Diagnosis Of Gastroesophageal Reflux Research Articles

Utility of Water Siphon Maneuver during Barium Esophagography in Diagnosis of Gastroesophageal Reflux

Background: The water siphon maneuver (WSM) is performed during barium swallow test (BST) to elicit gastroesophageal reflux (GERD) in patients without identifiable spontaneous reflux. The objective of this study was to measure the correlation between WSM-induced reflux with pathologic GERD as determined by gold standard ambulatory pH testing. Methods: A retrospective review of consecutive adult patients that underwent both BST with WSM and pH testing at our institution from 2015 to 2019 (n = 228). Pathologic GERD was defined as total esophageal acid exposure time >6% on pH testing (Lyon consensus). Exclusion criteria included history of foregut procedures and pH testing on proton pump inhibitors. Correlation between WSM-induced reflux and GERD by pH testing was assessed using Fisher’s exact test. Results: A total of 116 patients were included. Pathologic GERD was diagnosed on 28.4% (n = 33) of pH tests while reflux was observed in 69.8% (n = 81) of WSM. There was no correlation between positive WSM and pH test-detected pathologic GERD ( P = .415). The sensitivity and specificity of WSM for GERD relative to pH testing were 63.6% and 27.7% while positive and negative predictive values were 25.9% and 65.7%, respectively. Accuracy of the WSM was consistently low across both wireless or impedance pH testing and for the entire cohort (n = 228). Conclusion: This is the largest study to date comparing WSM during BST to ambulatory pH testing in the evaluation of GERD. WSM has limited sensitivity and negative predictive value for pathologic GERD, and therefore cannot reliably confirm or discard this diagnosis.

Gastric antral web presenting with esophageal stricture and severe malnutrition

Gastric antral web is a rare cause of gastric outlet obstruction in children. Common complaints include intermittent non-bilious vomiting, bloating, pain, loss of appetite, and weight loss. Herein, we report a case of gastric antral web presenting with esophageal stricture and malnutrition, which was followed for many years with a misdiagnosis. An 8-year-old African boy was referred to our pediatric gastroenterology clinic due to recurrent vomiting and severe malnutrition. According to his medical history, the patient began experiencing non-bilious vomiting at 40 days of age and a diagnosis of gastroesophageal reflux was made. He was hospitalized multiple times and received nasogastric tube feedings in the following 4 years. He was re-evaluated for growth retardation and malnutrition at 4 years of age. He had been diagnosed with gluten enteropathy and was fed a gluten-free diet. Recently, he developed difficulty swallowing solid food and was only able to consume liquid meals. Esophagography revealed segmental stenosis in the distal portion of the esophagus. After stricture excision with thoracotomy, upper gastrointestinal series with a radiopaque substance indicated normal esophageal passage; however, prolonged gastric emptying time was also noted. Upon examination during laparotomy, a congenital web was detected in the antral region and was excised. Esophageal and gastric pathologies were consistent with stricture caused by reflux esophagitis and gastric antral web. Today, gastric antral web is mostly diagnosed and treated in infancy. Near total obstruction is relatively easy to diagnose; however, many patients with partial obstruction are followed-up for years with an incorrect diagnosis. Therefore, it should be considered in such cases, persistent vomiting and gastroesophageal reflux may be associated with esophageal stricture.

Prescribing trends of proton pump inhibitors and histamine blockers among children in the United Kingdom (1998-2019): A population-based assessment.

To describe the prescribing trends of proton pump inhibitors (PPIs) and H2 receptor antagonists (H2 RAs) among children with gastroesophageal reflux in the United Kingdom between 1998 and 2019. We conducted a population-based retrospective cohort study using data from the Clinical Practice Research Datalink that included all children aged ≤18 years with a first ever diagnosis of gastroesophageal reflux between 1998 and 2019. Using negative binomial regression, we estimated crude and adjusted annual prescription rates per 1000 person-years and corresponding 95% confidence intervals (CIs) for PPIs and H2 RAs. We also assessed rate ratios of PPIs and H2 RAs prescription rates to examine changes in prescribing over time. Our cohort included 177 477 children with a first ever diagnosis of gastroesophageal reflux during the study period. The median age was 13 years (IQR: 1, 17) among children prescribed PPIs and 0.2 years (IQR: 0.1, 0.6) among those prescribed H2 RAs. The total prescription rate of all GERD drugs was 1468 prescriptions per 1000 person-years (PYs) (95% CI 1463-1472). Overall, PPIs had a higher prescription rate (815 per 1000 PYs, 95% CI 812-818) than H2 RAs (653 per 1000 PYs 95% CI 650-655). Sex- and age-adjusted rate ratios of 2019 versus 1998 demonstrated a 10% increase and a 76% decrease in the prescription rates of PPIs and H2 RAs, respectively. Prescription rates for PPIs increased, especially during the first half of the study period, while prescription rates for H2 RA decreased over time.

`Tis the season

It was one of those busy days in the Children's Emergency Department (ED) in December. Concerns about Group A streptococcal infections resulted in sore throats and scarlet fever being referred to ED. There was a general air of heightened anxiety among clinicians and parents. The children were happy go lucky clients. They would come in febrile and clingy. Following a dose of antipyretics and Peppa Pig, they were pleased as punch and would go home clutching presents, compliments of the season. Lurking quietly among the many febrile children would be that one child with sepsis. One had to be watchful. Amidst all this, an innocuous looking 3-week-old arrived with a history of intermittent vomiting since birth and generalised rash. He was seen by the registrar, a diagnosis of gastroesophageal reflux and cows milk protein allergy was made. The consultant reviewed the baby with the registrar. The baby's father (about 6 ft 5 in. tall) was holding a tiny incredibly alert baby with a large towel under his neck. The consultant had a fondness for babies. A quick cuddle always warms the heart especially in a busy ED setting. History was revisited again with the baby in her arms. The baby took in the proceedings with interest staring keenly at her with piercing blue eyes. He was born at term, the second child in the family. He had intermittent, small volume, non-projectile vomiting since birth. Abdominal examination was unremarkable. Hydrolysed formula and reflux medications were prescribed. The father then gave the baby a bottle. He had a small vomit, then animatedly gulped the feed, this was not quite the behaviour of a baby with reflux. The consultant watched this curious behaviour and requested a blood gas. ED became busy with an influx of febrile children, the consultant and the registrar were pulled away in different directions. An hour later, having received medications the father prepared to go home, the baby was now peacefully sleeping in his arms. He was requested to wait as the blood gas was not done as yet. The blood gas as it turned out showed hypochloremic, hypokalaemic, metabolic alkalosis suggestive of pyloric stenosis, later confirmed by ultrasound. The consultant went back to the father, apologised and explained the new plan. Father took it stoically, but expressed puzzlement. He explained that he had been feeling the baby's belly and there was no lump. Father then whipped up his shirt and showed a little scar around his umbilicus. It turned out that he had been operated for pyloric stenosis and was instructed by his mother to monitor the baby post-feed. The baby too had surgery and went home in time for Christmas. Pyloric stenosis is usually seen in infants aged 3 weeks to 3 months and can be mistaken for other conditions.1 Pyloric stenosis can run in families and a family history is a risk factor, besides this child being first born and male. The infant will usually have a period of normal feeding for the first weeks of life. However, this baby had intermittent vomiting since birth, vomiting was not forceful and the classic findings of mass abdomen and weight loss were not present. Observation in ED is as important as history and examination. The baby's feeding was the clue: there was no irritability during feeds and the voracious appetite in an alert baby was unusual. And therein lies the magic of paediatrics, there will always be the one, among many febrile children, who will come in to teach us a lesson.

Fatores associados aos problemas vocais em professores de Montes Claros, Minas Gerais

Teachers use their voices as a work tool and end up exposing themselves to risks of overload and vocal effort, which may impair professional performance. This study aimed to verify the prevalence and factors associated with vocal problems in teachers during the COVID-19 pandemic. This is a cross-sectional, analytical study, formed by 82 elementary school teachers from three state schools in Montes Claros, Minas Gerais, Brazil. To assess vocal problems, the Screening Index for Voice Disorder - SIVD was used. Data collection was carried out in July and August 2020, using the Google Forms Platform. A bivariate analysis was performed, followed by Poisson regression at a 5% significance level. The prevalence of vocal problems was 42.7% (n=35) and of possible vocal disorders was 11.0% (n=9). The most reported symptoms were phlegm (25.6%), hoarseness (19.5%), strained speech (17.1%), and dry throat (15.9%). In the final analysis of vocal problems, the diagnosis of gastroesophageal reflux (PR=2.245; 95%CI=1.548-3.256) and depressive symptoms (PR=1.722; 95%CI=1.020-1.907) were associated. The shift to remote classes showed the need for guidance for healthy vocal quality.

Gastroesophageal Reflux after Peroral Endoscopic Myotomy: Myth or Reality?

AbstractPeroral endoscopic myotomy (POEM) is an accepted treatment for achalasia cardia (AC), and results are comparable to those of laparoscopic Heller myotomy (LHM). In recent years, several reports have confirmed higher incidence of gastroesophageal reflux (GER) following POEM. This review evaluates the current evidence regarding post-POEM GER, critically examines the potential contributing factors responsible for GER, limitations of the current available functional testing, and precautions and preventive measures, and provides future directions for research. Factors conclusively contributing to increased post-POEM GER include injury to the sling fibers of the lower esophageal sphincter, length of gastric myotomy > 2 cm, and others. Historically, these same factors have been implicated for development of GER after surgical (laparoscopic) myotomy. Although less invasive, optimal technique of POEM may be important to control post-POEM GER. Most post-POEM GER occurs during the immediate post-POEM period, is mild, and is easily treatable using proton-pump inhibitors. GER incidence plateaus at 2 years and is comparable to that after LHM. Patients should therefore be prescribed proton-pump inhibitors for at least 2 years. Antireflux procedures (ARPs) are infrequently required in these patients as the incidence of refractory GER is low. Novel ARPs have been recently described and are currently under evaluation. Conclusive diagnosis of GER is a clinical challenge. Most patients are asymptomatic, and GER is diagnosed only on abnormal esophageal acid exposure (EAE). Studies have demonstrated that current measures to diagnose GER are inadequate, inaccurate, and cannot differentiate between true GER and abnormal EAE due to food fermentation in the distal esophagus. The Lyon Consensus criteria should be implemented for confirmation of diagnosis of GER. Finally, the review recommends an evidence-based clinical algorithm for evaluation and management of post-POEM GER and provides guidelines for future research in this field.

Risk Factors and Outcomes for Gastroparesis After Lung Transplantation.

Gastroparesis is common after lung transplantation and is associated with worse transplant outcomes, including the development of chronic lung allograft dysfunction (CLAD). This study sought to identify the prevalence, risk factors, and outcomes associated with a new diagnosis of gastroparesis after lung transplantation. This was a single-center retrospective study of patients who underwent lung transplantation in 2008-2018. The primary outcome was a new diagnosis of gastroparesis within 3years of transplant. Secondary outcomes included a new diagnosis of gastroesophageal reflux and the association between gastroparesis and both post-transplant survival and CLAD-free survival. Multivariable logistic regression was used to compare diagnosis of gastroparesis and gastroesophageal reflux, while multivariable Cox proportional hazards models were used to analyze gastroparesis and post-transplant outcomes. Of 616 patients with no prior history of gastroparesis, 107 (17.4%) were diagnosed with delayed gastric emptying within 3years of transplant. On multivariable logistic regression, black race (OR 2.16, 95% CI 1.18-3.98, p = 0.013) was significantly associated with a new diagnosis of gastroparesis. Age, sex, history of diabetes, connective tissue disease, type of transplant, diagnosis group, renal function, and body mass index were not predictive of gastroparesis post-transplant. Gastroparesis was significantly associated with CLAD (HR 1.76, 95% CI 1.20-2.59, p = 0.004), but not with overall mortality (HR 1.16, p = 0.43). While gastroparesis is common after lung transplantation, it remains difficult to predict which patients will develop these complications post-transplant. Black patients were more likely to be diagnosed with gastroparesis after adjusting for relevant confounders. Gastroparesis is associated with increased risk of CLAD, and further studies are needed to assess whether early detection and treatment can reduce the incidence of CLAD.

Exclusive Breastfeeding Lowers Incidence of Gastroesophageal Reflux in Infants: a 12-month Cohort Study

Introduction: Gastroesophageal reflux (GER) is the involuntary passage of stomach contents to the esophagus with or without regurgitation and vomiting. Studies conducted in Indonesia showed that episodes of regurgitation persisted longer and its incidence was 2 times higher than other ethnics even in 12 months old. In fact, prolonged regurgitation may lead to gastroesophageal reflux disease. This study aims to evaluate exclusive breastfeeding as protective factor toward incidence of GER in infants aged 0-1 month old. Materials and method: This study was a prospective cohort study involving all infants aged 0-1 month old in several hospitals at Surabaya, Sidoarjo, and Gresik. Subjects were classified into 2 groups: exclusively breastfed groups and non-exclusively breastfed groups. Diagnosis of GER was made from history taking and physical examination, according to Rome IV criteria. Follow-ups were conducted at 3, 6, and 12 months in order to know if subjects showed any symptoms of GER or not. Results: A total of 222 subjects followed this study until 12 months. Result showed that fewer infants under exclusively breastfed group showed symptoms of GER after 6 months duration or more. Incidence of GER in both exclusively breastfed group and non-exclusively breastfed group did not differ significantly at 3 months. Conclusion: Exclusive breastfeeding exhibited protective effect toward GER in infants aged 0-1 year. Meanwhile, non-exclusively breastfed infants either bottle-fed with breastmilk, formula-fed, or any combination between breastfed and formula-fed, increased risk for GER by 1.45 times. Therefore, it is highly recommended to give exclusive breastfeeding for infants.

Primary contributors to gastrostomy tube placement in infants with Congenital Diaphragmatic Hernia

ObjectiveTo identify factors associated with gastrostomy tube (GT) placement in infants with congenital diaphragmatic hernia (CDH). MethodsRetrospective cohort study of 114 surviving infants with CDH at a single tertiary care neonatal intensive care unit from 2010–2019. Prenatal, perinatal and postnatal characteristics were compared between patients who were discharged home with and without a GT. Prenatal imaging was available for 50.9% of the cohort. Logistic regression was used to assess the association between GT placement and pertinent clinical factors. ROC curves were generated, and Youden's J statistic was used to determine optimal predictive cutoffs for continuous variables. Elastic net regularized regression was used to identify variables associated with GT placement in multivariable analysis. ResultsGT was placed in 43.9% of surviving infants with CDH. Prenatal variables predictive of GT placement were percent predicted lung volume (PPLV) <21%, total lung volume (TLV) <30 ml, lung-head ratio (LHR) <1.2 or observed to expected LHR (O/E LHR) <55%. Infants who required a GT were diagnosed earlier prenatally (23.6 ± 3.4 vs. 26.4 ± 5.6 weeks). Patients whose stomach was above the diaphragm on prenatal ultrasound (up) had a higher odds of GT placement compared to those with stomachs below the diaphragm (down) position by a factor of 2.9 (95% CI: 1.25, 7.1); p = 0.0154. Postnatally, infants with GT had lower Apgar scores at 1 and 5 min, longer lengths of stay and higher proportion of flap closures. Infants with a type C or D defect and extracorporeal membrane oxygenation (ECMO) were associated with increased odds of needing a GT. Postnatal association included being NPO for >12 days, need for transpyloric (TP) feeds for >10 days, >14 days to transition to a 30 min bolus feed, presence of gastro-esophageal reflux (GER), chronic lung disease and pulmonary hypertension. In multivariable analysis, duration of NPO, time to TP feeds, transition to 30 min bolus feeds remained significantly associated with GT placement after adjusting for severity of pulmonary hypertension (PH), GER diagnosis and sildenafil treatment. ConclusionIdentification of risk factors associated with need for long-term feeding access may improve timing of GT placement and prevent prolonged hospitalization related to feeding issues. Level of Evidence RatingLevel II (Retrospective Study)

Adenoma in Ectopic Pancreas: A Case Report

Introduction: The presence of pancreatic tissue that lacks anatomical or vascular communication with the pancreatic organ has a frequency in autopsy studies that ranges between 0.5% and 13.7%. It is most commonly found in the stomach, specifically in the antrum. Treatment is not clearly established. Surgical resection is recommended in symptomatic patients whose only cause of symptoms is ectopic pancreatic tissue or cancerous formations. Objective: Report a case of ectopic pancreatic adenoma given its low incidence. Case Report: This study reports the case of a 45-year-old male with a history of clinical diagnosis of gastroesophageal reflux disease and a Nissen fundoplication. He presented poor evolution 6 months after the surgery. An endoscopy which revealed postpyloric “polyp” at the level of the duodenal bulb and an inconclusive histopathological study of the same were performed. Reassessment with CT showed a tumor in the first portion of the duodenum measured at 2.2cm, without adenopathies, and a normal-appearing pancreas. It has been made a subtotal gastrectomy and Roux “Y” reconstruction, without complications, with good postoperative evolution, discharged at home on the sixth day. With hematoxylin and eosin technique, the histopathology report reported bile duct adenoma originating in ectopic pancreatic tissue, positive immunohistochemistry for cytokeratin 7 (IHC-7), predominantly expressed by ductal epithelial cells of the pancreatobiliary tract. The patient after surgery had a good clinical evolution and disappearance of symptoms. Conclusion: The clinical cases of rare pathologies are presented to increase the world bibliography and to be able to compare the diagnosis and treatment. In this case, a heterotopic pancreatic adenoma was presented, which is a diagnostic challenge.

The Gastrointestinal and Gastroesophageal Reflux (GIGER) Scale for Infants and Toddlers

The purpose of this study was to describe the development of the Gastrointestinal and Gastroesophageal Reflux (GIGER) Scale for Infants and Toddlers, and determine its factor structure and psychometric properties. Items were developed to comprehensively assess gastrointestinal (GI) and gastroesophageal reflux (GER) symptoms observable by a parent. Exploratory factor analysis on 391 responses from parents of children under 2 years old resulted in a 36-item scale with 3 subscales. Internal consistency reliability was acceptable (α = .78-.94). The GIGER total score and all 3 subscales were correlated with the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R) (P < .05) and Infant Gastrointestinal Symptoms Questionnaire (IGSQ) (P < .05). GIGER total score was higher in infants with a diagnosis of GER (P < .05) or constipation (P < .05) compared to those without. The GIGER is a parent-report measure of GI and GER symptoms in children under 2 years old with adequate psychometric properties.

S0353 The Addition of Provocation Testing Enhances the Accuracy of Barium Esophagography Testing for Gastroesophageal Reflux Disease

INTRODUCTION: Gastroesophageal Reflux (GER) is a common digestive disorder that affects one-third of the population. The main confirmatory method for detecting pathologic acid reflux is pH monitoring with 24-hour pH impedance or 96-hour wireless pH testing, which may not be readily accessible. We studied the accuracy of barium esophagram (Cine) to detect GER using pH testing as the reference standard. METHODS: We analyzed data on patients from The Johns Hopkins Heartburn Center prospectively enrolled from 2017-2019 evaluated with Cine, Esophagogastroduodenoscopy (EGD) and 24 hour pH impedance or 96-hour wireless pH testing. Patients on acid reflux therapy at the time of pH study or history of anti-reflux procedure were excluded. Subjects were observed for unprovoked spontaneous GER on Cine. If GER was not seen, positional maneuvers were done by turning the patient from supine to lateral positions. If no GER, the water siphon test (WST) was performed with the patient drinking water through a straw while lying supine then rolling to right posterior oblique position. Cine maneuvers were completed in this order and stopped once GER was seen. The test was positive if barium was noted at minimum 2 cm above the gastroesophageal junction. Total acid exposure time > 6% during pH testing was considered abnormal and corresponded to GER as the reference standard. The presence of esophagitis on EGD based on LA grade classification and/or Barrett’s esophagus on biopsy were considered positive for reflux disease. RESULTS: 98 patients were selected (40 male, 58 female, mean age 55.2). 60 (61%) had GER based on pH testing, 44 (45%) had reflux during Cine. The overall sensitivity, specificity, and accuracy of the Cine for GER were 64.2%, 74.2%, and 67.3%, respectively. WST showed sensitivity of 55.2%, specificity of 90.3%, and accuracy of 67.5% (Table 1). Receiver operating characteristic (ROC) curve analyses showed that the area under the curve (AUC) for Cine is equivalent to EGD showing Barrett’s esophagus or esophagitis for all GERD, LPRD, and regurgitation-predominant GERD/LPRD (Table 2). In 29 of 70 (41%) patients with EGD inconclusive or negative for GERD, Cine with provocation testing showed GER. CONCLUSION: Esophagram with provocative maneuvers is an inexpensive, simple test that might act as an initial diagnostic tool in the workup of GER. WST improves specificity, positive predictive value, and accuracy for the diagnosis of GER compared to unprovoked observation or position change alone.Table 1Table 2

Diagnosis of gastroesophageal reflux: an update on current and emerging modalities.

Gastroesophageal reflux disease (GERD) is a common condition characterized by troublesome symptoms or esophageal mucosal lesions attributed to excessive esophageal acid exposure. Various pathophysiological mechanisms account for GERD, including impaired esophageal peristalsis and anatomical or physiological defects at the esophagogastric junction (EGJ). Endoscopy identifies GERD complications and detects potential alternative diagnoses. However, if symptoms persist despite proton pump inhibitor therapy, functional esophageal tests are useful to characterize reflux burden and define the symptom association profile. Ambulatory pH or pH-impedance monitoring measures the 24-h acid exposure time, which remains the most reproducible reflux metric and predicts response to antireflux therapy. Apart from identifying peristaltic dysfunction, esophageal high-resolution manometry defines the morphology and contractile vigor (EGJ-CI) of the EGJ. Novel metrics obtained from pH-impedance monitoring include the postreflux swallow-induced peristaltic wave index and mean nocturnal baseline impedance, which augment the diagnostic value of pH-impedance testing. Mucosal impedance can also be recorded using a probe inserted through a gastroscope, or a novel balloon catheter with arrays of impedance electrodes inserted following sedated endoscopy. The latest developments in functional esophageal tests define the GERD phenotype based on pathogenesis, reflux exposure, structural or motility disorders, and symptom burden, facilitating appropriate treatment.

Üst Gastrointestinal Sistem Floroskopi Yapılan Pediatrik Hastalarda Gastroözofageal Reflü Tanısını Etkileyen Faktörler

Objective: The aim of this study was to evaluate the results of upper gastrointestinal fluoroscopy in infants and children and to investigate factors affecting results and the diagnosis of gastroesophageal reflux (GER). Material and Methods: Patients between the ages of 1 month and 18 years who underwent upper gastrointestinal fluoroscopy at the Radiology Department of Dr. Sami Ulus Research and Training Hospital between January 1, 2018 and December 31, 2018 were included in the study. The files of the patients were reviewed retrospectively. Results: Of the 76 patients who underwent upper gastrointestinal fluoroscopy, 46.1% were male and median age was 10 months. Among these, 2.6% (n=2) were diagnosed with mild GER, 18.4% (n=14) with moderate GER, and 38.2% (n=29) with severe GER. The accompanying anatomic pathologies were: malrotation (5.3%), operated esophageal atresia and diaphragmatic hernia (2.6%), organoaxial volvulus and prepyloric web (1.3%). Reasons of requesting upper gastrointestinal fluoroscopy were persistent vomiting in 40.8% (n=31), intermittent vomiting in 10.5% (n=8), and coughing in 11.8% (n=9). The most common accompanying pathologies were prematurity and growth retardation in 6.6% (n=5). 74.4% of those younger than 1 year of age were diagnosed with GER, while this percentage was 39.4% in those aged 1 year or older. The incidence of GER in patients younger than 1 year of age was found to be significantly higher (p=0.002). GER was present in 74.2% (n=23) of patients who had persistent vomiting, while it was present in 48.9% (n=22) of patients who underwent upper gastrointestinal fluoroscopy for other reasons. This difference was also statistically significant (p=0.027). Conclusion: In cases where gastroesophageal reflux disease is suspected, if the patient is younger than 1 year of age or has persistent vomiting, upper gastrointestinal fluoroscopy may be useful to confirm the diagnosis. However, anatomical disorder can be detected in very few of the recommended UGF. From this point of view, it would be more appropriate for clinicians to recommend UGF in more suitable cases considering radiation related risks and procedure difficulties.

Brief resolved unexpected event: prevalence, etiology and epidemiologic characteristics in Lebanon. a retrospective study of hospitalizations in a tertiary-care center

Objective: A Brief Resolved Unexplained Event (BRUE) is a common condition in infancy. However, no epidemiological study has been undergone in Lebanon. This study aims to establish the prevalence and the characteristics of the population hospitalized after a BRUE. Material and methods: A single-center retrospective study performed from 1998 to 2018 included 156 hospitalized infants, aged less than one year old, in a tertiary medical center. Data were collected from hospital archives. Results: Most infants (92.9%) hospitalized after a BRUE were aged less than 6 months old, with a slight masculine predominance (52.6%). No pathognomonic symptom was identified. In terms of recurrence of the initial episode, it occurred in 55.1% of the cases. A transfer to a reanimation unit took place in 35.9% of patients, with an average stay of 6.3 days. Two infants were deceased and six were readmitted for the same chief complaint. Final confirmed diagnosis was a Gastro-Esophageal Reflux (GER) in 60.9%. Consequently, a milk change occurred in 17.9% and a GER treatment in 65.4%. Conclusion: Infants younger than one year and hospitalized for a BRUE present a majority of confirmed GER diagnosis, and seem to have an excellent prognosis.

Impact of gastroesophageal reflux in the pathogenesis of tracheal stenosis.

Benign airway stenosis is a multifactorial and heterogeneous disease often occurring after tracheal intubation. Despite the frequent finding of pathological gastroesophageal reflux (GER) in benign tracheal stenosis, the cause-and-effect relationship between these two entities and its impact on the outcome of the stenosis itself have not been established. The altered ventilatory dynamics caused by an increased thoracoabdominal pressure gradient in such patients has been proposed as a central cause. The presence of GER in a setting of microaspiration can also induce changes in the local collagen proliferation response, as well as in the local microbiome of the tracheal stenosis site, which may potentially cause and enhance the harm imposed to the already diseased tracheal wall. Diagnosis of GER remains underestimated in the general population, thus making its accurate detection and treatment in central airway stenosis a matter of investigation. The high prevalence of GER in tracheal stenosis patients often occurs in the absence of typical upper digestive signs and symptoms, therefore requiring an objective assessment using a 24-hour ambulatory esophageal pH/impedance study that has shown abnormal results in more than half the patients. The impact of the treatment of GER in patients with benign tracheal has been scarcely reported. Our group showed recently that the surgical control of GER through laparoscopic fundoplication in selected patients with tracheal stenosis can improve substantially the chance of resolution of the tracheal stenosis as opposed to the medical management with high dose proton pump inhibitors. This chapter describes the impact of GER in the pathogenesis of tracheal stenosis with a focus on its mechanisms, diagnosis and treatment strategy.

Evaluation of Gastroesophageal Reflux by Transabdominal Ultrasound in Adults: Focused on Subdiaphragmatic Esophageal Length, His angle, Moment of Reflux

Background/Objectives: The purpose of this retrospective study was to evaluate factors affecting the diagnosis of gastroesophageal reflux (GER) using transabdominal ultrasound. Methods/Statistical analysis: The patient group comprised of 18 adults with upper endoscopy results of Los Angeles (LA)-classifications A or above, while the control group included of 68 adults with normal upper endoscopy. The ultrasonography was used to measure the subdiaphragmatic esophageal length, gastroesophageal angle (His angle) and real-time ultrasonography at the moment of reflux. Findings: The subdiaphragmatic esophageal length was 29.2±3.6 ? in the control group, and 22.7±3.2 ? in the patient group. The results showed statistically significant difference between the two groups. The cut-off value for the subdiaphragmatic esophageal length was 25.1 ?. Sensitivity and specificity were 88.9% and 86.9% respectively. The gastroesophageal angle measured 121.9±12.3° in the control group and 141.5±8.8° in the patient group. The cut-off value of 134.6° showed a sensitivity of 83.3% and specificity of 83.8%. There were statistically significant differences (p = 0.001) during real-time ultrasonography with reflux in 77.8% of the patient group and 10.3% in the control group. The real-time ultrasonography showed a sensitivity of 77.8%, specificity of 89.7%, positive predictive value of 66.7% and negative predictive value 93.8%. Improvements/Applications: This study suggests that the transabdominal ultrasound used in measuring the subdiaphragmatic part of the esophageal length, His angle and real-time ultrasonography to be good predictive factors in diagnosing GER disease. Therefore, a medical examination with a noninvasive procedure such as transabdominal ultrasound may be a useful procedure in predicting gastroesophageal disorders.

The Relationship between Primary Acquired Nasolacrimal Duct Obstruction and Gastroesophageal Reflux

ABSTRACTPurpose/Aim of the study: To evaluate if there is any relationship or coincidence between gastroesophageal reflux disease (GERD) and primary acquired nasolacrimal duct obstruction (PANDO).Material and Methods: We enrolled 180 patients with PANDO, confirmed by positive regurgitation on sac squeezing or by irrigation test. In the control group, any patient with lacrimal drainage obstruction was excluded. For diagnosis of gastroesophageal reflux we used a (Gerd Q) questionnaire by R. Jones.Results: According to Gerd Q, prevalence of gastroesophageal reflux in patients with PANDO was 20% (36 out of 180 patients) and in the control group, it was 10.6% (19 out of 180 patients), which was significantly higher in the presence of PANDO (p valve = 0.013). In women, 28 patients (23.5%) in the case group versus 13 patients (10.9%) in the control group has gastroesophageal reflux (p value = 0.01), which was not significant among men (p value = 0.870). When we considered age as an independent variable, results reveled significant value only for patients over 60 years old (p value = 0.008).Conclusion: The prevalence of gastroesophageal reflux disease was significantly higher in patients with PANDO. This statistical relationship was greater among women and patients over 60 years old. In this study, we found an association between GERD and PANDO.

Sleep Disordered Breathing May Signal Laryngomalacia

Background: Pediatric anesthesiologists are often confronted with children with sleep-disordered breathing (SDB) presenting for tonsillectomy and/or anesthesia. The typical patient has symptoms of obstructive sleep apnea (OSA) with enlarged tonsils; however, a subset of patients may have underlying laryngomalacia (LM) without tonsillar hypertrophy. Both OSA and LM significantly increase the risk of intra- and postoperative airway obstruction and sensitivity to narcotics. The prevalence of LM may be underestimated, because direct laryngoscopy (DL) is not routinely performed in the diagnostic evaluation of patients with SDB who lack tonsillar hypertrophy. Aim: To identify the prevalence and DL findings in pediatric patients with SDB without tonsillar hypertrophy. Methods: Retrospective chart review of 108 patients with SDB who underwent general anesthesia for adenotonsillectomy (TA) or adenoidectomy with concomitant DL. The following data were collected: demographic information, medical comorbidities, polysomnography results, anesthetic techniques, and postoperative complications. Results: 94.5% of children had DL findings consistent with LM, including a retropositioned epiglottis and short aryepiglottic folds. Postglottic edema was observed in 42.2%, and these patients were significantly more likely to have a diagnosis of gastroesophageal reflux (P=0.023). 57.8% had vocal cord edema. 75.3% of children who received routine postoperative follow-up care experienced complete symptom resolution. Postoperative complications following discharge from hospital occurred in 12.4% of patients, and 15.7% underwent supraglottoplasty for continued SDB symptoms after TA or adenoidectomy. Conclusion: A substantial proportion of patients with SDB who lacked tonsillar hypertrophy had findings consistent with LM, suggesting that the larynx may be the primary site of upper airway obstruction in these patients. This has significant implications in terms of perioperative management. The majority of patients with SDB had symptomatic improvement following TA or adenoidectomy; however, a subset required further surgical intervention with supraglottoplasty.

Assessment of Clinical Symptoms and Multichannel Intraluminal Impedance and pH Monitoring in Children After Thoracoscopic Repair of Esophageal Atresia and Distal Tracheoesophageal Fistula.

Motility disturbances of the esophagus and gastroesophageal reflux disease (GERD) are observed frequently in children after repair of congenital esophageal atresia with distal tracheoesophageal fistula (EA/TEF). Recently, in many pediatric surgical centers, thoracoscopic repair was introduced, which theoretically would change the postoperative course. The goal of the study was to assess physical development, disease symptoms, and GERD symptom frequency in children who underwent thoracoscopic surgery of congenital EA/TEF. The study comprised 22 children (14 boys and 8 girls), aged 16 to 79 months (average age 47.3 months) after surgery of EA/TEF. Clinical symptoms and physical development were analyzed. In 19 children, multichannel intraluminal esophageal impedance connected with pH-metry (MII/pH) was performed. In 11 patients, esophagogastroduodenoscopy with a histological study of mucosa samples was done. The most frequent symptoms were dysphagia, belching, cough and recurrent bronchitis. In 31.5% of the children, body mass deficiency was observed and in 28.6%, low body mass and short stature. Prematurity was present in half of the patients. Depending on the result of the MII/pH study, the children were divided into two groups: 10 children with GERD and 9 children without diagnosis of gastroesophageal reflux. In the 10 with GERD, acid reflux was diagnosed in 9 and non-acid reflux was diagnosed in one. MII/pH demonstrated statistically significant differences in the number of reflux episodes, reflux index, bolus exposure index, mean time of esophageal exposure and acid exposure and mean acid clearance time in children with GERD in comparison to children without this disease. In 36.4% of children who underwent endoscopy, esophagitis was diagnosed, esophageal stricture in 18% and gastric metaplasia in 9.1%. In children who underwent corrective thoracoscopic surgery of EA/TEF, GERD caused by motility disorders of the esophagus was frequently observed. These children require constant monitoring and early treatment of the complication.