24-hour Intraesophageal pH Monitoring Research Articles

The clinical characteristics of gastroesophageal reflux disease in patients with laryngeal symptoms who are referred to gastroenterology

The prevalence of gastroesophageal reflux disease (GERD) has increased recently in Asia-Pacific countries. However, little is known about its prevalence and clinical characteristics in GERD patients with atypical symptoms in Asia. The aim of this study was to investigate the clinical characteristics of GERD in patients who had laryngeal symptoms in Korea. Data were gathered retrospectively from patients who presented with atypical symptoms, such as throat discomfort, globus pharyngeus, hoarseness, and chronic cough. They underwent a 24-hour ambulatory intraesophageal pH monitoring and filled in a validated reflux questionnaire. Overall, 128 patients (36 men and 92 women) with laryngeal symptoms were included. Of these 128, 43 patients (34%) had erosive esophagitis or pathological reflux from 24-hour ambulatory pH monitoring, and 24 (19%) had a positive Bernstein test or positive symptom index from 24-hour pH monitoring. Sixty-one patients (48%) had no evidence of reflux esophagitis on upper endoscopy and pathological acid reflux on 24-hour pH monitoring. Fifty-six patients (44%) had weekly heartburn or regurgitation. Typical symptoms and dyspepsia were significantly more common in patients with GERD who had laryngeal symptoms than non-GERD. Fifty-two percent of patients had laryngeal symptoms that were associated with GERD. The presence of typical reflux symptoms and dyspepsia are risk factors for GERD in patients who present with laryngeal symptoms.

Focus on Diagnosis: New Technologies for the Diagnosis of Gastroesophageal Reflux Disease

1. Jason E. Dranove, MD* 1. *Clinical Fellow, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, Indianapolis, Ind Gastroesophageal reflux (GER), the regurgitation of gastric contents into the esophagus or mouth, is a common phenomenon among healthy infants, with approximately 50% of 0- to 3-month-old infants and 67% of 4-month-old infants experiencing at least one episode of vomiting per day. GER typically improves through the first postnatal year, with only 5% of healthy 12-month-olds experiencing vomiting. Uncomplicated GER usually can be diagnosed from the history and physical examination, and treatment often is instituted without extensive diagnostic testing. When symptoms do not respond to treatment as expected, symptoms persist much beyond 1 year of age, GER is suspected to be the cause of epigastric abdominal pain or substernal pain, or extraesophageal symptoms are present (eg, poor weight gain, apparent life-threatening episodes [ALTEs], apnea, pneumonia, treatment-resistant asthma, or chronic cough), GER often is called “complicated GER” or gastroesophageal reflux disease (GERD). GERD has been reported to affect up to 8% of infants and children. When GERD is suspected, diagnostic testing often is warranted. A commonly employed test, the upper gastrointestinal (GI) barium study, can rule out anatomic abnormalities of the upper GI tract, such as malrotation, but only captures one moment in time. The upper GI barium study lacks sensitivity (31% to 86%) and specificity (21% to 83%) for diagnosis of pathologic GER compared with the gold standard of 24-hour intraesophageal pH monitoring. Similarly, although the gastric scintiscan provides useful information about gastric emptying and may detect episodes of GER and pulmonary aspiration, its utility is limited by poor sensitivity compared with 24-hour pH monitoring (15% to 59%), a lack of standardized technique, and the absence of age-normative data. Intraesophageal pH monitoring, a test that documents esophageal exposure to refluxed gastric contents over a longer period of time, and the ability to correlate reflux episodes with the symptoms in question …

Inflammation of the gastric cardia in children with symptoms of acid peptic disease

ObjectivesTo assess the severity and causes of inflammation of the gastric cardia in children undergoing endoscopy for symptoms of acid peptic disease. Study designPatients undergoing upper gastrointestinal endoscopy for symptoms of acid peptic disease had biopsies from gastric cardia, gastric, and esophageal sites, and 24-hour intraesophageal pH monitoring. Gastric cardia was defined at endoscopy as the anatomic zone from the squamocolumnar junction to 0.5 cm below it. Severity of gastric cardia inflammation was scored 0 to 9 according to densities of inflammatory cells and epithelial abnormalities in surface and pit epithelium. A score ≥2 was considered positive. ResultsForty-seven children (median age, 6.5 years; range, 3–15) had Helicobacter pylori infection, gastroesophageal reflux disease (GERD), or both. In 22 patients, H pylori was detected in cardiac biopsies by rapid urease test and histology; it was detected also in the corpus and antrum in only seven of the 22. No patient had H pylori in gastric corpus/antrum without having the organism at the cardia as well. In 12 H pylori-positive patients, GERD was also diagnosed. Twenty-five patients had GERD and no H. pylori infection. Severity score was 3.8±0.8 in the H pylori group and 2.08±0.9 in the GERD alone group (P<.001); however, there was no difference in reflux index (24-hour % of gastroesophageal reflux) between the two groups. In neither group was correlation found between reflux index and severity score (H pylori, r=0.22; GERD alone, r=0.31; NS) nor between cardia inflammation and esophagitis grade (H pylori, r=0.37; GERD alone, r=0.22; NS). ConclusionsIn children with symptoms of acid peptic disease, inflammation of the gastric cardia does occur. It is more severe when the cardiac zone is infected with H pylori than in its absence. Of major practical significance is the finding that the gastric cardia is a highly sensitive site for the detection of H pylori infection.

Diagnostik von refluxbedingten Beschwerden im HNO-Bereich mittels 2-Kanal-pH-Metrie

Patients with gastroesophageal reflux disease (GERD) may suffer from a large variety of symptoms in the upper aerodigestive tract such as globus sensation, chronic cough, hoarseness and many others. Diagnosis and causal therapy may sometimes be difficult with gastroenterologic evaluation sometimes revealing no pathologic result. The objective of this study was to determine the impact of 24-hour intraesophageal pH monitoring with 2 channels (gastric and laryngeal) in the diagnosis of reflux-induced otolaryngologic disorders. This study included 22 patients presenting to the Department of Otolaryngology with symptoms like chronic cough (n = 3), globus sensation and dysphagia (n = 11), heartburn (n = 2), hoarseness and dysphonia (n = 2) or burning sensation of the tongue (n = 1). Three patients had a pathologic formation in the glottic area (leukoplakia, granuloma, polyp). All patients underwent a otolaryngological examination, a gastroenterological investigation and a 24-hour intraesophageal pH monitoring with 2 channels. All 22 patients showed laryngeal mucosal lesions (posterior laryngitis). The gastroenterological evaluation with esophagogastroduodenoscopy was normal in 4 cases. 13 patients showed a hiatal hernia, 4 patients were suffering from a reflux-esophagitis grade I and 2 patients from grade II. One patient had an erythema and 5 patients showed erosions of the gastric mucosa. Seven patients had more than one of the above mentioned diagnoses. Intraesophageal pH-monitoring with 2 channels over 24 hours revealed a gastroesophageal reflux of all 22 patients and a high reflux to the laryngeal level of 21 patients, probably causing laryngopharyngeal symptoms. Therapy of the patients consisted of medical antireflux treatment with proton pump inhibitor esomeprazol (Nexium, 40 mg, 1-0-0). Within 4 weeks 15 of 22 patients had no more laryngopharyngeal symptoms or at least a significant reduction. Patients with laryngopharyngeal symptoms such as hoarseness, globus sensation or dysphagia can suffer from GERD, even if typical symptoms such as heartburn or retrosternal pain do not exist and gastroesophageal intervention reveals a normal result. The best diagnostic instrument for the diagnosis of reflux-induced otolaryngologic disorders is a 24-hour intraesophageal pH-monitoring with 2 channels (measure-points at the distal esophagus and laryngeal level). Medical antireflux treatment should consist of proton pump inhibitors (e. g. Nexium) in a dose of 40 mg per day over at least 4 weeks.

Reproducibility of 24-Hour Intraesophageal pH Monitoring

To the Editor. I read with interest the article published in your journal by Mahajan et al1 concerning the reproducibility of 24-hour intraesophageal pH monitoring in children. I think that their article is an extremely important article with respect to understanding the limitations of ambulatory esophageal pH monitoring in children for the diagnosis of gastroesophageal reflux disease. The poor correlation that they found between the first and second 24-hour periods for patients studied with intraesophageal pH monitoring can be explained by additional factors that I do not believe they covered adequately in their article. These factors can be divided into technical problems and limitations with the equipment that they used and methodological problems with respect to the way in which they analyzed the esophageal pH record. The technical limitations and problems with respect to the equipment that they used involve the limitations of using a computerized system with a Digitrapper or storing data in a compartment where the data are later displayed on a computer screen and output using a printer. Unless the authors printed out each and every recording on a printer and went over the recordings, they cannot be sure that there were not equipment malfunctions that produced faults or misleading data that was interpreted as acid reflux. To the best of my knowledge, this equipment has an indicator for loose leads that will only detect loose leads in which there has been complete loss of electrical contact with the patient. Unfortunately, an incomplete loss of electrical contact with a loose lead, such as a loose reference electrode patch, cannot be detected by the machine and will produce a downward drift in the pH recording that would be misinterpreted by the computer, and possibly by the reader of the record, as acid reflux. This downward drift is …

IS THERE A ROLE FOR THE PROXIMAL pH PROBE WHEN DIAGNOSING GASTROESOPHAGEAL REFLUX IN CHILDREN?

15 INTRODUCTION: Extended 24-hour intraesophageal pH monitoring is the gold standard to diagnose GER. A range of normal values for the distal reflux index (DRI) is well established. However, limited data are available regarding a range of normal values for the proximal reflux index (PRI) and its clinical significance. OBJECTIVES: To establish a range of normal values for the proximal pH probe and to assess the clinical usefulness of the proximal pH probe data. METHODS: A retrospective study of 189 pediatric 24 hour esophageal dual pH probe studies carried out at our hospital during the last 5 years. The proximal pH probe was located 5 cm from the distal probe. The DRI and PRI were calculated as the percentage of time, esophageal pH was < 4.0 at the distal and proximal probes respectively. There were 114 negative studies (DRI < 5%) and 75 positive studies (DRI >5%). For the determination of normal values for PRI only 81 patients of the 114 negative studies were utilized because of artifact in the other 33 negative studies. RESULTS: The normal range of values for PRI are as follows: (Table)CONCLUSION: We established a reference range of normal values for the proximal pH probe. Although further studies are needed, the current data suggest that the proximal pH probe does not add clinically significant information.TABLE

Nonspecific esophageal motility disorders in children without gastroesophageal reflux.

Nonspecific esophageal motility disorders (NEMDs) have been identified in up to 50% of adults with noncardiac chest pain or dysphagia. This study sought to determine the incidence of NEMDs in children with upper gastrointestinal tract symptoms and to evaluate the clinical course of pediatric patients with these manometric abnormalities. The study involved 154 children aged 4 to 18 years (mean age, 11.6+/-2.6 years [SE]) who had upper gastrointestinal, swallowing-related symptoms. The children were evaluated by 24-hour intraesophageal pH monitoring, esophageal manometry, and esophagogastroduodenoscopy. Gastroesophageal reflux (GER) was diagnosed by pH study in 109 (71%) of 154 patients, and examination of biopsy specimens demonstrated esophagitis in 70 children with GER. Results of esophageal manometry were abnormal in 30 (67%) of 45 children without GER. A variety of motility disorders were diagnosed in 17 of the patients without GER, whereas NEMDs were diagnosed in the remaining 13 children (mean age, 10.6+/-2.7 years; 10 boys, 3 girls). Patients with GER showed normal esophageal wave propagation; however, mean lower esophageal sphincter pressure was significantly lower in patients with GER than in children with NEMDs. The children with NEMDs exhibited a diverse array of symptoms, including esophageal food impaction in 4 of the 13 patients. During a 36.2+/-4.3-month follow-up period, no correlation was found between therapeutic intervention and clinical course in the 13 patients with NEMDs. Symptomatic improvement occurred in 6 of 13 patients, including 3 children for whom no pharmacologic therapy was prescribed. These data indicate that NEMDs represent a common group of esophageal manometric abnormalities in children with upper gastrointestinal tract symptoms and without GER. Food impaction appears to be a relatively frequent complication, and NEMDs should be considered in children who have this finding.

Reproducibility of 24-hour intraesophageal pH monitoring in pediatric patients.

Despite the widespread use of 24-hour intraesophageal pH monitoring for evaluation of gastroesophageal reflux in infants and children, there is little published information regarding the reproducibility of ambulatory pH studies in this patient population. The purpose of our study was to evaluate the reproducibility of 24-hour intraesophageal pH monitoring in pediatric patients. We prospectively investigated 26 patients with symptoms suggestive of gastroesophageal reflux (14 females and 12 males) ranging in age from 1 month to 18 years (mean, 9.2 years). The patients underwent extended intraesophageal pH monitoring over two consecutive 24-hour periods. Data analysis revealed that the overall reproducibility of ambulatory 24-hour pH monitoring is only 69% (r = 0.32). Eight of 26 patients had conflicting results on day 1 compared with results on day 2. Of the 8 patients with conflicting results on day 1 versus day 2, 5 had normal studies on day 1, but demonstrated pathologic reflux on day 2. Thus, the false-negative rate for day 1 was 19.2%. The kappa statistic calculated for the total time the pH was abnormal was 0.32, with values < 0.4 representing poor correlation. Spearman correlation coefficients indicated that the percentage of time with pH < 4 (r = 0.64) and the number of reflux episodes (r = 0.71) per 24-hour period are the most reproducible pH parameters. The reproducibility of 24-hour intraesophageal pH monitoring in the pediatric population is suboptimal. The investigation should be extended or repeated if the result does not correlate with the patient's clinical history.

Reflux gastroœsophagien et troubles de la motricité œsophagienne chez des nourrissons porteurs d'une hyper-réflectivité vagale ayant présenté un malaise grave

Aim. — The aim of the study was to evaluate the prevalence of gastroesophageal reflux and abnormalities of esophageal motility in a population of neonates referred for apparently life threatening event (ALTE) and presenting vagal hyperreflectivity. Population and methods. — The study included 17 infants, who were examined after an ALTE. They were admitted at a mean age of 11.7 weeks (range 1–40 weeks). Vagal hyperreflectivity was confirmed in each infant by oculocardiac reflex. Before treatment, 24-hour intraesophageal pH-monitoring and esophageal manometry were performed. Results. — pH-monitoring and esophageal manometry were both normal in only two patients. pH-monitoring showed pathological reflux (% of time with pH < 4 more than 4.8%) in 10 17 (59%) patients. Manometric studies showed esophageal dysmotility in 12 17 (71%) of patients. Hypertensive lower sphincter was noted in 11 17 (65%) infants. Patients with normal manometry were older than patients presenting with esophageal dysmotility (P < 0.05). Conclusion. — This study shows a high frequency of gastroesophageal reflux and esophageal dysmotility in infants with vagal hyperreflectivity. Hypertensive lower esophageal sphincter as well as vagal hyperreflectivity may correspond to dysmaturity of autonomous nervous system and facilitate the occurrence of ALTE.

Prevalence of gastroesophageal reflux in patients who develop pneumonia following percutaneous endoscopic gastrostomy: A 24-hour pH monitoring study

Percutaneous endoscopic placement of feeding gastrostomies (PEG) was pioneered by Gauderer et. al. in 1980 [1]. Since then, it has become the preferred method of providing enteral nutritional support in children and adults because of advantages in morbidity and cost [2,3]. Pneumonia is a known sequel of this procedure, occurring at different rates, depending on the length of follow-up. Some series have shown an incidence of 10% at 30 days and others 56% at 11 months [4,5]. It does not appear that PEG feeding offers an advantage over the more traditional naso-enteric tube feeding methods in this respect. To study the prevalence of gastroesophageal reflux (GER) in PEG-fed patients, we quantitated GER by 24-hour intraesophageal pH monitoring in a group of patients who developed post-PEG pneumonia and compared it with a control group. Our study demonstrates an increased prevalence of GER in the pneumonia group compared with the control group. However, the exact contribution of this observed increased GER to the development of pneumonia needs to be determined.

The Otolaryngologic Manifestations of Gastroesophageal Reflux Disease (GERD): A Clinical Investigation of 225 Patients Using Ambulatory 24‐Hour pH Monitoring and an Experimental Investigation of the Role of Acid and Pepsin in the Development of Laryngeal Injury

Occult (silent) gastroesophageal reflux disease (GER, GERD) is believed to be an important etiologic factor in the development of many inflammatory and neoplastic disorders of the upper aerodigestive tract. In order ot test this hypothesis, a human study and an animal study were performed. The human study consisted primarily of applying a new diagnostic technique (double-probe pH monitoring) to a population of otolaryngology patients with GERD to determine the incidence of overt and occult GERD. The animal study consisted of experiments to evaluate the potential damaging effects of intermittent GER on the larynx. Two hundred twenty-five consecutive patients with otolaryngologic disorders having suspected GERD evaluated from 1985 through 1988 are reported. Ambulatory 24-hour intraesophageal pH monitoring was performed in 197; of those, 81% underwent double-probe pH monitoring, with the second pH probe being placed in the hypopharynx at the laryngeal inlet. Seventy percent of the patients also underwent barium esophagography with videofluoroscopy. The patient population was divided into seven diagnostic subgroups: carcinoma of the larynx (n = 31), laryngeal and tracheal stenosis (n = 33), reflux laryngitis (n = 61), globus pharyngeus (n = 27), dysphagia (n = 25), chronic cough (n = 30), and a group with miscellaneous disorders (n = 18). The most common symptoms were hoarseness (71%), cough (51%), globus (47%), and throat clearing (42%). Only 43% of the patients had gastrointestinal symptoms (heartburn or acid regurgitation). Thus, by traditional symptomatology, GER was occult or silent in the majority of the study population. Twenty-eight patients (12%) refused or could not tolerate pH monitoring. Of the patients undergoing diagnostic pH monitoring, 62% had abnormal esophageal pH studies, and 30% demonstrated reflux into the pharynx. The results of diagnostic pH monitoring for each of the subgroups were as follows (percentage with abnormal studies): carcinoma (71%), stenosis (78%), reflux laryngitis (60%), globus (58%), dysphagia (45%), chronic cough (52%), and miscellaneous (13%). The highest yield of abnormal pharyngeal reflux was in the carcinoma group and the stenosis group (58% and 56%, respectively). By comparison, the diagnostic barium esophagogram with videofluoroscopy was frequently negative. The results were as follows: esophagitis (18%), reflux (9%), esophageal dysmotility (12%), and stricture (3%). All of the study patients were treated with antireflux therapy. Follow-up was available on 68% of the patients and the mean follow-up period was 11.6 +/- 12.7 months.(ABSTRACT TRUNCATED AT 400 WORDS)

Pulmonary Disease in Progressive Systemic Sclerosis

Thirteen patients with progressive systemic sclerosis were studied to evaluate the possible role of gastroesophageal reflux as a contributing pathogenic factor in the pulmonary disease of the patients. The evaluation of all patients included fiberoptic esophagogastroduodenoscopy with biopsies of the esophagus, otolaryngologic evaluation, technetium Tc 99m sulfur colloid aspiration scan, pulmonary function testing, including the diffusing capacity for carbon monoxide (DLCO) test, and 24-hour intraesophageal pH monitoring with probes placed 5 and 15 cm above the lower esophageal sphincter. Eleven patients had microscopic and macroscopic evidence of proximal esophagitis, 12 patients had laryngeal changes suggestive of aspiration, and 12 patients had abnormal DLCO values. Using multiple regression analysis, the degree of DLCO impairment correlated with the proximal and distal reflux episodes and scores recorded by pH monitoring. There was direct and indirect evidence for proximal gastroesophageal reflux and aspiration in the majority of patients, and a distinct correlation between the severity of reflux and the severity of pulmonary disease. Aggressive antireflux therapy may be helpful in reducing the pulmonary damage due to aspiration in these patients.

Utility of inpatient 24-hour intraesophageal pH monitoring in diagnosis of gastroesophageal reflux

The aims of the present study were to evaluate the accuracy of 24-hr intraesophageal pH monitoring in the diagnosis of gastroesophageal reflux in the hospital setting and to establish whether there were any differences in terms of reflux events between patients with and without endoscopic esophagitis. Fifteen control subjects and 47 patients with proven gastroesophageal reflux disease were studied. A composite score of reflux events (number of reflux episodes; total, upright, and supine reflux time; number of refluxes lasting more than 5 min; and duration of the longest reflux) provided the best discrimination between controls and patients (94% sensitivity and 100% specificity). Patients with esophagitis showed concurrently a longer total reflux time and supine reflux time, and more prolonged reflux episodes than those without esophagitis. On the other hand the severity of esophagitis was directly related to the duration of both total and supine reflux. The results indicate that inpatient 24-hr pH-metry is very accurate in the diagnosis of gastroesophageal reflux. They also suggest that prolonged esophageal exposure to acid, particularly at night, and slow esophageal acid clearing are factors that determine the appearance and/or perpetuation of esophagitis in patients with reflux.

Limitations of 24-hour intraesophageal pH monitoring in the hospital setting

Prolonged intraesophageal pH monitoring is considered by some to be the most sensitive and specific test of gastroesophageal reflux. We prospectively examined the ability of the test to discriminate 64 hospitalized patients with typical reflux symptoms from 20 age-matched hospitalized control subjects. Patients were subdivided based on endoscopic findings into two groups: group 1, normal endoscopy (n = 30); group 2, erosive esophagitis (n = 34). Six different individual reflux variables and a scoring system were evaluated. Total esophageal acid exposure time and the number of reflux episodes requiring longer than 5 min to clear were each found to have greater discriminatory power than other variables and the scoring system. Although the 64 patients had significantly more acid reflux than controls, only 48% had abnormal results (defined as 2 SD from the control mean). Group 1 patients had significantly more reflux than controls, though only 21% had abnormal results. Group 2 patients were significantly different than both controls and group 1, but 29% had normal studies. Ninety-three percent of the group 1 patients with normal studies responded to antireflux therapy, and only 1 patient had another explanation for the symptoms. The finding that 24-h pH monitoring was normal in half of the individuals presenting with reflux symptoms and in 29% of the patients with erosive esophagitis indicates that negative test results must be interpreted with caution. The insensitivity of the test may relate to the manner in which the study has traditionally been performed in the hospital, and outpatient ambulatory monitoring may improve its reliability.

Effectiveness of nissen fundoplication for gastroesophageal reflux in children as measured by 24-hour intraesophageal pH monitoring

Intraesophageal 24-hr pH monitoring was performed on each of six children with severe symptomatic GER both before and after (mean, 10.1 mo.) fundoplication. The frequency and duration of reflux as measured by esophageal pH below 4.0 was less following fundoplication than in control patients (p less than 0.01). The 24-hr esophageal pH correlates more closely with GER than does measurement of the LESP. The duration to be the best available test which correlates with detection of reflux and correction following fundoplication. The Nissen fundoplication appears to effectively prevent GER.