Abnormal Gastroesophageal Reflux Research Articles

S426 POEM Results in More Frequent and More Severe Reflux Than Heller Myotomy

Introduction: Achalasia is an esophageal motility disorder that is characterized by abnormal lower esophageal sphincter (LES) relaxation due to disrupted neuromodulatory responses. Relieving this outflow obstruction simultaneously disrupts the barrier against gastroesophageal reflux (GER). There is a need for comprehensive studies describing the comparative incidence of abnormal GER accounting for both pH testing and esophagogastroduodenoscopy (EGD) findings and specifically examining the incidence of severe reflux in peroral endoscopic myotomy (POEM) compared to laparoscopic Heller myotomy with Dor fundoplication (LHM). Methods: The charts of patients who underwent LHM or POEM between 2017 and 2019 at our institution were reviewed, and patients who had completed a 2-month post-treatment esophageal pH study off acid-lower agents were included. We also included patients who underwent EGD but did not undergo pH monitoring due to finding erosive esophagitis. Patients with a history of prior myotomy or who underwent Heller without Dor fundoplication were excluded. Results: Of the 236 patients included, 85 (36%) had undergone POEM while 151 (64%) had undergone LHM. The prevalence of abnormal gastroesophageal reflux using pH testing (TAE >4%) is 62% for POEM and 21% for LHM. When including abnormal EGD’s, the prevalence of abnormal GER (TAE >4% or reflux esophagitis or esophageal ulcer) becomes 72% and 28%, respectively. The incidence of severe reflux (defined by more than 10% time in reflux overall or Grade C/D esophagitis or esophageal ulcer) is 38.8% for POEM and 15.2% for LHM. The prevalence of gastritis was 7.9% in LHM vs 2.4% in POEM (NS), with a prevalence of gastric and duodenal ulcers of 2.6% in LHM vs 0% in POEM, but these were not statistically significant (Table). Conclusion: POEM is associated not only with a significantly higher incidence of abnormal GER (72% vs 28%, p< 0.001), but also with a higher incidence of severe GER (38.8% vs 15.2%, p< 0.001), accounting for both esophageal pH testing and upper endoscopy findings. Gastroenterologists should be aware of this association and follow post-POEM patients carefully given the risk of developing significant pathology due to severe reflux. Table 1. - Incidence of gastroesophageal reflux (GER) by different measures in POEM as compared to LHM Characteristic POEM LHM p-value TAE time >4% 62.4% 20.5% < 0.001 TAE time >10% 35.3% 10.3% < 0.001 Grade A/B esophagitis 17.6% 9.3% NS Grade C/D esophagitis 2.4% 6.6% 0.03 Esophageal Ulcer 1.2% 0.7% NS Gastroduodenal pathology* 2.4% 10.6% 0.022 Abnormal GER** 72% 28% < 0.001 Severely abnormal GER*** 38.8% 15.2% < 0.001 p-value significant if p4% or esophagitis. Severely abnormal GER was defined as TAE >10% or Grade C/D esophagitis or esophageal ulcer.

320. EFFICACY OF LAPAROSCOPIC FUNDOPLICATION IN PATIENTS WITH CHRONIC COUGH AND GASTRO-OESOPHAGEAL REFLUX

Abstract The outcome of anti-reflux surgery in patients with cough suspected to be induced by gastro-oesophageal reflux disease is frequently uncertain. The aims of this study were to assess the efficacy of laparoscopic fundoplication (LF) for controlling cough in a patient population suffering chronic cough when alternative aetiologies (e.g. asthma) had been excluded and pathologic gastro-oesophageal reflux had been confirmed on ambulatory pH monitoring, and to identify predictors of response. From a prospective database of 1,598 patients who had undergone laparoscopic fundoplication, 66 (4%) had a principal presenting symptom of chronic cough as well as objective evidence of gastro-oesophageal reflux disease (GORD). Patients completed questionnaires for GORD symptoms (modified DeMeester score) and severity of cough (visual analog scale) both before and after LF, and had pre-operative gastroscopy and 24-hour pH monitoring before operation. Patients were considered to have responded to LF if they had no cough or the cough had improved by 50% or more after operation. Follow-up data was available for 66/66 patients (100%), with a median follow-up time of 43 months (range 14–104 months) after operation. Cough was relieved in 40/66 (61%), while typical GORD symptoms (heartburn, regurgitation) was relieved in 44/49 (90%). The presence of typical GORD symptoms, oesophagitis, or pH study variables did not predict the response of the cough to LF. At 1 year, 67% of patients were satisfied with the results of their surgery, 20% were not and 13% were unsure. For comparison, the 1430/1598 patients in the database with no laryngopharyngeal symptoms had a satisfaction rate of 94%. Based on our study and available literature, it appears there are no reliable pre-operative clinical predictors of a satisfactory response of cough to LF. This probably reflects a current inability to obtain an accurate aetiological diagnosis of chronic cough, even in the presence of known abnormal gastro-oesophageal reflux disease. Regardless, in a well-chosen cohort of patients with chronic cough, LF can yield good patient satisfaction rates, albeit less than for patients with typical GORD symptoms.

Antacid Medication and Antireflux Surgery in Patients with Idiopathic Pulmonary Fibrosis: A Systematic Review and Meta-Analysis.

Rationale: Idiopathic pulmonary fibrosis (IPF) is a fibrosing interstitial pneumonia with impaired survival. Previous guidelines recommend antacid medication to improve respiratory outcomes in patients with IPF. Objectives: This systematic review was undertaken during the development of an American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and Asociación Latinoamericana del Tórax guideline. The clinical question was, "Should patients with IPF who have documented abnormal gastroesophageal reflux (GER) with or without symptoms of GER disease 1) be treated with antacid medication or 2) undergo antireflux surgery to improve respiratory outcomes?" Methods: Medline, Embase, the Cochrane Central Register of Controlled Trials, and the gray literature were searched through June 30, 2020. Studies that enrolled patients with IPF and 1) compared antacid medication to placebo or no medication or 2) compared antireflux surgery to no surgery were selected. Meta-analyses were performed when possible. Outcomes included disease progression, mortality, exacerbations, hospitalizations, lung function, respiratory symptoms, GER severity, and adverse effects/complications. Results: For antacid medication, when two studies were aggregated, there was no statistically significant effect on disease progression, defined as a 10% or more decline in FVC, more than 50-m decline in 6-minute walking distance, or death (risk ratio [RR], 0.88; 95% confidence interval [CI], 0.76-1.03). A separate study that could not be included in the meta-analysis found no statistically significant effect on disease progression when defined as a 5% or more decline in FVC or death (RR, 1.10; 95% CI, 1.00-1.21) and an increase in disease progression when defined as a 10% or more decline in FVC or death (RR, 1.28; 95% CI, 1.08-1.51). For antireflux surgery, there was also no statistically significant effect on disease progression (RR, 0.29; 95% CI, 0.06-1.26). Neither antacid medications nor antireflux surgery was associated with improvements in the other outcomes. Conclusions: There is insufficient evidence to conclude that antacid medication or antireflux surgery improves respiratory outcomes in patients with IPF, most of whom had not had abnormal GER confirmed. Well-designed and adequately powered prospective studies with objective evaluation for GER are critical to elucidate the role of antacid medication and antireflux surgery for respiratory outcomes in patients with IPF.

EPISODES OF HEARTBURN AND BLOATING IN MEDICAL PRACTICE

The aim of the study was to study the frequency and nature of episodes of heartburn and bloating in patients with duodenal and gastric ulcers in the Georgian population, considering the histomorphological and morphometric changes of the gastric mucosa and the parameters of gastric secretion. At the same time, we were interested in analyzing patients' anamnesis before being hospitalized for the last 2 months. The analysis of the material showed that incidence of heartburn episodes in the Georgian population is clearly higher in patients with peptic ulcer disease 12 - (79.9%) than in patients with gastric ulcer (9 - 31.9%). Episodes of heartburn in these patients are characterized not only by increasing of rate (more than 50 episodes), both day and night, but the intensity and duration (which is due to abnormal gastroesophageal reflux). This is a high risk for the occurrence of heartburn episodes. As for bloating, it was detected in patients with duodenal ulcer (11–26.2%), in gastric ulcer 11– (32.9%). The main pathogenetic aspects of heartburn episodes were found to be diffuse fundal glands hyperplasia and high acidity (duodenal ulcer and pyloric anterior ulcer). It was also found that a large percentage of patients were not treated properly, leading to impaired ability to work and changes in quality of life and disease progression.

Comorbid insomnia and sleep apnea: characterization of the syndrome and understanding its associations with comorbid sleep conditions

Obstructive sleep apnea (OSA) is traditionally associated with excessive daytime sleepiness. Insomnia is characterized by hyperarousal, and is seen as a predominant feature in a subgroup of patients with OSA. The aim of this study was to describe the prevalence of comorbid insomnia and sleep apnea (COMISA) in a sleep apnea population and to characterize its features. This was a chart review of patients who underwent overnight polysomnography (PSG). All patients completed questionnaires with the Epworth Sleepiness Scale (ESS), and symptoms of insomnia and other sleep-related comorbidities. Patients with OSA on the PSG were included. A total of 296 patients withOSA were included, of which 80% reported at least 1 major symptom of insomnia: 57% reported sleep onset insomnia, 68% sleep maintenance insomnia, and 48% had early morning awakenings. COMISA (OSA plus 2 or more major symptoms of insomnia) was seen in 63%. These patients were more likely to report an abnormal ESS score, gastroesophageal reflux (GER), and restless legs (RL) than those without; no difference was seen in self-reported sleep bruxism. Among the patients with COMISA, 85% reported at least 1 representative symptom of psychophysiological insomnia (PPI); each of the 5 PPI symptoms was present in at least 40% of patients with COMISA. Insomnia is extremely prevalent in our population of patients with OSA, accompanied by daytime sleepiness and symptoms of PPI, GER, and RL. Further study is needed to determine the interactions between symptoms and OSA treatments in these patients.

Optimization of impedance-measured reflux events in GORD utilizing acid exposure time

BackgroundCombining impedance with pH monitoring improves the detection and characterization of gastro-oesophageal reflux (GOR), yet the two modalities frequently differ in GOR quantification. Ambulatory 24-h pH-impedance monitoring often reveals more significant oesophageal acid exposure than impedance-measured reflux activity in patients with symptomatic gastro-oesophageal reflux disease (GORD). The purpose of this study is to elucidate the discrepancies between these modalities by assessing the predictive accuracy of impedance compared to acid exposure standards.MethodsA single-institution, retrospective review of sequential 24-h pH-impedance results of 72 patients with symptomatic GOR off anti-secretory therapy was conducted. Reflux events measured by impedance were stratified by patient position and compared to oesophageal acid exposure time (AET). Oesophageal AET limits for GORD detection were utilized as gold standards to generate serial receiver operator characteristics (ROC) curves to assess the sensitivity and specificity of current impedance GORD detection limits and identify optimized impedance standards based on area under the curve (AUC) analysis.ResultsMean total AET time was 10.5% (± 9.9%), and 63.8% of patients had elevated AET. By impedance, median GOR frequency was 43 (IQR 21–68), and 22.2% exceeded conventional GOR frequency limits of normal. ROC curve analysis revealed the current impedance standard of > 73 GOR events has a sensitivity of 32.6% and specificity of 96.5% (AUC 0.74) for GORD detection. By AUC analysis, an impedance threshold of > 41 GOR events is optimal for GORD detection (sensitivity 69.6%, specificity 80.7%, AUC 0.83).ConclusionConventional impedance standards for abnormal GOR frequency are weakly sensitive for the detection of GORD, providing a possible explanation to discrepancies in AET and impedance interpretation. Lowering impedance-measured GOR frequency limits to > 41 optimizes sensitivity and specificity while increasing congruence between pH and impedance metrics.

A125 ABNORMAL REFLUX IS UNCOMMON IN PATIENTS PRESENTING WITH ISOLATED OROPHARYNGEAL SYMPTOMS

Abstract Background Gastroesophageal reflux disease (GERD) is often implicated as a potential etiology for various oropharyngeal (OP) symptoms. Although ambulatory reflux monitoring has been recommended by professional societies for the assessment of OP symptoms, it is unclear if objective measures of acid exposure in the esophagus correlate with the presence of these OP symptoms. Aims The aim of this study is to determine the prevalence of abnormal 24-hour pH monitoring in patients presenting with various OP symptoms in our motility unit. Methods A retrospective chart review was performed on all patients referred for 24-hour pH monitoring for the evaluation of OP symptoms to the open-access Clinical Motility Unit at the University Health Network between January 1, 2008 and June 1, 2019. Seven symptom categories were examined including cough, globus, throat discomfort, voice change, dental erosion, altered taste, and sensation of phlegm in the throat. The results of the 24-hour pH monitoring were collected. A test was considered abnormal if while off anti-secretory therapy the overall acid exposure (pH &amp;lt; 4) in the distal esophagus was greater than 4.2% of the total time or if while on anti-secretory therapy the overall acid exposure in the esophagus was greater than 1.2% of the time. Descriptive statistics were performed to analyze the data. Results 384 patients were included in the final analysis. 167 patients (43.5%) presented with cough, 63 (16.4%) with globus, 86 (22.4%) with throat discomfort, 19 (5.9%) with voice changes, 13 (3.4%) with dental erosion, 17 (4.4%) with altered taste and 19 (4.9%) with sensation of phlegm in the throat. Overall, 19.5% of patients presenting with oropharyngeal symptoms had abnormal 24-hour pH monitoring. Abnormal 24-hr pH monitoring was present in 24.6% of those with cough, 15.9% of those with globus, 16.3% of those with throat discomfort, 21.1% of those with voice changes, 23.1% of those with dental erosion, 5.9% of those with altered taste and 10.5% of those with sensation of phlegm in the throat. Conclusions This study demonstrates that only a small proportion of patients with OP symptoms have abnormal gastroesophageal acid reflux based on objective 24-hour pH monitoring. Given these findings, future studies to examine the factors that predict having abnormal 24-hour pH monitoring in patients presenting with OP symptoms will help guide resource management of motility testing to determine which patients would benefit most from this type of evaluation. Funding Agencies None

Esophagogastric Junction Morphology on Hill's Classification Predicts Gastroesophageal Reflux with Good Accuracy and Consistency.

Hill's classification provides a reproducible endoscopic grading system for esophagogastric junction morphology and competence, specifically whether the gastroesophageal flap valve (GEFV) is normal (grade I/II) or abnormal (grades III/IV). However, it is not routinely used in clinical practice. We report a systematic review and meta-analysis to determine association between abnormal GEFV and gastroesophageal reflux disorder (GERD). A comprehensive literature search of MEDLINE and Scopus databases was conducted to identify studies that reported the association between abnormal GEFV and GERD. The search and quality assessment were performed independently by two authors. Fixed- and random-effects meta-analyses were conducted using symptomatic GERD and erosive esophagitis as outcomes. A total of 11 studies met inclusion criteria that included a total of 5054 patients. In the general population, patients with abnormal GEFV had greater risk of symptomatic GERD compared to patients with a normal GEFV (risk ratio [RR] 1.88, 95% CI 1.57-2.24). Further, in patients with symptomatic GERD, patients with abnormal GEFV had greater risk of erosive esophagitis compared to patients with normal GEFV (RR 2.17, 95% CI 1.40-3.36). Finally, the specificity of abnormal GEFV for symptomatic GERD was 73.3% (95% CI 69.3-77.0%) and 75.7% (95% CI 65.9-83.4%) for erosive esophagitis in symptomatic GERD. Our systematic review and meta-analysis showed consistent association between abnormal GEFV indicated by Hill's classification III/IV and symptomatic GERD and erosive esophagitis. Our recommendation is to include Hill's classification in routine endoscopy reports and workup for GERD.

Gastroesophageal reflux after laparoscopic hiatal hernia repair in patients with axial hiatal hernia

To find out significance of the main locking mechanisms of lower esophageal sphincter in the relapse of GERD in patients with axial hiatal hernia after previous antireflux laparoscopic surgery. There were 103 patients with GERD and axial hiatal hernia who underwent original circular laparoscopic esophagofundoplication with correction of hiatal opening dimensions by crural and hiatal repair. Depending on generalized DeMeester index (within the normal range or its excess), all patients were divided into two groups - without relapse (group 1, n=88) and with recurrent GERD (group 2, n=15). Both groups were comparable by the main characteristics and postoperative follow-up period (mean - 6 years). Antireflux function was investigated by X-ray examination and endoscopy, manometry of the esophageal-gastric passage, intra-esophageal 24-hour pH-monitoring. Processing and graphical presentation of data was carried out using Statistica v.10.0 Rus software (StatSoft, USA) and Microsoft Office Excel 2013 (USA). Abnormal gastroesophageal reflux was detected in 14.56±3.48% of patients after laparoscopic anti-reflux surgery. Recurrent hiatal hernia occurred in 20±10.33% of these patients, malfunction of lower esophageal sphincter - in 80±10.33%. Failure of cardia was caused by shortening of its length by 30.43% and decrease of tone by 6.78% with significantly (61.09%) increased tone of the stomach. Failure of cardia was manifested by increase of generalized DeMeester index in the lower third of the esophagus by 3.2 times, acidic gastroesophageal refluxes, reflux index and index reflux values. Preserved esophageal motility combined with shortening of time of esophageal clearance in patient's lying position was associated with reduced incidence of reflux-esophagitis by 77.26% even in case of recurrent GERD. Abnormal reflux after antireflux laparoscopic surgery due to GERD with axial hiatal hernia is caused by recurrent hiatal hernia in every fifth patient while the main reason is failure of LES cuff with increased intragastric pressure.

Endoscopic Variceal Sequential Ligation Does Not Increase Risk of Gastroesophageal Reflux Disease in Cirrhosis Patients

BackgroundEndoscopic variceal sequential ligation (EVSL) is currently endorsed in our hospital, as the preferred endoscopic treatment for prevention of variceal rebleeding and achieving adequate hemostasis. There is currently a lack of consensus surrounding EVSL-induced changes in esophageal motor function and abnormal reflux.AimsTo explore alterations in esophageal motor function and risk of abnormal gastroesophageal reflux in liver cirrhosis patients with esophageal varices, after EVSL.MethodsTwenty-one liver cirrhosis patients with esophageal varices were studied using manometry and 24-h pH monitoring 1 day prior to and 1 month following EVSL. The EVSL consisted of performing esophageal variceal ligation using a multi-band ligator, which was repeated every 4 weeks until the varices were eradicated.ResultsThe amplitude and duration of peristaltic contraction waves and the percentage of abnormal esophageal contraction waveforms were unaltered in both the proximal (P > 0.05) and the distal (P > 0.05) esophagus after EVSL. However, the lower esophageal sphincter pressure was decreased following EVSL (16.1 ± 7.9 mmHg vs 21.1 ± 6.3 mmHg (P < 0.05)). Various quantitative parameters including percentage of total monitoring time with pH < 4.0, total number of reflux episodes, number of reflux episodes > 5 min, and DeMeester scores were not increased in post-EVSL patients. Abnormal reflux monitored by 24-h pH monitoring occurred in ten (47.6%) pre-EVSL patients and 11 (52.4%) post-EVSL patients.ConclusionsAlthough EVSL affects esophageal motility by relatively decreasing LES pressure, it does not induce substantial motor abnormalities nor increase risk of abnormal gastroesophageal reflux disease in cirrhosis patients.

PREVALENCE OF ACIDIC AND NON-ACIDIC REFLUXES IN PATIENTS WITH FUNCTIONAL DYSPEPSIA AND ITS RISK FACTORS INVESTIGATED BY MEANS OF MULTICHANNEL INTRALUMINAL PH-MONITORING

Introduction: Previous studies performed by conventional pH-monitors showed that a significant proportion of patients with functional dyspepsia have abnormal acidic gastroesophageal reflux. The investigation, using advantages of multichannel intraluminal pH-monitoring, were not conducted. The aim to reveal the prevalence of all types of refluxes in patients with functional dyspepsia and to estimate risk provoking factors for abnormal reflux. Methods and materials: Patients were divided into 6 groups. The 1st, 2nd and 3rd groups covered 127 adult patients with epigastric pain syndrome, postprandial distress syndrome and mixed variant respectively. The 4th included 69 NERD patients suffered from frequent (more than one episode per week) heartburn. The 5th group also consisted of 22 NERD patients without heartburn or with rare heartburn-regurgitation. The reference group included 30 subjects without dyspeptic complaint and established diagnoses of gastro-esophageal diseases. For all persons the 200-min MII-pH-monitoring was performed with standardized stimulating breakfast (507kcal, 100 mg caffeine, 300ml) recording basal and postprandial phases. Results: It was found that the difference in comparison to the reference group in the number of refluxes is determined by the number of acid refluxes and not by weakly-acidic and weakly-alkaline refluxes. Patients with functional dyspepsia from all subgroups had an excessive amount of acidic refluxes in comparison with the reference group - 3.7±0.7, 4.7±0.8 and 2.8±0.7 vs 1.8±0.3 episodes (p<0.05). Using the previously obtained threshold values for abnormal acidic reflux (> 6 episodes per 200 min.) and total refluxes (>17 episodes per 200 min.) it was revealed that 22.8% patients with FD had abnormal GER. In addition, 16.5% had an isolated excess of non-acidic reflux. All three dyspeptic groups didn't have a significant difference in the distribution of patients among subtypes of abnormal presence or absence of acidic/non-acidic refluxes. Conclusion: In functional dyspepsia abnormal acidic reflux are common and affect 22.8% of patients. It is independently associated with hiatal hernia (OR=4.17), previously healed a peptic ulcer (OR=3.90), occasional heartburn (OR=1.25), body mass index (OR=1.11), younger age (OR=0.97).

Laparoscopic anti-reflux surgery for the treatment of idiopathic pulmonary fibrosis (WRAP-IPF): a multicentre, randomised, controlled phase 2 trial

Abnormal acid gastro-oesophageal reflux (GER) is hypothesised to play a role in progression of idiopathic pulmonary fibrosis (IPF). We aimed to determine whether treatment of abnormal acid GER with laparoscopic anti-reflux surgery reduces the rate of disease progression. The WRAP-IPF trial was a randomised controlled trial of laparoscopic anti-reflux surgery in patients with IPF and abnormal acid GER recruited from six academic centres in the USA. We enrolled patients with IPF, abnormal acid GER (DeMeester score of ≥14·7; measured by 24-h pH monitoring) and preserved forced vital capacity (FVC). We excluded patients with a FVC below 50% predicted, a FEV1/FVC ratio of less than 0·65, a history of acute respiratory illness in the past 12 weeks, a body-mass index greater than 35, and known severe pulmonary hypertension. Concomitant therapy with nintedanib and pirfenidone was allowed. The primary endpoint was change in FVC from randomisation to week 48, in the intention-to-treat population with mixed-effects models for repeated measures. This trial is registered with ClinicalTrials.gov, number NCT01982968. Between June 1, 2014, and Sept 30, 2016, we screened 72 patients and randomly assigned 58 patients to receive surgery (n=29) or no surgery (n=29). 27 patients in the surgery group and 20 patients in the no surgery group had an FVC measurement at 48 weeks (p=0·041). Intention-to-treat analysis adjusted for baseline anti-fibrotic use demonstrated the adjusted rate of change in FVC over 48 weeks was -0·05 L (95% CI -0·15 to 0·05) in the surgery group and -0·13 L (-0·23 to -0·02) in the non-surgery group (p=0·28). Acute exacerbation, respiratory-related hospitalisation, and death was less common in the surgery group without statistical significance. Dysphagia (eight [29%] of 28) and abdominal distention (four [14%] of 28) were the most common adverse events after surgery. There was one death in the surgery group and four deaths in the non-surgery group. Laparoscopic anti-reflux surgery in patients with IPF and abnormal acid GER is safe and well tolerated. A larger, well powered, randomised controlled study of anti-reflux surgery is needed in this population. US National Institutes of Health National Heart, Lung and Blood Institute.

SWALLOWING IN PATIENTS WITH LARYNGITIS.

Dysphagia is described as a complaint in 32% of patients with laryngitis. The objective of this investigation was to evaluate oral and pharyngeal transit of patients with laryngitis, with the hypothesis that alteration in oral-pharyngeal bolus transit may be involved with dysphagia. Videofluoroscopic evaluation of the swallowing of liquid, paste and solid boluses was performed in 21 patients with laryngitis, 10 of them with dysphagia, and 21 normal volunteers of the same age and sex. Two swallows of 5 mL liquid bolus, two swallows of 5 mL paste bolus and two swallows of a solid bolus were evaluated in a random sequence. The liquid bolus was 100% liquid barium sulfate and the paste bolus was prepared with 50 mL of liquid barium and 4 g of food thickener (starch and maltodextrin). The solid bolus was a soft 2.2 g cookie coated with liquid barium. Durations of oral preparation, oral transit, pharyngeal transit, pharyngeal clearance, upper esophageal sphincter opening, hyoid movement and oral-pharyngeal transit were measured. All patients performed 24-hour distal esophageal pH evaluation previous to videofluoroscopy. The evaluation of 24-hour distal esophageal pH showed abnormal gastroesophageal acid reflux in 10 patients. Patients showed longer oral preparation for paste bolus and a faster oral transit time for solid bolus than normal volunteers. Patients with laryngitis and dysphagia had longer preparation for paste and solid boluses, and a faster oral transit time with liquid, paste and solid boluses. A longer oral preparation for paste and solid boluses and a faster transit through the mouth are associated with dysphagia in patients with laryngitis.

Extraesophageal Symptoms and Diseases Attributed to GERD: Where is the Pendulum Swinging Now?

The purpose of this review is to outline the recent developments in the field of extraesophageal reflux disease and provide clinically relevant recommendations. The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations: Best Practice Advice 1: The role of a gastroenterologist in patients referred for evaluation of suspected extra esophageal symptom is to assess for gastroesophageal etiologies that could contribute to the presenting symptoms. Best Practice Advice 2: Non-GI evaluations by ENT, pulmonary and/or allergy are essential and often should be performed initially in mostpatients as the cause of the extraesophageal symptom is commonly multifactorial or not esophageal inorigin. Best Practice Advice 3: Empiric therapy with aggressive acid suppression for 6-8 weeks with special focus on response of the extraesophageal symptoms can help in assessing association between reflux and extraesophageal symptoms. Best Practice Advice 4: No single testing methodology exists to definitively identify reflux as the etiology for the suspected extra esophageal symptoms. Best Practice Advice 5: Constellation of patient presentation, diagnostic test results and response to therapy should be employed in the determination of reflux as a possible etiology in extra esophageal symptoms. Best Practice Advice 6: Testing may need to be off or on proton pump inhibitor (PPI) therapy depending on patients' presenting demographics and symptoms in assessing the likelihood of abnormal gastroesophageal reflux. A. On therapy testing may be considered in those with high probability of baseline reflux (those with previous esophagitis, Barrett's esophagus or abnormal pH). B. Off therapy testing may be considered in those with low probability of baseline reflux with the goal of identifying moderate to severe reflux at baseline. Best Practice Advice 7: Lack of response to aggressive acid suppressive therapy combined with normal pH testing off therapy or impedance-pH testing on therapy significantly reduces the likelihood that reflux is a contributing etiology in presenting extraesophageal symptoms. Best Practice Advice 8: Surgical fundoplication is discouraged in those with extra esophageal reflux symptoms unresponsive to aggressive PPI therapy. Best Practice Advice 9: Fundoplication should only be considered in those with a mechanical defect (e.g., hiatal hernia), moderate to severe reflux at baseline off PPI therapy who have continued reflux despite PPI therapy and have failed more conservative non-GI treatments.

Esophagogastric junction and esophageal body contraction metrics on high-resolution manometry predict esophageal acid burden.

Distal contractile integral (DCI) and esophagogastric junction contractile integral (EGJ-CI) are high-resolution manometry (HRM) software metrics assessing esophageal motor function in gastroesophageal reflux disease (GERD). Patients undergoing HRM and ambulatory pH monitoring off antisecretory therapy prospectively completed symptom questionnaires assessing symptom burden and a global symptom score (GSS) at baseline and after GERD therapy. DCI<450mmHg/cm/s in ≥5 swallows diagnosed ineffective esophageal motility (IEM); proportions of failed (DCI<100mmHg/cm/s) and weak (DCI 100-450mmHg/cm/s) sequences were separately assessed. EGJ-CI assessed vigor of the EGJ barrier. Univariate and multivariate analyses addressed performance of esophageal body and EGJ metrics in predicting abnormal esophageal reflux burden, and symptom outcome from antireflux therapy. Of 188 patients (55.2±0.9year, 64% F), 42.6% had low EGJ-CI, and 25.0% had IEM. While low EGJ-CI was associated with abnormal reflux burden (P=0.003), IEM alone was not (P=0.2). Increasing proportions of failed swallows predicted abnormal AET better than the current IEM definition. Combined low EGJ-CI and IEM segregated abnormal total and supine acid burden compared to patients with normal EGJ-CI and no IEM (P≤0.007 for each comparison). Medical therapy and surgical antireflux therapy were similarly effective in improving symptom burden; surgery resulted in better outcomes with low EGJ-CI (P≤0.04), especially with intact esophageal body motor function (P=0.02). While abnormal EGJ and esophageal body metrics are collectively associated with elevated esophageal reflux burden, increasing proportions of failed swallows are better predictors of reflux burden and outcome compared to the current IEM definition.

Characteristics of gastroesophageal reflux in pediatric patients with neurological impairment.

To clarify the characteristics of gastroesophageal reflux (GER) in pediatric patients with neurological impairment (NI). Twenty-six patients with NI, 1-17-year-old, fed via a nasogastric tube were categorized based on the absence (group I) or presence (group II) of abnormal GER, defined with multichannel intraluminal impedance-pH monitoring as %time with an esophageal pH <4.0 being ≥5.0% or number of liquid/mixed bolus reflux events(RE) >70 in 24h. %Time and number of distal and proximal bolus REs were not significantly different between acid and nonacid REs. %Time of acid bolus RE and that of acid and total number of distal and proximal bolus REs were significantly higher in group II than in group I. Mean acid clearance time was significantly longer in group II. Median bolus clearance time was similar between the groups. No bolus RE parameters were significantly different between acid and nonacid REs in group I. Acid bolus RE was significantly higher than nonacid RE in terms of %time and number of proximal bolus RE in group II. Acid REs significantly increased in pediatric patients with NI with abnormal GER. The number of acid and nonacid REs was comparable in patients without abnormal GER.

Gastrointestinal Motility Disorders and Their Clinical Implications in Cirrhosis.

Gastrointestinal motility is impaired in a substantial proportion of patients with cirrhosis. Cirrhosis-related autonomic neuropathy, increased nitric oxide production, and gut hormonal changes have been implicated. Oesophageal dysmotility has been associated with increased frequency of abnormal gastro-oesophageal reflux. Impaired gastric emptying and accommodation may result in early satiety and may have an impact on the nutritional status of these patients. Small intestinal dysmotility might be implicated in small intestinal bacterial overgrowth and increased bacterial translocation. The latter has been implicated in the pathophysiology of hepatic encephalopathy and spontaneous bacterial peritonitis. Enhanced colonic motility is usually associated with the use of lactulose. Pharmacological interventions aiming to alter gastrointestinal motility in cirrhosis could potentially have a beneficial effect reducing the risk of hepatic decompensation and improving prognosis.

Laparoscopically Assisted Proximal Gastrectomy with Esophagogastrostomy Using a Novel “Open-Door” Technique

Laparoscopy-assisted proximal gastrectomy (LAPG) with esophagogastrostomy using a novel “open-door” technique was introduced recently, with the aim of preventing gastroesophageal reflux. However, quantitate assessment of gastroesophageal reflux after this surgery has not been performed till date. The aims of the current study were to investigate the safety and feasibility of this operation and to elucidate the postoperative reflux status. Twenty consecutive patients (18 men) with (y)cStage I gastric cancer in the upper third of the stomach who underwent LAPG at Kitasato University Hospital from May 2015 through September 2016 were retrospectively reviewed. We performed 24-h impedance-pH monitoring 3 months after surgery for the first eight patients and analyzed the postoperative reflux status. Median operation time was 333 min, while median anastomotic time was 81 min. None of the 20 patients experienced anastomotic leakage while two patients experienced anastomotic stricture requiring endoscopic balloon dilatation. No patient experienced heartburn without antacid drugs. During the 24-h impedance-pH monitoring, all but one patient had normal gastroesophageal acid reflux with the acid percent time of <1.1% and reflux percent time of <1.4%. One patient with marginally abnormal postoperative gastroesophageal reflux had a normal DeMeester score of 3.0. Our results showed that esophagogastrostomy using the “open-door” technique is a safe and feasible procedure for LAPG. The degree of gastroesophageal reflux was acceptable using this technique. Randomized controlled trials with long-term follow-ups are required to confirm that this technique would be superior to the others.

Laparoscopic anti-reflux surgery for idiopathic pulmonary fibrosis at a single centre.

We sought to assess whether laparoscopic anti-reflux surgery (LARS) is associated with decreased rates of disease progression in patients with idiopathic pulmonary fibrosis (IPF).The study was a retrospective single-centre study of IPF patients with worsening symptoms and pulmonary function despite antacid treatment for abnormal acid gastro-oesophageal reflux. The period of exposure to LARS was September 1998 to December 2012. The primary end-point was a longitudinal change in forced vital capacity (FVC) % predicted in the pre- versus post-surgery periods.27 patients with progressive IPF underwent LARS. At time of surgery, the mean age was 65 years and mean FVC was 71.7% pred. Using a regression model, the estimated benefit of surgery in FVC % pred over 1 year was 5.7% (95% CI -0.9-12.2%, p=0.088) with estimated benefit in FVC of 0.22 L (95% CI -0.06-0.49 L, p=0.12). Mean DeMeester scores decreased from 42 to 4 (p<0.01). There were no deaths in the 90 days following surgery and 81.5% of participants were alive 2 years after surgery.Patients with IPF tolerated the LARS well. There were no statistically significant differences in rates of FVC decline pre- and post-LARS over 1 year; a possible trend toward stabilisation in observed FVC warrants prospective studies. The ongoing prospective randomised controlled trial will hopefully provide further insights regarding the safety and potential efficacy of LARS in IPF.

Idiopathic Pulmonary Fibrosis: Novel Concepts of Proton Pump Inhibitors as Antifibrotic Drugs.

The prevalence of abnormal acid gastroesophageal reflux (GER) is higher in patients with idiopathic pulmonary fibrosis (IPF) than in matched control subjects. Several studies demonstrated that more than one-third of patients with IPF have abnormal esophageal acid exposures. In addition, many of these studies indicate that the majority of patients with IPF have silent reflux with no symptoms of GER. Findings of abnormal reflux persist in a large proportion of patients with IPF placed on antacid therapy such as proton pump inhibitors (PPIs). This seemingly paradoxical observation suggests that either patients with IPF are somehow resistant to PPI-based intervention or PPIs are inherently unable to suppress acid GER. By contrast, patients with IPF who undergo Nissen fundoplication surgery are effectively relieved from the complications of GER, and retrospective studies suggest improved lung function. Retrospective, anecdotal data suggest a beneficial role of PPIs in IPF including stabilization of lung function, reduction in episodes of acute exacerbation, and enhanced longevity. The recent evidence-based guidelines for treatment of IPF approved conditional recommendation of PPIs for all patients with IPF regardless of their GER status. Recently, we have reported that PPIs possess antiinflammatory and antifibrotic activities by directly suppressing proinflammatory cytokines, profibrotic proteins, and proliferation of lung fibroblasts. Our study provides an alternative explanation for the beneficial effect of PPIs in IPF. In this Perspective, we reviewed emerging progress on antifibrotic effect of PPIs using IPF as a disease model. In addition, we summarized surgical and pharmacological interventions for GER and their downstream effect on lung physiology.