that investigated the feasibility of dynamic features of 24-hour pH recording. Wavelet energy, information entropy, and wavelet entropy were estimated for three groups (severe, mild-to-moderate, and normal). The results suggest that wavelet energy and entropy are physiologically meaningful since they differentiated patients with varying degrees of GERD. K-means clustering algorithm was employed to obtain the sensitivity and specificity of new parameters. It is obvious that information entropy goes with the highest sensitivity of 87.3% and wavelet energy has the highest specificity of 97.1%. This would allow a more accurate definition of the best indicators to detect and quantify GERD as well as provide an alternative insight into the early diagnosis of GERD.

Functional Assessment of the Esophagogastric Junction After Laparoscopic Sleeve Gastrectomy

The relation between bariatric procedures and gastroesophageal reflux disease (GERD) seems to be quite complex and unclear. The present trial aimed to assess the functional changes that occur in the esophagogastric junction (EGJ) after laparoscopic sleeve gastrectomy (LSG) using objective methods for assessment as esophageal manometry and ambulatory 24-hour pH monitoring in attempt to correlate these changes with either the deterioration or the alleviation of GERD symptoms after LSG. This prospective case series study was conducted on patients with morbid obesity who were treated with LSG in the General Surgery Department, Mansoura University Hospitals. All patients were assessed pre- and postoperatively for the presence of GERD both clinically and with esophagogastrodudenoscopy (EGD). Functional assessment of the EGJ was done before LSG and at six months of follow-up using esophageal manometry and ambulatory 24-hour esophageal pH monitoring. Twenty morbidly obese patients (16 females & 4 males) of a mean age of 29.4 years had underwent functional assessement of the EGJ before and at six months after LSG. The mean BMI at the time of surgery was 51.6 ± 8.7 kg/m². Thirteen patients had no symptoms related to GERD preoperatively, all of these patients remained symptom-free after LSG. Seven (35%) patients had preoperative symptoms of GERD, three reported no change in their symptoms at six months of follow-up, and four reported significant improvement of their symptoms six months after LSG. Overall, no significant changes in the manometric parameters were noticed. However, a significant decrease in the resting LES pressure was noticed after LSG in patients with no preoperative GERD symptoms, but not in patients with symptomatic GERD. Seven (35%) patients had high preoperative DeMeester scores and prolonged total acid reflux time percentage, all of them got normalized postoperatively except two patients. Absolute concordance of the four parameters studied was observed in seven (35%) patients only. Esophageal manometry has a limited utility in the detection or exclusion of GERD postoperatively since the significant decrease in the resting LES pressure observed was not associated with symptoms of GERD. On the other hand, 24-hour pH monitoring was able to detect improvement or persistence of GERD in the patients studied.

PTU-176 Implementation Of Objective Activity Monitoring To Supplement The Interpretation Of Ambulatory Oesophageal Ph Investigations

IntroductionConventional catheter-based systems used for ambulatory oesophageal pH monitoring have been reported to affect patient behaviour. As physical activity has been associated with gastro-oesophageal reflux disease (GORD), there is a...

Significance of the Lower Esophageal Sphincter Preservation in Preventing Alkaline Reflux Esophagitis in Patients After Total Gastrectomy Reconstructed by Roux-en-Y for Gastric Cancer

To clarify the significance of the lower esophageal sphincter (LES) for prevention of alkaline reflux esophagitis (ARE) after total gastrectomy reconstructed by Roux-en-Y (TGRY) for gastric cancer, we investigated LES function and lower esophageal pH in TGRY patients with or without LES preservation. A total of 51 patients 5 years after TGRY were divided into groups A (26 patients without preserved LES) and B (25 patients with preserved LES) and compared with 22 control participants (group C). Manometric study and ambulatory 24-hour esophageal pH monitoring were performed on all patients. Symptomatic and endoscopic AREs in group A were significantly higher than those in group B (P < 0.05). The length of LES and maximum LES pressure in group A were significantly shorter and lower, respectively, than in groups B and C (P < 0.01). The length of LES and maximum LES pressure in patients with symptomatic ARE were significantly shorter and lower, respectively, than in patients without symptomatic ARE (P < 0.01). Percentages of time with pH >7 and pH >8 within 24 hours in group A were significantly higher than those in groups B and C (P < 0.01). Preservation of the LES may be necessary to prevent ARE after TGRY.

Hypercontractile Esophagus With Atypical Symptoms

A 57-year-old man presented with frequent belching for 10 years. Some ambiguous chest discomforts had usually preceded and often disappeared after belching. However, when the discomfort persisted even after belching, he often felt dizziness. Chest pain and gastroesophageal regurgitation were not accompanied. He underwent coronary angiography and tests for arrhythmia, but no abnormal findings were found. He had visited many gastroenterologic clinics because of the aggravated symptoms and took several medicines including proton pump inhibitors for the last 2 years, but the symptoms did not improve. After he was referred to our hospital, he underwent gastroduodenal endoscopy. Whitish discoloration of gastroesophageal junction was observed, which was minimal changes of reflux esophagitis. Under the suspicion of the combined esophageal dysmotility, high-resolution impedance manometry (HRIM) was recommended with pH monitoring. HRIM in upright position revealed vigorous esophageal contraction which exceeded 8,000 mmHg·sec·cm of distal contractile integral (DCI) in most of the 10 times liquid-swallowing (Figure). Although integrated relaxation pressure was slightly elevated, peristalsis was intact. Also, contractile front velocity and distal latency were within normal range. Collectively, these results were compatible with Jackhammer esophagus. However, he refused the ambulatory 24-hour esophageal pH monitoring. Figure High-resolution impedance manometry of a patient with hypercontractile esophagus. Extremely abnormal contraction (DCI > 8,000 mmHg · sec · cm) is noted. The esophago-gastric junction relaxation is equivocal (integrated relaxation ... The patient was prescribed 60 mg of nifedipine daily for 8 weeks and instructed to take 5 mg of flunarizine if he felt dizziness. He eventually reported decreased frequency and severity of belching and dizziness up to 80% compared to baseline. The current Chicago classification of esophageal motility disorders defines a hypercontractile esophagus by the presence of at least one contraction over 8,000 mmHg·sec·cm-DCI.1 This motility disorder is rare as to be 4.1% among 200 patient's series2 and displays dysphagia, reflux or chest pain.3 Current pathophysiologic concept for hypercontractile esophagus includes excessive cholinergic drive or hypertrophy of myocytes.4 Therefore, in the absence of abnormality of lower esophageal sphincter relaxation, nitrate and calcium channel blockers can be recommended for this motility disorder. Belching is not a typical symptom of esophageal hypertensive peristaltic disorder. It is also possible that gastroesophageal reflux disease which might coexist with Jackhammer esophagus could cause belching.5 However, regarding that the improvement of symptoms with calcium-channel blockers, which had been refractory to the previous proton pump inhibitor therapy, we cannot exclude a certain relationship between this esophageal dysmotility and belching in this case.

Multimodality evaluation of patients with gastroesophageal reflux disease symptoms who have failed empiric proton pump inhibitor therapy

Patients with symptoms suggestive of gastroesophageal reflux disease (GERD), such as chest pain, heartburn, regurgitation, and dysphagia, are typically treated initially with a course of proton pump inhibitors (PPIs). The evaluation of patients who have either not responded at all or partially and inadequately responded to such therapy requires a more detailed history and may involve an endoscopy and esophageal biopsies, followed by esophageal manometry, ambulatory esophageal pH monitoring, and gastric emptying scanning. To assess the merits of a multimodality 'structural' and 'functional' assessment of the esophagus in patients who have inadequately controlled GERD symptoms despite using empiric PPI, a retrospective cohort study of patients without any response or with poor symptomatic control to empiric PPI (>2 months duration) who were referred to an Esophageal Studies Unit was conducted. Patients were studied using symptom questionnaires, endoscopy (+ or - for erosive disease, or Barrett's metaplasia) and multilevel esophageal biopsies (eosinophilia, metaplasia), esophageal motility (aperistalsis, dysmotility), 24-hour ambulatory esophageal pH monitoring (+ if % total time pH < 4 > 5%), and gastric emptying scanning (+ if >10% retention at 4 hours and >70% at 2 hours). Over 3 years, 275 patients (147 men and 128 women) aged 16-89 years underwent complete multimodality testing. Forty percent (n= 109) had nonerosive reflux disease (esophagogastroduodenoscopy [EGD]-, biopsy-, pH+); 19.3% (n= 53) had erosive esophagitis (EGD+); 5.5% (n= 15) Barrett's esophagus (EGD+, metaplasia+); 5.5% (n= 15) eosinophilic esophagitis (biopsy+); 2.5% (n= 7) had achalasia and 5.8% (n= 16) other dysmotility (motility+, pH-); 16% (n= 44) had functional heartburn (EGD-, pH-), and 5.8% (n= 16) had gastroparesis (gastric scan+). Cumulative symptom scores for chest pain, heartburn, regurgitation, and dysphagia were similar among the groups (mean range 1.1-1.35 on a 0-3 scale). Multimodality evaluation changed the diagnosis of GERD in 34.5% of cases and led to or guided alternative therapies in 42%. Overlap diagnoses were frequent: 10/15 (67%) of patients with eosinophilic esophagitis, 12/16 (75%) of patients with gastroparesis, and 11/23 (48%) of patients with achalasia or dysmotility had concomitant pathologic acid reflux by pH studies. Patients with persistent GERD symptoms despite empiric PPI therapy benefit from multimodality evaluation that may change the diagnosis and guide therapy in more than one third of such cases. Because symptoms are not specific and overlap diagnoses are frequent and multifaceted, objective evidence-driven therapies should be considered in such patients.

Comparison of Distribution of Intraesophageal pH During Nighttime Recumbency Among Patients With Gastroesophageal Reflux Disease

Nighttime reflux has been demonstrated to be associated with a more aggressive presentation of gastroesophageal reflux disease (GERD). However, it has remained unknown until now if the difference in nighttime reflux between the different GERD groups is related to the distribution of intraesophageal pH level or duration of acid exposure. To compare distribution of intraesophageal pH during nighttime between patients with erosive esophagitis (EE) versus those with nonerosive reflux disease (NERD). Patients with heartburn symptoms at least 3 times per week were included in this study. Patients were not receiving any antireflux treatment. All patients underwent an upper endoscopy to determine if esophageal inflammation was present or absent. Subsequently, patients underwent ambulatory 24-hour esophageal pH monitoring. Only those with NERD and EE were included in this study. Nighttime period was defined as the time from the moment patients entered the bed to fall asleep and until they woke up the next morning. Distribution of intraesophageal pH during nighttime was generated using a special computer program that analyzed all registered pH measurements. Nineteen patients were found to have NERD and 31 EE. Time in bed was not different between the 2 groups. The mean number of acid reflux events, mean reflux time pH<4, and mean % total time pH<4 during nighttime were significantly lower in the NERD group as compared with the EE group (13.05±4.6, 19.7±7.09, 3.6±1.2% vs. 25.44±4.4, 29.3±7.97, 5.3±1.5%, respectively, all P<0.05). Symptom index for EE was 43.8% versus 21% for NERD, P<0.05. Overall, the distribution of intraesophageal pH during nighttime was similar between NERD and EE patients for all pH ranges. Patients with EE demonstrated a significantly higher nighttime esophageal acid exposure as compared with NERD, but the overall distribution of the acid exposure was similar between the 2 groups. This suggests that duration rather than intensity of nighttime intraesophageal acid exposure accounts for the difference between EE and NERD.

Females without reflux symptoms or gastroesophageal reflux disease have less distal esophageal acid exposure than males without reflux symptoms or gastroesophageal reflux disease

Ambulatory 24-hour esophageal pH monitoring is the gold standard examination to assess esophageal acid exposure. Gender-related variation is a well-recognized physiologic phenomenon in health and disease. To date, limited gender-specific 24-hour esophageal pH monitoring data are available. The aim of this study was to obtain values of esophageal pH monitoring in males and females without reflux symptoms or gastroesophageal reflux disease (GERD) to determine if gender variation exists in esophageal acid exposure among individuals without these factors. Twenty-four-hour dual esophageal pH monitoring was performed in male and female volunteers without reflux symptoms or GERD. Values for total number of reflux episodes, episodes longer than 5 minutes, total reflux time in minutes, % time with pH below 4, and longest reflux episode in the proximal/distal esophagus were obtained and recorded for both groups. The distal channel was placed 5 cm and proximal channel 15 cm above the manometrically determined lower esophageal sphincter. Means were compared using an independent sample t-test. Sixty-seven males and 69 females were enrolled. All subjects completed esophageal 24-hour pH monitoring without difficulty. There was no age or body mass difference between groups. Females had significantly fewer reflux episodes at both esophageal measuring sites and, significantly less total reflux time and % time with pH below 4 in the distal esophagus than males. All other parameters were similar. Significant gender-related differences exist in esophageal acid exposure, especially in the distal esophagus in individuals without reflux symptoms or GERD. These differences underscore the need for gender-specific reference values for 24-hour pH monitoring, allowing for an accurate evaluation of esophageal acid exposure in symptomatic patients.

Evaluation of gastroesophageal reflux disease questionnaire in diagnosis of gastroesophageal reflux disease

Objective To evaluate the feasibility of gastroesophageal reflux disease questionnaire (GerdQ) in diagnosis of gastroesophageal reflux disease(GERD) and clinical characteristics of patients with GERD in China. Meanwhile, a standard for diagnostic trial of GERD using proton pomp inhibitor (PPI) for Chinese population was developed. Methods A multicenter study on diagnosis of GERD based on GerdQ was carried out in five hospitals of China. All patients were presented with a 6-item GerdQ. The diagnostic value of GerdQ was assessed according to the positive findings of enoscopy, 24hour ambulatory esophageal pH monitoring or PPI trial. The pre-established criterion for PPI trial was compared with findings of enoscopy or 24-hour ambulatory esophageal pH monitoring in order to get optimized criterion for GerdQ. Results The sensitivity of the pre-established PPI trial was 0. 6627 and the specificity was 0. 4872. The statistical analysis indicated that the optimized standard for PPI trial was defined as the total scores of heartburn and regurgitation in last 3 days of the first week treatment being decreased by 3 points in comparison with those before treatment. The optimized standard for PPI trial had sensitivity of 0. 3787, specificity of 0. 8077, positive predictive value of 0. 8101 and negative predictive value of 0. 3750, as well as the maximum Youden index of 0. 1864. After rectification of the population, a cut-off points of ten had a sensitivity of 0. 6690 and specificity of 0. 4390 with maximum Youden index of 0. 4390. The diagnostic value of GerdQ was decreasing when the scoring was increasing in female patients aged 50 or above. Conclusions The GerdQ is approved of value in diagnosis of GERD. For those with obvious symptom and hardly response to PPI trial, the diagnosis of GERD must be made carefully. It is better for evaluation of PPI trial using scores in the last 3 days of the first week treatment. Key words: Gastroesophageal reflux disease; Questionnaire; Proton pomp inhibitors

S201 – The Progress of Reflux‐Related Symptoms in Healthy Persons

Objectives To evaluate prospectively the progress of pharyngeal and esophageal symptoms in previously healthy subjects. Methods 33 healthy persons (mean 57 yrs) earlier included in a normative pH monitoring study were contacted. After a mean follow-up period of 13 years, the subjects completed 2 symptom questionnaires, Short Form 36, and ambulatory 24-hour pharyngeal and esophageal pH monitoring. Results 24 subjects, 9 males and 15 females (mean age, 57 years), completed the study. All subjects were symptom-free at baseline. At follow-up, 11 of the 24 (46%) subjects (p=0.001) reported typical reflux symptoms, e.g. heartburn or regurgitation, of mild to moderate severity. Extraesophageal symptoms occurring at least 1–2 days/week developed across time in 10 of the 24 (42%) subjects. The most common symptoms were throat clearing, excessive phlegm, and daytime cough, in that order. There was no statistically significant correlation between reflux parameters and the occurrence of symptoms (p&gt;0.01). The esophageal, or airway symptoms, or combination of them were similar among persons with and without LPR at baseline and at the follow-up. The perceived health by 10 subjects who had upper airway symptoms at follow-up, or those 8 subjects who had pharyngeal reflux at follow-up, as reflected by the domain specific and summary SF-36 scores, was not significantly different from the age- and gender-matched randomly selected sample from the Swedish normative database. Conclusions The increase in the upper airway as well as esophageal symptoms across time is not correlated to perceived health, or increase in the occurrence of reflux.

The Effect of Auditory Stress on Perception of Intraesophageal Acid in Patients With Gastroesophageal Reflux Disease

Most patients with gastroesophageal reflux disease (GERD) report that stress exacerbates their symptoms, yet mechanisms underlying this association remain unknown. We sought to determine the effect of an acute laboratory stressor on perceptual and emotional responses to intraesophageal acid perfusion in healthy controls and patients with GERD. Forty-six patients with heartburn and 10 healthy controls underwent upper endoscopy and, if negative, pH monitoring. Assessment of psychologic factors and health-related quality of life was done by a questionnaire. Perceptual and emotional responses to intraesophageal acid at baseline, during auditory stress, and during an auditory control condition were determined using a randomized crossover design. Plasma levels of norepinephrine, adrenocorticotropic hormone, and cortisol were assessed. Twenty-nine subjects were identified as nonerosive reflux disease and 17 as erosive esophagitis. Quality of life, psychologic profile, and personality assessment variables were similar among the 2 patient groups and the controls. There was a significant reduction in mean lag time to initial symptom perception and an increase in mean intensity rating and mean acid perfusion sensitivity score in the 2 patient groups during the stress period, which was not seen during the control condition. Healthy controls demonstrated lack of a significant change in all parameters of stimulus response functions to acid, regardless of condition. Acute auditory stress can exacerbate heartburn symptoms in GERD patients by enhancing perceptual response to intraesophageal acid exposure. This greater perceptual response is associated with greater emotional responses to the stressor.

Long-term functional results after laparoscopic surgery for esophageal achalasia

Background Evidence on the long-term outcome of laparoscopic Heller–Dor surgery is limited. The aim of this study was to assess the long-term outcome of achalasic patients after surgery, particularly in relation to the radiologic preoperative stage of the disease. Methods Sixty-eight patients with achalasia were assessed clinically and by esophageal radiology, manometry, and 24-hour ambulatory esophageal pH monitoring before and at 3 months, 1, 1 to 3, 3 to 5, and 5 to 8 years after a laparoscopic Heller-Dor procedure. Results At 1 year after surgery the symptom score was significantly lower than the preoperative score ( P < .001), and a satisfactory clinical outcome was seen in more than 90% of the patients with stage I, II, and III disease at the preoperative radiologic assessment. Only 50% of stage IV patients reported satisfactory results. An adequate opening of the lower esophageal sphincter (LES) and LES resting pressure of less than 8 mm Hg was achieved in all patients, and esophageal emptying was accelerated significantly ( P < .001). At the consecutive follow-up evaluation (1–8 y), a satisfactory outcome was maintained in all stage I, II, and III responders. Stage IV patients with initially unsatisfactory results reported a worsening of symptoms ( P < .02). Patients with pseudodiverticulum had a higher symptom score ( P < .01). LES opening and resting pressure remained at levels of the 1-year follow-up evaluation. Esophageal emptying remained satisfactory in stage I, II, and III responders, but deteriorated in stage IV nonresponders and in 6 of the 10 patients with a pseudodiverticulum. Conclusions A satisfactory outcome of the laparoscopic Heller–Dor procedure in stage I, II, and III achalasic patients seems to last. Stage IV nonresponders tend to deteriorate over time. The development of pseudodiverticulum is associated with an increased symptom score.

Value of Heartburn for Diagnosing Gastroesophageal Reflux Disease in Severely Obese Patients

To evaluate the prevalence of gastroesophageal reflux disease (GERD) in severely obese patients and the association between symptoms and objective data of GERD in this population. A total of 158 consecutive severely obese patients (BMI > or = 40 kg/m(2)) were prospectively evaluated. Symptoms were evaluated by a structured clinical questionnaire. Objective assessment was made by ambulatory 24-hour esophageal pH monitoring and endoscopy. GERD was defined by the presence of symptoms or complications (esophagitis). The clinical criterion defining GERD was the presence of at least two episodes of heartburn per week. The mean age of the 138 patients subjected to complete study was 42.6 +/- 10.2 years, with a BMI of 50.1 +/- 6.9 kg/m(2) (range, 40.6 to 69.4 kg/m(2)); 78% were women. The prevalence of GERD evaluated by symptoms and/or esophagitis was 33.3% (46/138). Clinical criteria of GERD were present in 31/138 cases (22.5%), and 26 (18.8%) had esophagitis. In 69/138 patients (50%), pHmetry was abnormal. Fifty-three patients with esophagitis and/or abnormal pHmetry were asymptomatic. The sensitivity of heartburn as a diagnostic criterion of GERD in patients with severe obesity was 29.3%, with a specificity of 85.7%. No significant association was observed between severe obesity grade and the prevalence of symptoms and/or objective data. Asymptomatic gastroesophageal reflux (abnormal esophageal acid exposure and/or reflux esophagitis) is more common than symptomatic gastroesophageal reflux in severely obese patients. Increased BMI is not associated with a greater prevalence of GERD in these patients.

Vocal cord dysfunction concurrent with a nutcracker esophagus and the role of gastroesophageal reflux disease

Psychological disorders were originally thought to be the sole cause of vocal cord dysfunction (VCD). Subsequently, other organic diseases, including structural laryngeal abnormalities, have also been reported to be associated with VCD. To describe the first patient with VCD concurrent with a nutcracker esophagus and to establish the association between VCD and gastroesophageal reflux disease (GERD) by using the Bernstein test. Symptom assessments, neuropsychiatric evaluations, fiberoptic laryngoscopy, pulmonary function tests, allergic skin prick tests, radiographs of the chest and sinuses, esophageal manometry (including 24-hour ambulatory esophageal pH monitoring), and the Bernstein test were performed. A 36-year-old woman had dyspnea, hoarseness, chest pain, and wheezes without relief for a decade. Neuropsychiatric evaluations disclosed mild depression. Fiberoptic laryngoscopy showed posterior laryngitis and paradoxical vocal cord adduction with audible inspiratory stridor. Pulmonary function tests showed attenuation of the inspiratory limb with notching in both flow-volume loops and a mid-vital capacity expiratory to inspiratory flow ratio of 4. All the symptoms except chest pain were improved dramatically by speech therapy and empirical treatment for GERD. Esophageal manometry revealed a nutcracker esophagus; 24-hour ambulatory esophageal pH monitoring demonstrated multiple short reflux episodes. The Bernstein test was conducted, and all the manifestations were reproduced with 0.1 N hydrochloric acid but not with isotonic sodium chloride infusion. This is the first human case report confirming that GERD can trigger an acute attack of VCD and may induce chest pain as a nutcracker esophagus in patients with VCD. It strengthens this association and expands our knowledge of diverse manifestations of this clinical entity.

ASGE Technology Status Evaluation Report: wireless esophageal pH monitoring system

ASGE Technology Status Evaluation Report: wireless esophageal pH monitoring system

Severe chest pain from an indwelling Bravo pH probe

Continuous ambulatory esophageal pH monitoring can be helpful in the management of patients with refractory or atypical GERD. Until recently, the only available method for pH monitoring was placement of a transnasal catheter that contained a pH electrode 5 cm proximal to the manometrically identified lower esophageal sphincter. The catheter is left in place for 24 hours, and data are collected to quantify esophageal acid exposure. Although this method is reliable, it may be associated with significant patient discomfort and social embarrassment, leading many patients to modify their daily activity during the study. In turn, this may decrease the validity and reliability of the procedure. 1 Fass R. Hell R. Sampliner R.E. Pulliam G. Graver E. Hartz V. et al. Effect of ambulatory 24-hour esophageal pH monitoring on reflux-provoking activities. Dig Dis Sci. 1999; 44: 2263-2269 Crossref PubMed Scopus (139) Google Scholar

Ambulatory 24-hour esophageal pH monitoring: why, when, and what to do.

The incidence of gastroesophageal reflux disease (GERD) is increasing and if left untreated can lead to significant patient morbidity and even death. The disease results from the abnormal reflux of gastric contents into the distal esophagus causing symptoms in most and subsequent mucosal damage in some. Several investigations can be used to confirm the diagnosis, but most are dependent on the presence of sequelae and complications of the disease. The physiologic test of ambulatory 24-hour esophageal pH monitoring has proved to be the most sensitive and specific diagnostic investigation. It measures increased esophageal exposure to gastric juice by detecting the concentration of hydrogen ions (pH <4) in the distal esophagus. The technique measures gastric juice exposure at a point 5 cm above the manometrically determined upper border of the lower esophageal sphincter. The exposure is measured in components of frequency of reflux episodes, duration of reflux episodes, and accumulated exposure time. The components are integrated into a composite score, which is reproducible, gender and race independent, and correlates with the degree of esophageal epithelial damage determined histologically. The composite score has been shown to be the most reliable measurement of a therapeutic acid suppression regimen or an effective antireflux operation.

Factors affecting esophageal motility in gastroesophageal reflux disease.

There are conflicting data concerning the effect of gastroesophageal reflux disease (GERD) on esophageal motor function. Duration of GERD might affect severity of symptoms, grade of esophageal mucosal injury, and esophageal motor behavior. Retrospective study of a defined cohort. Two referral centers, one of them academic, for esophageal gastrointestinal motility disorders. One hundred forty-seven patients with documented GERD. Symptoms, grade of mucosal injury on esophagoscopy, esophageal manometry, ambulatory esophageal pH monitoring, and esophagogram. Patients with GERD had significantly decreased lower esophageal sphincter resting pressure (P =.02), lower amplitude of esophageal peristalsis at all levels of measurement (P<.001), and more delayed esophageal transit (P =.007) compared with control subjects. Patients with dysphagia, severe esophagitis, and Barrett esophagus presented with a longer history of the disease, significantly worse esophageal motor function (P<.01), and more prolonged esophageal transit than patients without the above features of the disease. Impairment of esophageal peristalsis and lower esophageal sphincter resting pressure were significantly inversely related to the duration of the disease (P<.001). Also, delay of esophageal transit was significantly related to the duration of the disease (P =.002) and inversely related to the amplitude of esophageal peristalsis (P<.001). Unlike the manometric variables, the extent of reflux, as assessed by ambulatory 24-hour esophageal pH monitoring, was not related to the duration of the disease. A long history of GERD is more commonly associated with presence of dysphagia, delayed esophageal transit, severe esophagitis, presence of Barrett esophagus, and impaired esophageal motility.