Antisecretory Therapy Research Articles

Implications of the Updated Lyon Consensus 2.0 in Clinical Practice

Over the past few decades, efforts have been made to refine the characterization of gastroesophageal reflux disease (GERD) and delineate accurate diagnostic criteria. The original Lyon Consensus published in 2018 defined conclusive diagnostic criteria for GERD, and its subsequent iteration, Lyon Consensus 2.0, provides an updated assessment for actionable GERD. We aim to review the modifications made to the updated consensus, review the supporting literature for said changes, and highlight how these changes may alter clinical practice. The key revisions in the updated consensus are the recommendations to discontinue antisecretory therapy before endoscopic grading, the modifications to endoscopic criteria for proven GERD, the incorporation of wireless pH testing parameters, and the establishment of the threshold for pH-impedance monitoring on antisecretory therapy. Apart from enhancing diagnostic reliability using conclusive and inconclusive thresholds for defining GERD, Lyon Consensus 2.0 provides medical and surgical clinicians the guidance they need to provide clear management pathways for patients with GERD symptoms.

Saliva Production and Esophageal Motility Influence Esophageal Acid Clearance Related toPost-reflux Swallow-Induced Peristaltic Wave.

The post-reflux swallow-induced peristaltic wave (PSPW) brings salivary bicarbonate to neutralize residual distal esophageal mucosal acidification. To determine if reduced saliva production and esophageal body hypomotility would compromise PSPW-induced pH recovery in the distal esophagus. In this multicenter retrospective cross-sectional study, patients with confirmed Sjogren's syndrome and scleroderma/mixed connective tissue disease (MCTD) who underwent high resolution manometry (HRM) and ambulatory pH-impedance monitoring off antisecretory therapy were retrospectively identified. Patients without these disorders undergoing HRM and pH-impedance monitoring for GERD symptoms were identified from the same time-period. Acid exposure time, numbers of reflux episodes and PSPW, pH recovery with PSPW, and HRM metrics were extracted. Univariate comparisons and multivariable analysis were performed to determine predictors of pH recovery with PSPW. Among Sjogren's syndrome (n = 34), scleroderma/MCTD (n = 14), and comparison patients with reflux symptoms (n = 96), the scleroderma/MCTD group had significantly higher AET, higher prevalence of hypomotility, lower detected reflux episodes, and very low numbers of PSPW (p ≤ 0.004 compared to other groups). There was no difference in pH-impedance metrics between Sjogren's syndrome, and comparison patients (p ≥ 0.481). Proportions with complete pH recovery with PSPW was lower in Sjogren's patients compared to comparison reflux patients (p = 0.009), predominantly in subsets with hypomotility (p < 0.001). On multivariable analysis, diagnosis of Sjogren's syndrome, scleroderma/MCTD or neither (p = 0.014) and esophageal hypomotility (p = 0.024) independently predicted lack of complete pH recovery with PSPW, while higher total reflux episodes trended (p = 0.051). Saliva production and motor function are both important in PSPW related pH recovery.

Refractory Gastroesophageal Reflux Disease: Diagnosis and Management.

Gastroesophageal reflux disease (GERD) is common, with increasing worldwide disease prevalence and high economic burden. A significant number of patients will remain symptomatic following an empiric proton pump inhibitor (PPI) trial. Persistent symptoms despite PPI therapy are often mislabeled as refractory GERD. For patients with no prior GERD evidence (unproven GERD), testing is performed off antisecretory therapy to identify objective evidence of pathologic reflux using criteria outlined by the Lyon consensus. In proven GERD, differentiation between refractory symptoms (persisting symptoms despite optimized antisecretory therapy) and refractory GERD (abnormal reflux metrics on ambulatory pH impedance monitoring and/or persistent erosive esophagitis on endoscopy while on optimized PPI therapy) can direct subsequent management. While refractory symptoms may arise from esophageal hypersensitivity or functional heartburn, proven refractory GERD requires personalization of the management approach, tapping from an array of non-pharmacologic, pharmacologic, endoscopic, and surgical interventions. Proper diagnosis and management of refractory GERD is critical to mitigate undesirable long-term complications such as strictures, Barrett's esophagus, and esophageal adenocarcinoma. This review outlines the diagnostic workup of patients presenting with refractory GERD symptoms, describes the distinction between unproven and proven GERD, and provides a comprehensive review of the current treatment strategies available for the management of refractory GERD.

Understanding of Eosinophilic Esophagitis in Children - A Comprehensive Study on Epidemiology, Clinical Manifestations, Diagnosis and Innovative Treatment Modalities

Introduction:&#x0D; In the late 1960s, probable cases of eosinophilic esophagitis (EoE) emerged, initially linked to esophageal rings and congenital causes or gastroesophageal reflux disease (GERD). Doubts about the GERD association arose due to poor responses to antisecretory therapy. EoE is now a significant pediatric health concern, impacting 1 to 7 cases per 10,000 children.&#x0D; Purpose of the Study:&#x0D; This study aims to comprehensively explore EoE's epidemiology, etiology, subtypes, clinical manifestations, diagnostic methods, and treatment modalities.&#x0D; Materials and Methods:&#x0D; The study employs a cross-sectional analysis of pediatric EoE patients, utilizing endoscopic evaluation and histological assessment. Three distinct EoE subtypes are identified based on pathogenic characteristics. Clinical manifestations, diagnostic methods, and treatments, including endoscopy, are examined.&#x0D; Results:&#x0D; Clinical manifestations span a broad spectrum in the pediatric population. Diagnostic methods include endoscopy, esophageal manometry, impedance-pH monitoring, capsule endoscopy, and string tests. Three distinct EoE subtypes are identified with unique characteristics. Treatment modalities involve dietary management, proton pump inhibitors, topical corticosteroids, biologic therapies, allergen immunotherapy, and endoscopic interventions.&#x0D; Conclusion:&#x0D; Formerly associated with GERD, EoE is now a significant pediatric health concern. The study underscores the importance of comprehensive diagnostic approaches and diverse treatment modalities, including promising biologic therapies and allergen immunotherapy. Understanding these aspects is crucial for effective management and improved outcomes in patients.

Probable gastrointestinal disease factors in postmenopausal age women receiving antihypertensive therapy

The frequency of achieving control as a result of taking antihypertensive drugs in women in the age group 55-64 years reaches 78.9%, the frequency of gastrointestinal symptoms occurring during treatment of hypertension is up to 62%. The aim: to analyze the probable causes of the development of symptoms of diseases of the gastrointestinal tract in postmenopausal patients receiving antihypertensive therapy. Material and methods. A comprehensive clinical examination of out-patient and in-patient patients of health care institutions of the Smolensk region with hypertension aged 50 to 84 years, (group AG, n=160) mean age 67.4 ± 17.4 years. Results. Complex examination and observation on the basis of standard methods with high probability shows the formation of gastroesophageal reflux disease, gastritis, simple erosions of the gastric mucosa, biliary dysfunction, chronic pancreatitis steatohepatosis in the observed patients. Conclusions: In postmenopausal women receiving antihypertensive therapy, there are major gastrointestinal symptoms of varying severity, arising in conditions of irrational nutrition, psycho-emotional and physical stress on the background of irregular medication. Based on the analysis of modern scientific sources, it can be argued that complex rational antihypertensive, antiplatelet, hypolipidemic, antisecretory and eradication therapy and the correction of modifiable risk factors ensures the achievement of remission of gastrointestinal and cardiovascular disease in the optimal time, improves the quality, life expectancy of patients and improves disease prognosis.

Possibilities and place of endoscopy in improving the results of treatment of gastroduodenal bleedings

The results of treatment of gastroduodenal bleedings in the Russian Federation leave much to be desired. According to the chief surgeon and endoscopist of the Russian Federation, Academician A. Sh. Ramishvili [2], operative mortality in the treatment of gastroduodenal bleedings is 19 %, and only in 32 % of cases, bleeding was stopped endoscopically. The article analyzes the problems in the treatment of gastroduodenal bleedings. The main problem is organizational. Strict implementation of national clinical recommendations by surgeons and endoscopists is necessary for high-quality care for patients with gastroduodenal bleedings (1). Special conditions should be created in hospitals to help patients with gastroduodenal bleedings. These are the presence of a surgical team, intensive care unit, blood transfusion department or cabinet, 24-hour endoscopy (department or cabinet) equipped with modern digital endoscopes and all the tools to stop bleedings. It is necessary to treat not the bleeding but the patient with bleeding. For this purpose, it is necessary to use drug antisecretory therapy after endoscopic treatment. It is very important that surgeons and endoscopists equally understand the complexity of the problem – the treatment of gastroduodenal bleedings.

Esophagoprotective agent in the treatment of gastroesophageal reflux disease in children

Gastroesophageal reflux disease (GERD) prevalence in children and adolescents is estimated as high. GERD has a wide variety of clinical signs that significantly reduce the patients' quality of life. Typical symptoms include heartburn, belching, and regurgitation (regurgitation). Extraesophageal symptoms are mainly represented by complaints indicating the involvement of the respiratory, ENT organs, and oral cavity organs in the process. In addition, gastroesophageal reflux disease is a major risk factor for Barrett's esophagus and esophageal adenocarcinoma. The main factors predisposing to the development of gastroesophageal reflux disease in children are obesity, overeating, congenital anomalies of the esophagus, surgical interventions at the cardioesophageal junction, immature autonomic nervous system, nervous system diseases, administration of certain drugs, as well as vices such as smoking and alcohol drinking in adolescence. The mainstay of treatment of gastroesophageal reflux disease is antisecretory therapy with proton pump inhibitors. However, some patients using proton pump inhibitors at a standard dosage fail to achieve the clinical and endoscopic remission of the disease. The causes of the gastroesophageal reflux disease refractoriness to the adequate therapy most often include impaired barrier function and increased esophageal mucosal permeability. The use of esophagogastroprotective agents contributes to the optimization of therapy of gastroesophageal reflux disease and aims at achieving the disease remission in a larger number of patients. Clinical case reports of diagnosis and treatment of patients aged 12 and 16 years with gastroesophageal reflux disease are presented. The use of the esophagoprotective agent provided rapid relief of both esophageal and extraesophageal symptoms of the gastroesophageal reflux disease. In addition, complete healing of erosive esophagitis was achieved during its therapy.

Intermittent Hiatus Hernia on High-Resolution Manometry Associates With Abnormal Reflux Burden Similar to Persistent Hiatus Hernia.

Hiatus hernia is characterized by axial separation between the lower esophageal sphincter and the crural diaphragm, and higher reflux burden. Impact on reflux is unclear if such separation is intermittent rather than persistent. Reflux burden off antisecretory therapy was compared between no hernia (n = 357), intermittent hernia (n = 42), and persistent hernia (n = 155) after review of consecutive high-resolution manometry and reflux monitoring studies. Proportions with pathologic acid exposure was similar between intermittent and persistent hernia (45.2% vs 46.5%, respectively), and both were significantly different from no hernia (28.7%, P ≤ 0.002). Intermittent hiatus hernias are clinically relevant in gastroesophageal reflux pathophysiology.

Twenty-four-hour pH metry alone is inferior to additional impedance monitoring in the diagnosis of gastroesophageal reflux disease, particularly in presence of reduced gastric acid secretion.

Current gold standard for the diagnosis of gastroesophageal reflux disease (GERD) is 24-hour pH metry though it fails to detect non-acidic reflux. The sensitivity of 24-hour pH metry alone (both catheter-based and Bravo capsule) is questionable, especially if gastric acid secretion is low due to reduced parietal cell mass, Helicobacter pylori-induced gastric atrophy and antisecretory therapy. Accordingly, we analyzed the diagnostic ability of 24-hour pH metry as compared to impedance monitoring in relation to the gastric pH without antisecretory therapy. A retrospective analysis of prospectively collected data from 150 patients with suspected GERD undergoing a 24-hour pH impedance study was done. Among 150 patients with symptoms suggestive of GERD, 106 (70.6%) had confirmed GERD diagnosed either by 24-hour pH metry alone (10 [9.4%]), impedance monitoring alone (49 [46.2%]) or both (47 [44.3%]). Abnormal reflux of acidic and non-acidic gastric contents was detected by 24-hour pH metry and 24-hour impedance monitoring in 57/106 (53.7%) and 96/106 (90.5%) of patients, respectively (p < .00001). Patients with GERD diagnosed by 24-hour impedance monitoring had a higher mean gastric pH (2.9 [median 1.3, IQR 5.3]) than those diagnosed by 24-hour pH metry (2.1 [median 1.4, IQR 2.6]) or both (1.6 [median 1.2, IQR 2.1]) (p = 0.001). Twenty-four-hour impedance monitoring detects GERD more often than 24-hour pH metry. Patients with higher mean gastric pH leading to non-acidic reflux were more often diagnosed by 24-hour impedance monitoring than 24-hour pH metry. Thus, 24-hour pH metry alone is inferior to additional impedance monitoring in the diagnosis of GERD, particularly in presence of reduced gastric acid secretion.

Endoscopic ultrasound-guided cystogastrostomy in the treatment of the complicated form of acute pancreatitis in children

Acute pancreatitis is relatively rare in children, with approximately 313 cases per 100,000 populations annually, and complicated forms are three times less common than those in adults. However, recently, the number of acute pancreatitis cases in children has increased, which entails a relatively higher incidence of complicated acute pancreatitis, including parapancreatic acute fluid accumulation, and determines the relevance of this problem for pediatric surgeons.&#x0D; In this study, using two sample observations, parapancreatic pseudocyst puncture under ultrasound and X-ray control was presented, a conductor string was introduced into the cavity of the pseudocyst, and further stenting of this anastomosis was performed with two plastic double-pigtail stents. In the first case, a 12-year-old boy underwent surgery for idiopathic pancreatitis and acute parapancreatic fluid accumulation in the pancreatic tail. In the second case, a 10-year-old girl presented with a parapancreatic pseudocyst, which was caused by drug-induced pancreatitis (a complication of the long-term use of valproic acid, an antiepileptic drug). Both children underwent surgery using this technique. Antisecretory therapy was performed postoperatively. In the catamnesis after 1 year and 6 months, the children had no complaints, and ultrasound and X-ray studies did not reveal any pathology. Endoscopic cystogastrostomy under ultrasound guidance is widely performed in complicated pancreatitis in adults. These observations show its effectiveness in pediatric practice. However, the relatively short observation period of treatment results requires additional research on a much larger number of cases and outcomes of these surgical interventions in children.

Features of the Parameters of 24-Hours pH-Impedance and High-Resolution Esophageal Manometry in Patients with Barrett's Esophagus on Proton Pump Inhibitors

Аim: to identify predictors of insufficient effectiveness of proton pump inhibitors based on the evaluation of the results of 24-hour pH-impedance and high-resolution esophageal manometry in patients with Barrett's esophagus.Materials and methods. 52 patients with histologically confirmed Barrett's esophagus who are on therapy with proton pump inhibitors were examined. All patients underwent daily pH-impedance and high-resolution esophageal manometry.Results. According to daily pH-impedance, group 1 consisted of 37 patients who responded satisfactorily to antisecretory therapy, group 2 of 15 patients who demonstrated insufficient response to acid-suppressive therapy, 11 of whom had no clinical manifestations. The total number of reflux averaged 55 in group 1 and 106 in group 2. The average number of acid reflux in group 1 was 5.68, in group 2 — 48.5. The average number of non-acid reflux prevailed in patients of group 2 and averaged 58, in group 1 the indicator averaged 47. Evaluation of the results of high-resolution esophageal manometry showed that violations of the structure and function of the esophago-gastric junction were detected in 21 patients out of 52. Disorders of the motility of the thoracic esophagus were detected in 31 patients out of 52. When comparing the frequency of motor disorders from the thoracic esophagus in groups 1 and 2, no significant differences were obtained. However, significantly more frequent registration of violations of the structure and/or function of the esophago-gastric junction was found in the group with unsatisfactory effectiveness of proton pump inhibitors.Conclusion. In a number of patients with Barrett's esophagus, there is an insufficient effect of acid-suppressive therapy and at the same time an asymptomatic course of the disease, which may increase the risk of its progression. Predictors of insufficiently successful treatment of patients with Barrett's esophagus may be both insufficient pharmacological effect of proton pump inhibitors themselves, and motility disorders that cause the presence of non-acid reflux, decreased esophageal clearance, which in turn may cause the patient's symptoms to persist and adversely affect the condition of the esophageal mucosa.

Eosinophilic esophagitis in children: Experience in diagnosis, clinical observation in a multidisciplinary hospital

This study presented the characteristics of seven patients with eosinophilic esophagitis from age 1 year and 2 months to age 17 years and 4 months. The follow-up duration ranged from 1 to 7.5 years.&#x0D; Disease onset was observed at different ages: aged 2 years (n=6) and 2 months (n=1). The period between the occurrences of the first symptom to diagnosis ranged from 3 months to 9 years. In one patient, the symptoms were associated with cows milk allergy, whereas the cause was not identified in other cases. Allergic diseases (i.e., atopic dermatitis, allergic rhinitis, and asthma) were observed in six patients.&#x0D; Treatment was provided according to the clinical guidelines. Six patients were prescribed topical steroids (budesonide) and an empirical elimination diet. One patient was prescribed only with an empirical elimination diet due to the steroid phobia of the parents. However, the ineffectiveness of the diet was the basis for topical steroid prescription. During the follow-up, a relapse was observed in two patients who required repeated treatments.&#x0D; A clinical case of eosinophilic esophagitis in a 6-year-old child, with 7.5 years of follow-up, was described. According to the anamnesis, the patient visited a gastroenterologist 4 years after the onset of dysphagia symptoms. Endoscopy revealed cicatricial stenosis of the upper third of the esophagus (grades 23). A morphological study of the esophageal mucosa, which was performed after repeated endoscopic bougienage and a 5-month course of antisecretory therapy was deemed ineffective, revealed massive eosinophilic infiltration. Eosinophilic esophagitis was confirmed based on the anamnesis, clinical symptoms, and endoscopic and morphological data. An elimination diet and topical corticosteroids (budesonide) were prescribed. Following the treatment, the patient showed significant improvements. Subsequently, during the follow-up, a relapse of eosinophilic esophagitis was diagnosed twice (with an interval of 2.3 and 2.5 years), which required topical steroids (case 1) and proton pump inhibitors (case 2).&#x0D; This paper highlights the importance of a multidisciplinary approach, involving an allergist-immunologist, pediatrician, gastroenterologist, endoscopist, and pathologist, in the management of eosinophilic esophagitis in children.

Clinical Use of Gastric Antisecretory Drugs in Hospitalized Pediatric Patients.

Antisecretory drugs are frequently used in the treatment of pediatric gastrointestinal disorders. This study was aimed to assess the prescribing patterns and the safety of ranitidine and proton pump inhibitors (PPIs) in a cohort of Italian pediatric patients. Children aged >1 month to <16 years that were admitted to our Pediatric Clinic between 2016 and 2018 were enrolled in this retrospective observational study. All data were obtained from medical records and a parent telephone questionnaire. The exclusion criteria included the use of antisecretory therapy at hospital admission, failure to collect the relevant clinical data, and failure to administer the questionnaire. This study included 461 subjects, who were divided into four age groups: <2 years, 2−5 years, 6−11 years, and ≥12 years. Ranitidine was prescribed in 396 (85.9%) patients, mainly for the acute treatment of gastrointestinal symptoms, and a PPI was given to 65 (14.1%) children to treat gastroesophageal reflux disease, gastritis/ulcer, or for gastroprotection. During the study period, the percentage of patients treated with ranitidine progressively increased, except in the 2−5-year age group. We observed eighty-seven adverse drug reactions (ADRs), 61 of which occurred in the ranitidine group and 26 in the PPI group. The most common ADR was constipation (n = 35), which occurred more frequently in children treated with PPIs and in the 6−11-year age group. Ranitidine was the most used antisecretory drug in all the age groups, especially for acute treatment. Conversely, PPIs were the drugs of choice for prolonged treatments. Further research should be focused on developing an effective and safer alternative to ranitidine.

Подходы к терапии ГЭРБ с учетом разнообразия ее клинических форм

Approximately one third of gastroesophageal reflux disease (GERD) patients are resistant or partially responsive to proton pump inhibitors (PPIs). It is assumed that non-acid reflux is the cause of 15–62% of cases concerning the PPI therapy inefficacy in GERD patients. The review reveals the issues on the prevention and therapy of non-acid GERD types, ways to improve the treatment efficacy. Understanding the patterns of reflux and pathogenetic mechanisms of non-acid GERD types makes it possible to choose the right drugs. For the prevention and treatment of bile reflux, it is necessary to normalize esophageal, gastric and duodenal motility, as well as biliary system function, and prescribe adequate antisecretory and cytoprotective therapy. The basic drugs for the GERD treatment are PPIs. In order to elevate the GERD therapy effect, drugs are used that can enhance the protective factors of the mucous membranes, i.e., cytoprotectors. UDCA drugs are the basis of GERD therapy with a predominance of bile reflux. Prokinetics are used in the treatment of duodenogastroesophageal reflux to normalize the biliary system function, as well as the motor-evacuation function of the stomach and intestines. Heterogeneity of pathogenesis, including the possibility of acid and non-acid gastroesophageal reflux, necessitates GERD differentiated therapy. KEYWORDS: GERD, reflux, prokinetic, gastroprotectors, cytoprotector, proton pump inhibitors. FOR CITATION: Seliverstov P.V., Lazareva Yu.A., Egorov D.V. Methods for GERD therapy according to its clinical form diversity. Russian Medical Inquiry. 2023;7(7):432–438 (in Russ.). DOI: 10.32364/2587-6821-2023-7-7-5.

Proton pump inhibitors in the treatment of gastroduodenal ulcer bleeding: optimization of drug therapy methods

Currently, peptic ulcer disease remains the most common disease of the digestive system. Ulcerative bleeding is a terrible complication. The main condition for the successful conservative treatment of gastrointestinal bleeding that occurs against the background of acid-dependent diseases is adequate acid-reducing therapy. We conducted a study comparing the different modes of administration of proton pump blockers. To this end, three groups of the study were formed: the first group: the drug Rabeprazole was obtained as an antisecretory therapy. The dosing regimen consisted in the introduction of a bolus of 80 mg, then a constant infusion of the drug at a rate of 8 mg per hour for the first 72 hours, after which the transfer to the oral form of 20 mg ×2 times a day; the second group: received the drug rabeprazole intravenously in a dosage of 40 mg 2 times a day; the third group: received the drug rabeprazole intravenously in a dosage of 20 mg 2 times a day for the first 72 hours, then transfer to the oral form of 20 mg ×twice a day. The use of PPIs in various dosages in the study groups significantly reduced the risk of bleeding relapses and deaths. We have shown that the use of PPIs in reduced dosages is also an effective method of treating patients with ulcerative gastroduodenal bleeding.

Features of duodenogastric refl ux in gastric ulcer

At the moment the approach to the treatment of gastric ulcer (GU) does not depend on the location of the ulcer in one or another part of the stomach. We compared gastric secretion, duodenogastric refl ux characteristics and Helicobacter pylori infection in patients with “high” and “low” gastric ulcers. 96 patients with recurrent GU were examined; 71.9% of men and 28.1% of women. In 58 patients, a “high” localization of the ulcer was detected, and in 38 patients, a “low” (pyloroantral) ulcer was diagnosed. All patients underwent esophagogastroduodenoscopy and daily intragastric pH-metry prior to the appointment of antisecretory therapy. The data were compared with the results of healthy volunteers. The frequency of detection of Helicobacter pylori infection was comparable with diff erent localization of gastric ulcer. We were able to show that with “high” ulcers, intragastric acidity in terms of fundal and antral pH and its circadian dynamics were comparable to healthy people. With “high” ulcers, the frequency of duodenogastric refl ux was close to normal, but their total duration was higher due to an increase in the proportion of prolonged and high refl ux. With “low” gastric ulcers, we noted a very high and monotonous acidity in the body and antrum of the stomach, combined with a decrease in the frequency and duration of duodenogastric refl ux. Consequently, both “high” and “low” stomach ulcers suggest the appointment of antisecretory drugs. At the same time, the detection of “high” stomach ulcers associated with excessive duodenogastric refl ux can be considered as a basis for prescribing bismuth tricalium dicitrate, including as part of the Helicobacter pylori eradication therapy, or ursodeoxycholic acid.

S2274 Bravo Capsule Aspiration

Introduction: Bravo wireless capsule is a catheter-free pH monitoring system used to diagnose GERD in patients who fail anti-secretory therapy. Several adverse events have been reported in the literature; these include nose or throat discomfort and dislocation from positioned sites. Case Description/Methods: A 72-year-old man with a history of GERD, prostate cancer, hypothyroidism, obstructive sleep apnea, presented for esophagogastroduodenoscopy (EGD) with Bravo™ placement due to persistent esophageal reflux symptoms despite appropriate therapy. The Bravo™ capsule (Medtronic, Minneapolis, MN) with a delivery system was introduced through the mouth and advanced into the esophagus. The device was placed with visual confirmation; however, the patient had severe a coughing fit. Suction was applied and the delivery system was then withdrawn. Repeat EGD was performed and no Bravo™ was seen in esophagus, stomach, or duodenum. Due to suspicion of dislodgement, a chest x-ray was performed and Bravo™ was seen in the left lung (figure 1, panel A). The patient was admitted to the hospital, and the pulmonology service was consulted for device removal. Bronchoscopy was performed successfully with the extraction of a capsule from the left main bronchus (Figure 1, panel B). After 24 hours observation, the patient did not have any symptoms or signs of aspiration pneumonitis and was discharged home. Discussion: We present a case of an adult patient with aspiration of the capsule into the lungs. This is an unusual complication with pH monitoring techniques(3). Given the limited number of cases of Bravo™ aspiration, there are no definite guidelines or gold-standard treatment up to date. A patent airway and good oxygenation must be maintained. The initial diagnostic evaluation includes chest radiographs, since the Bravo™ capsule is radiopaque(4).Once located, bronchoscopic tools can usually reveal the capsule, as was done with our patient.Figure 1.: Panel A, left: X-ray showing bravo capsule in left lung panel B, right: bronchoscopy showing reveals bravo capsule in left main bronchus.

Therapeutic efficacy of “Omeprazole” in horses with equine gastric ulcer syndrome

Gastric ulcer syndrome most often appears in horses as erosions and ulcers of the squamous gastric mucosa. It is believed that gastric ulcers of various etiologies are determined by the amount of gastric acidity regulated by the secretion of hydrochloric acid (HCL). At the same time, the squamous portion of the stomach is the most sensitive to HCL. When ulcers appear, medical treatment is effective. This medicine includes gastric acid suppressor drugs like “Omeprazole”. The mechanism of action whose final stage is to inhibit HCL secretion at the cellular level. Today the importance of antisecretory therapy is well known in treating gastroesophageal reflux and peptic ulcer diseases in humans. However, the acid-suppressive effect of “Omeprazole” in horses with gastric ulcers requires further research. This study aimed to determine the therapeutic efficacy and acid-suppressive effect of the proton pump inhibitor “Omeprazole” in doses of 2 mg/kg and 4 mg/kg. For this purpose, n = 14 horses were selected for the research with the equine gastric squamous disease of various degrees. Gastric squamous portion were observed by gastroscopy procedure and presented with mild lesions in selected horses. Diagnosis of lesions and determination of therapeutic efficacy of the drug was carried out based on gastroscopy results. The drug was administered per os for 21 days. The intragastric pH value determined the acid-supressive effect of the drug. Collection of the samples was conducted on the 1st, 5th, 10th, and 21st day of the medical therapy. Before “Omeprazole” was administrated, the basal pH level was 3.45 ± 0.23. After the first dose of the “Omeprazole” was administered at 4 mg/kg the average pH value was 5.25 ± 0.34. At the same time, the “Omeprazole” at a dose of 2 mg/kg provides intragastric pH 4.41 ± 0.33. The therapeutic efficacy of “Omeprazole” is closely related to the intragastric pH of the horses. The “Omeprazole” at a dose of 4mg/kg is highly effective in treating squamous lesions grade 2, 3. However, the duration of therapy for 21 days may not be sufficient to achieve complete healing of the affected tissues. Administration of the “Omeprazole” at a dose of 2 mg/kg is effective in treating small or multifocal lesions and hyperemia of the squamous mucosa.

Characterization of Crural Repair in Antireflux Surgery: Preliminary Experience with a Standardized Technique

Purpose: To define and optimize cruroplasty in laparoscopic repair of hiatal hernia (LRHH). Background: Crural closure and crural repair in LRHH are used interchangeably. While crural closure entails obliteration of the diaphragmatic defect, cruroplasty involves restoring the anatomy and producing a “functional closure.” Methods: This is an IRB-approved retrospective study. Inclusion criteria were sliding hiatal hernia ≤6 cm in axial length, abnormal pH study or erosive esophagitis, use of the endostitch device to standardize surgical bite, and endoscopic fundoplication to standardize the wrap. Exclusion criteria were a history of antireflux surgery, gastroparesis, or preexisting esophageal stricture. Results: A total of 68 patients, 21 males, and 47 females met the inclusion criteria. The median age and BMI were 59 and 28, respectively. The average follow-up was 26.3 (12–62) months. There were three anatomical recurrences 3/68 (4.4%) and two of them had symptomatic recurrence. All but eight patients discontinued antisecretory therapy 60/68 (88.2%). Five of these eight patients used these medications at lesser dose or frequency rendering the overall improvement of patients to 65/68 (95.5%). There was no postoperative dysphagia. Conclusions: Laparoscopic hiatal hernia repair should focus on crural repair, not merely closure. Optimizing cruroplasty can be achieved by understanding the functional anatomy, recreating the crural sling, and adjusting the crural suture tension. This results in a low recurrence rate of hiatal hernias, a high discontinuation rate of proton pump inhibitors, significant objective clinical improvement of GERD symptoms, and no postoperative dysphagia.

Gastroesophageal Reflux Disease: Diagnosis, Medication, Balneotherapy

The article presents modern views on the problem of gastroesophageal reflux disease (GERD). Data on the prevalence and risk factors for the development of the disease are presented. Emphasis is placed on the special role of slightly acidic and slightly alkaline reflux in the pathogenesis of GERD, which, in combination with dysfunction of the lower esophageal sphincter and impaired motor-evacuation function of the stomach, are important factors, determining the the lack of effectiveness of standard antisecretory therapy. The exceptional importance of the 24-hour pH impedanceometry method is emphasized for the differential diagnosis of the non-erosive form of GERD with functional heartburn and hypersensitivity of the esophagus to reflux (the so-called hypersensitive esophagus). The data of the results of domestic and foreign studies devoted to the evaluation of the effectiveness of the use of physiotherapeutic methods and drinking balneotherapy in patients with GERD are given.