Ambulatory 24-hour pH Monitoring Research Articles

Metabolic syndrome is associated with gastroesophageal reflux disease based on a 24-hour ambulatory pH monitoring

Several studies have focused on the relationship between metabolic syndrome and gastroesophageal reflux disease (GERD). They were based on GERD complications, whereas little is known about the association between metabolic syndrome and objectively measured esophageal acid exposure. The aim of our study was to assess the relationship between metabolic syndrome and GERD based on a 24-hour pH testing. It was a cross-sectional study including 100 consecutive patients who underwent a 24-hour pH-metry monitoring and were assessed for the five metabolic syndrome components as well as for body mass index (BMI). Among the 100 patients, 54 had a pathological acid GERD. The 46 GERD-free patients represented control group. Sex distribution was comparable between both groups but GERD patients were older than controls (44.59 vs. 37.63 years, P= 0.006) and more often obese or with overweight (83.3 vs. 60.9%, P= 0.01). Frequency of metabolic syndrome as a whole entity was higher among patients with GERD than those without GERD (50 vs. 19.56%; P= 0.002) with a crude odds ratio of 4.11 (95% confidence interval: 1.66-10.14). Multivariate regression analysis showed that metabolic syndrome as well as an age ≥ 30 years were independent factors associated to GERD but not BMI and sex. Abnormal waist circumference and fasting glucose level ≥ 100 mg/L were the only independent factors among the five components of metabolic syndrome. Metabolic syndrome but not BMI was an independent factor associated to GERD. These results confirm the hypothesis that central obesity is associated to GERD.

The significance of laryngopharyngeal reflux in benign vocal mucosal lesions

Objective To determine the significance of laryngopharyngeal reflux (LPR) in benign vocal mucosal lesions. Study Design and Setting A case-control study at the tertiary referral medical center. Subjects and Methods From April 2003 to December 2006, we studied 110 patients with benign vocal mucosal lesions who had undergone 24-hour ambulatory double pH monitoring. The control group included 200 patients who had undergone ambulatory 24-hour double-probe pH monitoring due to laryngopharyngeal reflux–related symptoms without specific findings of benign vocal mucosal lesions. Reflux symptom index and reflux finding score were measured. We compared the prevalence of pathologic laryngopharyngeal reflux and various parameters of the pH monitoring such as total reflux number, fraction time of pH below 4 in various positions, and DeMeester scores. Results The prevalence of pathologic laryngopharyngeal reflux was 65 percent in the control group, 66 percent in vocal nodule group, 75 percent in the vocal polyp group, and 90 percent in the Reinke's edema group. Patients with Reinke's edema had a significantly higher prevalence of pathologic laryngopharyngeal reflux than controls ( P = 0.016). LPR was associated with a significantly increased risk of Reinke's edema (odds ratio: 4.846, 95% confidence interval 1.093∼21.492). Total reflux number and DeMeester scores in the Reinke's edema group and fraction time of pH below 4 in the supine position in the vocal polyp group were significantly higher than those in the control group. Conclusion Laryngopharyngeal reflux might play a role as an etiologic factor in Reinke's edema and vocal polyps.

W1847 Characteristics of the Reflux Patterns in NERD Patients with Atypical Symptoms: A Study Using 24-Hour Ambulatory Impedance & pH Monitoring

W1847 Characteristics of the Reflux Patterns in NERD Patients with Atypical Symptoms: A Study Using 24-Hour Ambulatory Impedance & pH Monitoring

Dilated intercellular spaces in gastroesophageal reflux disease patients and the changes of intercellular spaces after omeprazole treatment

Gastroesophageal reflux disease (GERD) is a common disorder. Dilation of intercellular spaces of esophageal epithelium has been revealed at transmission electron microscopy both in the rabbit acid-perfused esophagus and in esophageal biopsies from GERD patients. This study aimed to observe the changes of the intercellular spaces of squamous epithelium of lower esophagus in patients with GERD and the changes of intercellular spaces of patients with erosive esophagitis (EE) before and after omeprazole treatment. Outpatients having GERD symptoms for more than 3 months and volunteers were collected. All of them underwent gastroendoscopy and 24-hour ambulatory pH monitoring. Biopsies were taken from the lower esophagus (2 cm above Z-line) for electron microscope examination. Five healthy volunteers, six non-erosive reflux disease (NERD) patients, and five EE patients were enrolled. Intercellular spaces of GERD patients and controls were calculated. Then we selected 20 patients with EE diagnosed by gastroendoscopy. All of them were treated with omeprazole (Losec, 20 mg bid) for 4 weeks then underwent gastroendoscopy again. Biopsies were taken from 2 cm above Z-line for electron microscope examination. All the patients completed the questionnaire about reflux symptoms before and after treatment. Intercellular spaces of esophageal epithelial cell in volunteers, NERD patients and EE patients were (0.37 +/- 0.07) microm, (1.31 +/- 0.08) microm, and (1.33 +/- 0.14) microm, respectively, with significant differences between the control group and the NERD group (P = 0.000). In the 20 EE patients, the mean intercellular space before treatment was (1.14 +/- 0.15) microm. After treatment the intercellular space was (0.51 +/- 0.18) microm, a significant difference compared with pre-treatment measurements (P = 0.000). Dilated intercellular spaces (DIS) were seen in both NERD and EE cases. The dilated intercellular spaces of esophageal epithelium in EE patients could be recovered after a short time of treatment with omeprazole.

Change of Acoustic Parameters Before and After Treatment in Laryngopharyngeal Reflux Patients

To evaluate the usefulness of acoustic parameters as an indicator of laryngopharyngeal reflux (LPR) treatment efficacy. A prospective case series analysis. From January to September 2005, we prospectively analyzed 40 patients who were diagnosed with laryngopharyngeal reflux by 24-hour ambulatory double-probe pH monitoring. Laryngopharyngeal reflux patients were treated medically and voice analysis was conducted three times: before treatment, 1 to 2 months after treatment, and 3 to 4 months after treatment. Jitter, shimmer, and harmonic-to-noise ratio (HNR) were analyzed as the acoustic parameters. Pre- and posttreatment reflux symptom index and reflux finding score were documented. Jitter, shimmer, and HNR had improved significantly at 1 to 2 months after treatment and were maintained at 3 to 4 months after treatment. Jitter was significantly correlated with reflux symptom index. Acoustic parameters can be used as indicators of treatment efficacy for laryngopharyngeal reflux disease.

Endoscopic Grading of Gastroesophageal Flap Valve and Atrophic Gastritis Is Helpful to Predict Gastroesophageal Reflux

Background and aim: The endoscopic grading of the gastroesophageal flap valve (GEFV) has been suggested to be a good predictor of the reflux status. Atrophic gastritis is inversely associated with reflux esophagitis. The aim of this study was to investigate the association between GEFV, atrophic gastritis, and gastroesophageal reflux. Methods: A total of 608 patients (252 men and 356 women; mean age 51.1 years) who underwent endoscopy, esophageal manometry, and ambulatory 24-hour pH monitoring were included.

Barrett's Esophagus and Severe Reflux Esophagitis Share Common Pathophysiological Characteristics among Chinese in Taiwan

The pathophysiological data on Barrett's esophagus are scant in Asia, so the purpose of this study was to compare and analyze the pathophysiological characteristics of Barrett's esophagus and reflux esophagitis among Chinese in Taiwan. From November 2001 to January 2003, fifteen patients with Barrett's esophagus were consecutively enrolled as the Barrett's esophagus group. Fourteen patients with Los Angeles grade A/B esophagitis (mild esophagitis group) and fourteen patients with LA grade C/D esophagitis (severe esophagitis group) who were matched in age and gender with the Barrett's esophagus group were enrolled. The data of esophageal manometry and ambulatory 24-hour pH monitoring were collected. We found that the Barrett's esophagus group had significantly weaker lower esophageal sphincter (LES) pressure and distal esophageal body contractions (p<0.05) than the mild esophagitis group. Both the Barrett's esophagus group and severe esophagitis group had significantly higher esophageal acid reflux scores and frequency (p<0.05-0.01) compared to the mild esophagitis group. However, data on esophageal manometry and 24-hour pH monitoring in the Barrett's esophagus and severe esophagitis groups did not significantly differ. We concluded that Barrett's esophagus had significantly stronger acid reflux, lower LES pressure, and weaker distal esophageal peristalsis compared to mild esophagitis. Barrett's esophagus and severe reflux esophagitis share common pathophysiological characteristics among Chinese in Taiwan.

Distinct Clinical Characteristics Between Patients With Nonerosive Reflux Disease and Those With Reflux Esophagitis

It has been postulated that nonerosive reflux disease (NERD) and erosive reflux disease (ERD) are 2 distinct entities of gastroesophageal reflux disease. The aim of this study was to compare the clinical characteristics between patients with NERD and those with ERD. We prospectively recruited consecutive patients presenting with weekly attacks of heartburn or acid regurgitation. Exclusion criteria included gastric surgery, recent use of nonsteroidal anti-inflammatory drug or proton pump inhibitor, and peptic ulcer disease. Concomitant functional dyspepsia, irritable bowel syndrome, and psychological disorders were documented. Endoscopy, esophageal manometry, acid perfusion test, and 24-hour ambulatory pH monitoring were performed. Risk factors of NERD were determined by multivariate analysis. Two hundred fourteen patients (NERD, 113; ERD, 111) were studied. NERD patients were characterized by higher prevalence of Helicobacter pylori (36.3% vs 18%, P = .005), functional dyspepsia (64.6% vs 42.3%, P = .003), irritable bowel syndrome (44.2% vs 15.3%, P < .001), psychological disorders (9% vs 0.9%, P = .04), and positive acid perfusion test (40.7% vs 19.8%, P = .004). ERD patients had more hiatal hernias (35.1% vs 17.1%, P = .009), higher esophageal acid exposure (total time esophageal pH <4, 4.2% +/- 2.1% vs 5.9% +/- 2.3%; P = .01), and esophageal dysmotility (P < .05). With multivariate analysis, H pylori (odds ratio, 1.8; 95% confidence interval [CI], 1.1-3.2), irritable bowel syndrome (odds ratio, 2.8; 95% CI, 1.6-5.3), and positive acid perfusion test (odds ratio, 1.9; 95% CI, 1.4-2.8) were independent risk factors for NERD. Patients with NERD and ERD have distinct differences in clinical characteristics. NERD is characterized by higher prevalence of functional gastrointestinal disorders and esophageal acid hypersensitivity.

Gastroesophageal Flap Valve Is Associated with Gastroesophageal and Gastropharyngeal Reflux

Background: The endoscopic grading of the gastroesophageal flap valve (GEFV) is suggested to be a good predictor of the reflux status. The aim of this study was to investigate the association of the GEFV and gastroesophageal and gastropharyngeal reflux. Methods: A total of 364 patients (151 men and 233 women; mean age 52.2 years) who underwent endoscopy, esophageal manometry, and ambulatory 24-hour dual probe pH monitoring were included. GEFV was graded I through IV using Hill's classification: the GEFV was largely classified into 2 groups: the normal GEFV group (grade I and II) and the abnormal GEFV group (grade III and IV). Findings of endoscopy, esophageal manometry, and ambulatory pH monitoring were compared among the groups. Results: Increased GEFV grade was significantly associated with an increased prevalence of both reflux esophagitis and Barrett's epithelium (p < 0.001). LES pressure was significantly lower in the abnormal GEFV group compared to the normal GEFV group (p < 0.001). All variables showing gastroesophageal reflux in the distal probe were significantly higher in the abnormal GEFV group compared to the normal GEFV group (p < 0.001). In addition, all variables, except the supine time of pH below 4, showing the gastropharyngeal reflux in the proximal probe were significantly higher in the abnormal GEFV group compared to the normal GEFV group (p < 0.001). The frequency of gastroesophageal reflux disease and gastropharyngeal reflux disease was significantly higher in the abnormal GEFV group compared to the normal GEFV group (p < 0.001). Conclusions: Endoscopic grading of the GEFV is easy and provides useful information about the status of gastroesophageal and gastrophryngeal reflux.

Pepsin assay: A marker for reflux in pediatric glue ear

To evaluate if analysis of pepsin/pepsinogen in middle ear effusions can be considered a diagnostic marker for laryngopharyngeal reflux (LPR) in children with otitis media with effusion (OME). Ambulatory 24-hour dual-probe pH monitoring was carried out on 31 children with OME. Middle ear effusions were collected from 17 children during myringotomy. Total pepsin/pepsinogen concentrations in effusions were measured by ELISA using antipepsin antibody. Dual-probe pH monitoring showed that 22/31 (71%) of the studied children had significant LPR. The concentrations of pepsin/pepsinogen in middle ear effusions, ranged from 0.085 to 5.02 microg/ml, were found to be up to 4.5 to 231.44 times higher than the serum levels. There was a significant positive correlation between the level of pepsin/pepsinogen assayed in the effusions of the 17 children and the number of pharyngeal reflux episodes measured by pH monitoring. Control of LPR may be an essential component in the successful management of OME in pediatric patients. Pepsin/pepsinogen analysis in effusions of children, using ELISA, can be considered a reliable marker for assessment of reflux in children with OME.

Gastroesophageal reflux in patients with idiopathic pulmonary fibrosis referred for lung transplantation

The association between gastroesophageal reflux disease and idiopathic pulmonary fibrosis has not been fully characterized. The aims of this study were to determine in patients with idiopathic pulmonary fibrosis (1) the prevalence of reflux symptoms, (2) the esophageal manometric profile, and (3) the prevalence of proximal and distal esophageal reflux. Between May 1999 and March 2006, 30 patients with idiopathic pulmonary fibrosis were referred to the Swallowing Center at the University of California San Francisco. Each patient underwent a structured symptom assessment, esophageal manometry, and 24-hour dual sensor ambulatory pH monitoring. Twenty (67%) patients had abnormal esophageal reflux. Typical reflux symptoms, although more common in those with reflux, were not reliable as a screening test (sensitivity 65%, specificity 71%). Sixty-five percent of patients with abnormal reflux had a hypotensive lower esophageal sphincter. Abnormal esophageal peristalsis was more common among those with reflux (50% vs 10%; P = .03). In 9 (30%) patients, acid refluxed into the proximal esophagus for over 1% of the study time. A majority of patients with idiopathic pulmonary fibrosis have pathologic reflux. Symptoms do not distinguish between those with and without reflux. In these patients, reflux is associated with a hypotensive lower esophageal sphincter and abnormal esophageal peristalsis, and often extends into the proximal esophagus.

Gastroesophageal Reflux Disease and Obesity. Pathophysiology and Implications for Treatment

Although the etiology of gastroesophageal reflux disease (GERD) is multifactorial, the pathophysiology of the disease in morbidly obese patients remains incompletely understood. The aims of this study were to compare in morbidly obese (body mass index (BMI) ≥35) and nonmorbidly patients (BMI <35) with GERD: (a) lower esophageal sphincter (LES) profile; (b) esophageal body function; and (c) esophageal acid exposure. We reviewed esophageal manometry and ambulatory 24-hour pH monitoring studies of 599 consecutive patients with GERD (DeMeester score >14.7). Patients were divided into two groups according to the BMI: (1) 520 patients (86.8%) with BMI <35 and (2) 79 patients (13.2%) with BMI ≥35. While the DeMeester score was not different between the two groups, morbidly obese patients had higher LES pressure and higher amplitude of peristalsis in the distal esophagus (DEA). Among these patients, LES and DEA pressures were often hypertensive. A linear regression model showed that BMI, LES pressure, LES abdominal length, and DEA were independently associated with the DeMeester score. These data showed that: (a) BMI was independently associated to the severity of GERD; and (b) in most morbidly obese patients with GERD, reflux occurred despite normal or hypertensive esophageal motility. These findings show that the pathophysiology of GERD in morbidly obese patients might differ from that of nonobese patients, suggesting the need for a different therapeutic approach.

Endoscopic Grading of Atrophic Gastritis is Inversely Associated with Gastroesophageal Reflux and Gastropharyngeal Reflux

BackgroundReflux esophagitis is inversely associated with the presence of atrophic gastritis, and endoscopic grading of atrophic gastritis correlates with histological evaluation. The aim of this study was to investigate the association of the endoscopic grade of atrophic gastritis with gastroesophageal and gastropharyngeal reflux.MethodsA total of 627 patients, who underwent endoscopy and ambulatory 24-hour dual-probe pH monitoring, were included in this study. The grade of atrophic gastritis was endoscopically classified into 2 types with the atrophic pattern system: the closed-type (C-type) and the open-type (O-type). We compared the findings from endoscopy and ambulatory pH monitoring for these 2 types.ResultsThe O-type was significantly associated with a lower prevalence of reflux esophagitis (p=0.001). All variables showing gastroesophageal reflux in the distal probe were significantly lower in the O-type than in the C-type (p<0.05). Similarly for the proximal probe, all variables, except the supine time of pH<4, were significantly lower in the O-type than in the C-type (p<0.05). The frequency of gastroesophageal reflux disease and gastropharyngeal reflux disease was in significantly lower in the O-type than in the C-type (p<0.001, p=0.012, respectively).ConclusionsEndoscopic grading of atrophic gastritis is easy and is inversely associated with gastroesophageal and gastropharyngeal reflux.

Obesity Is Associated With Increased Transient Lower Esophageal Sphincter Relaxation

Obesity has been associated with gastroesophageal reflux disease (GERD) and its complication, but the mechanism is unclear. We evaluated the association between obesity and function of lower esophageal sphincter (LOS) in subjects without GERD. We prospectively recruited consecutive obese (BMI >30) patients referred for weight reduction procedure and age- and sex-matched overweight (BMI 25-30) and normal weight (BMI > or =20 and <25) subjects. Exclusion criteria included esophagitis, reflux symptoms, use of proton pump inhibitor, hiatus hernia >2 cm, and diabetes mellitus with microvascular complication. All participants underwent combined 2-hour postprandial esophageal manometry and pH monitoring after a standard test meal followed by 24-hour ambulatory pH monitoring. Eighty-four subjects (obese, 28; overweight, 28; normal weight, 28) were studied. All 3 groups had comparable mean LOS pressure, LOS length, and peristaltic function. During the postprandial period, both obese and overweight groups had substantial increase in 2-hour rate of transient lower esophageal sphincter relaxation (TLOSR) (normal weight: 2.1 +/- 1.2 vs overweight: 3.8 +/- 1.6 vs obese: 7.3 +/- 2.0, P < .001), proportion of TLOSR with acid reflux (normal weight: 17.6% +/- 22.0% vs overweight 51.8% +/- 22.5% vs obese: 63.5% +/- 21.7%, P < .001), and gastroesophageal pressure gradient (GOPG) (normal weight: 4.5 +/- 1.2 mm Hg vs overweight: 7.1 +/- 1.4 mm Hg vs obese: 10.0 +/- 1.5 mm Hg, P < .001). Using multiple regression model, BMI (r(2): 0.70, B: 0.28, 95% CI: 0.24-0.33, P < .001) and waist circumference (r(2): 0.65, unstandardized regression coefficient [B]: 0.10, 95% CI: 0.08-0.11, P < .001) were significantly correlated with TLOSR. Obesity is associated with increased TLOSR and acid reflux during the postprandial period in subjects without GERD. Abnormal postprandial LOS function may be an early event in the pathogenesis of obesity-related GERD.

The roles of Helicobacter pylori and pattern of gastritis in the pathogenesis of reflux esophagitis

Comparing the infection rates and density of Helicobacter pylori (H. pylori) and the patterns of gastritis in reflux esophagitis (RE) and non-erosive reflux disease (NERD) patients to investigate the role of H. pylori in the pathogenesis of RE. Two hundred and twenty-three out-patients with typical gastroesophageal reflux symptoms who consecutively visited the hospital underwent ambulatory 24-hour pH monitoring and gastroscopy, and biopsy of the gastric mucosa. RE and NERD were diagnosed based on the presentation of endoscopy. Gastritis was divided into four different patterns: chronic non-atrophic antritis (CNAA); chronic non-atrophic pan-gastritis (CNAG); chronic atrophic antritis (CAA); and chronic atrophic pan-gastritis (CAG). H. pylori infection was evaluated by Warthin-Starry staining. DeMeester score > or = 15 was considered as pathological acid reflux. Sixty-two patients (27.8%) were found to have RE, 161 (72.2%) were found to have NERD. Totally, 67 patients had H. pylori infection (30.0%). There was no significant difference in H. pylori infection rate between the RE and NERD groups (25.8% vs. 31.5%, P > 0.05). 45 of the 223 patients were diagnosed as with CNAA (20.2%), 88 (39.5%) with CNAG, 65 (29.2%) with CAA, and 25 (11.2%) with CAG. The CAG rates in the RE and NERD groups were 6.5% and 13.0% respectively (P > 0.05). There were no differences in abnormal pH monitoring rate and DeMeester score among the different patterns of gastritis. In the sixty-seven H. pylori-positive GERD patients, the 24 h pH monitoring positive rate of the moderate-severe H. pylori colonization density group was 46.4%, significantly higher than that of the mild H. pylori colonization density group (73.5%, P < 0.05); and the mean intra-gastric pH value during 24 hours of the moderate-severe H. pylori colonization density group was 2.3 +/- 0.8, significantly higher than that of the mild H. pylori colonization density group (2.0 +/- 1.1, P < 0.05). H. pylori infection is associated with the pattern of gastritis, but shows no relationship to the incidence of RE. High density of H. pylori colonization in gastric corpus may reduce the esophageal acid exposure. Diffuse atrophic gastritis may protect the patients from RE.

Evaluation of 96-Hour pH Monitoring with the Bravo Wireless System in 60 Patients

Introduction: Ambulatory 24-hour pH monitoring with a nasal catheter is currently the gold standard for measuring esophageal pH. The Bravo pH system is a catheter-free pH system which allows for monitoring of esophageal pH for more than 24-hour. The test normally last 48 hours (hs). Aims & Methods: The aim of this study was to determine the feasibility of performing extended (beyond 48 hs) pH monitoring using the Bravo system. From January to October 2005, 60 patients (pts), (32 women and 28 men, 23-62 years, mean age 44), were evaluated at our center for a recording period of 96 hs. For all pts the pH capsule was positioned transorally under direct endoscopic visualization at 6 cm from the GE junction. After the first 48 hs of recording, the pts returned to our outpatients' clinic where the data relating to the first two days of recording were uploaded into the computer. Then the recording was reprogrammed for another 48 hs. The pts then returned again at the end of this second 48 hs period and we compared the results obtained from the first and the second two days of recording. Results: In 27 of the 60 pts the capsule became detached from the esophageal mucosa before the end of the 96 hs period. The other 32 (53.3%) pts completed the study for the entire 96 hs. In those 27 pts where the capsule became detached prior to completing the entire 96 hs test, the recording of the first 48 hs was excellent and therefore perfectly suitable for diagnostic purposes. In 20 of the 32 pts who completed the full 96 hs of recording, the results from the two 48 hs periods were identical: 13 pts who experienced reflux in the first two days with a pathological DeMeester score also experienced reflux in the third and fourth days; 7 pts exhibited no relevant reflux during the entire recording period and therefore had a normal DeMeester. 12 (37,5%) of the 32 patients exhibited normal acid contact time during the first two days of recording while in the last two days they experienced reflux. Conclusion: Our study suggests that pH monitoring can be effectively extended beyond 48 hs in the majority of pts. Further testing beyond this period increases the diagnostic confidence for GERD. Prolonged studies (beyond 48 hs) identify subset of pts (28% in our study) that show cyclic pH fluctuations.

Acoustic Analysis Findings in Objective Laryngopharyngeal Reflux Patients

The aim of this study was to identify the effects of objective laryngopharyngeal reflux (LPR) on the acoustic parameters of patients by comparing their voice samples with that of control subjects. Prospective study in two tertiary reference hospitals. 48 consecutive patients with symptoms related to LPR and 64 control subjects were included in the study. Suspected LPR patients underwent a 24-hour ambulatory pH monitoring, and 25 (52%) of them were shown to have objective LPR. Acoustical evaluation results of objective LPR patients were compared with that of symptomatic LPR patients and control subjects. All frequency perturbation values obtained from objective and symptomatic LPR patients were higher than the control subjects (P<0.01). Mean fundamental frequency, amplitude perturbation measures, and noise-to-harmonics ratio were not significantly different between groups. LPR patients have significantly different frequency perturbation values than control subjects.

Diagnosis of Laryngopharyngeal Reflux Among Globus Patients

Laryngopharyngeal reflux (LPR) is suggested as one of the most common etiologic factors of globus; currently, however, only a few tools are available to carry out effective diagnosis of LPR in clinics. The goal of this study was to assess the validity of reflux finding score (RFS), reflux symptom index (RSI), and symptom checklist-90-revision (SCL-90-R) as diagnostic methods for LPR. We selected 57 globus patients who were divided into test and control groups according to the results of 24-hour double-probe ambulatory pH monitoring. RFS, RSI, and SCL-90-R were then compared between the 2 groups, and the logical products of the 3 tests were also compared. RFS and RSI showed low specificity and there was no significant difference between the test and control groups. However, SCL-90-R revealed significantly high scores in the control group. The logical product of combining positive RFS and negative SCL-90-R was significantly different between the groups. RFS and RSI are less valid as diagnostic tools for LPR when used independently. Patients with LPR are found to exhibit weaker psychological symptoms than non-LPR patients. B-2b.

Laryngopharyngeal Reflux: Prospective Cohort Study Evaluating Optimal Dose of Proton-Pump Inhibitor Therapy and Pretherapy Predictors of Response

Laryngopharyngeal reflux (LPR) is frequently treated with empiric proton-pump inhibitors (PPI), but the optimal dosing and duration is unknown. We performed an open label prospective cohort study to evaluate whether twice-daily (BID) PPI is more effective than once-daily (QD) PPI for the treatment of LPR. Patients diagnosed with LPR based on ear, nose, and throat (ENT) symptoms and laryngoscopy findings were enrolled. Questionnaire assessed demographics, ENT symptoms, symptom severity, and exposure to other potential laryngeal irritants. Esophageal manometry, ambulatory 24-hour pH monitoring, and upper gastrointestinal endoscopy were performed before initiation of therapy. Patients were consecutively assigned to three groups: BID PPI (lansoprazole 30 mg BID), BID PPI + H2 receptor antagonist (H2RA; omeprazole 20 mg BID + ranitidine 300 mg each night), or QD PPI (esomeprazole 40 mg QD). Greater than 50% primary symptom improvement from baseline defined symptom response. At 2 month follow-up, the same PPI dose was continued for responders, and PPIs were doubled for nonresponders for an additional 2 months. Repeat symptom assessment and laryngoscopy performed at 4 month follow-up. Eighty-five patients were enrolled (median age 49 years, interquartile range 44.0 - 65.0; 76% white; 34% male). Treatment groups were BID PPI for 30 patients, BID PPI + H2RA for 30 patients, and QD PPI for 25 patients. RESPONSE TO THERAPY: At 2 months, BID response occurred among 15 of 30 (50%) patients, BID + H2RA for 15 of 30 (50%), and QD for 7 of 25 (28%) (P = .03). No statistical difference found between the two BID PPI groups with and without H2RA. Among the QD group nonresponders, 7 of 13 (54%) achieved symptom response with additional 2 months of BID dosing. At 4 month follow-up, an additional 22% of responses were obtained from the two BID groups (43/60, 72%). The overall response rate for all three groups was 70% (54/77). PREDICTORS OF OUTCOME: Pretherapy interarytenoid mucosa and true vocal folds abnormalities were associated with twofold increase in symptom response (odds ratio 1.99 and 1.96, respectively, P = .017). BID PPI appears to be more effective than QD PPI in achieving clinical symptom response in suspected LPR. More response was achieved at 4 months compared with 2 months. Therefore, aggressive acid suppression with BID PPI for at least 4 months is warranted for treatment of LPR.

Endoscopic full-thickness plication for the treatment of GERD: 12-month follow-up for the North American open-label trial

The aim of this study was to assess the intermediate-term (12-month) safety and efficacy of endoscopic full-thickness plication in patients with symptomatic GERD. Sixty-four patients with chronic heartburn that required maintenance antisecretory therapy received a single, endoscopically placed, full-thickness plication in the gastric cardia 1 cm distal to the gastroesophageal junction. At baseline and 12 months after plication, patients completed the GERD Health Related Quality of Life questionnaire, Gastrointestinal Symptom Rating Scale, and SF-36 Health Survey, as well as a medication use diary. Ambulatory 24-hour pH monitoring and esophageal manometry were obtained at baseline and 3 months after plication. At 6 months after plication, the 24-hour pH study was repeated. Of the 57 patients who completed the 12-month follow-up, 40 (70%) were no longer taking a proton pump inhibitor. Median GERD Health Related Quality of Life scores were improved compared with baseline while taking medication (19.0 vs. 5.0; p < 0.0001) and while not taking medication (13.0 vs. 5.0; p < 0.002). At 6 months after the procedure, an improvement in distal esophageal acid exposure was demonstrated in 40 of 51 patients (80%), with a decrease of 39% in the median percentage of time the pH was less than 4 (p < 0.0001). Normal pH scores were observed in 30% of patients. All procedure-related adverse events occurred acutely, as previously reported, and no new adverse event was observed during extended follow-up. Full-thickness plication at the gastroesophageal junction is an effective endoscopic procedure for treatment of patients with symptoms caused by GERD. It reduces reflux symptoms and antisecretory medication use over at least a 1-year period.