Distal Esophageal pH Research Articles

Response of Laryngopharyngeal Symptoms to Transoral Incisionless Fundoplication in Patients with Refractory Proven Gastroesophageal Reflux.

Patients with laryngopharyngeal reflux (LPR) symptoms may not respond to proton pump inhibitors (PPI) if they have an alternative laryngeal diagnosis or high-volume reflux. Transoral incisionless fundoplication (TIF) or TIF with concomitant hiatal hernia repair (cTIF) are effective in decreasing symptoms of gastroesophageal reflux disease (GERD) but are not well studied in patients with LPR symptoms. This prospective multicenter study assessed the patient-reported and clinical outcomes after TIF/cTIF in patients with LPR symptoms and proven GERD. Patients with refractory LPR symptoms (reflux symptom index [RSI] > 13) and with erosive esophagitis, Barrett's esophagus, and/or pathologic acid reflux by distal esophageal pH testing were evaluated before and after a minimum of 6 months after TIF/cTIF. The primary outcome was normalization of RSI. Secondary outcomes were >50% improvement in GERD-Health-Related Quality of Life (GERD-HRQL), normalization of esophageal acid exposure time, discontinuation of PPI, and patient satisfaction. Forty-nine patients had TIF (n = 26) or cTIF (n = 23) with at least 6 months follow-up. Mean pre- and post TIF/cTIF RSI were 23.6 and 5.9 (mean difference: 17.7, P < .001). Post TIF/cTIF, 90% of patients had improved GERD-HQRL score, 85% normalized RSI, 75% normalized esophageal acid exposure time, and 80% discontinued PPI. No serious procedure-related adverse events occurred. Patient satisfaction was 4% prior to TIF/cTIF and 73% after TIF/cTIF (P < .001). In patients with objective evidence of GERD, TIF, or cTIF are safe and effective in controlling LPR symptoms as measured by normalization of RSI and improvement in patient satisfaction after TIF/cTIF. Level 4.

420 Assessing the Prevalence of Gastroesophageal Reflux in Gastroparesis: Putting the G Back in GERD

INTRODUCTION: Patients with gastroparesis experience a wide range of symptoms from early satiety to frequent emesis and severe abdominal pain. However, few studies have evaluated concomitant underlying esophageal pathology or frequency of gastroesophageal reflux episodes in patients diagnosed with gastroparesis. Prolonged gastric emptying may lead to increased intra-gastric pressure and volume of gastric contents that may result in increased frequency of distal esophageal reflux events. The aim of this study was to assess for significant differences in total duration of distal esophagus acid exposure and number of gastroesophageal reflux events as detected by impedance pH testing between gastroparesis and control cohorts. METHODS: A retrospective analysis of 84 patient charts who underwent both 4-hour gastric emptying studies and 24-hour ambulatory pH testing was performed. Patients with gastroparesis, as documented by abnormal 4-hour gastric emptying studies, were compared with age and gender matched controls. Patients taking PPI during testing were excluded from the study. Percent of total distal esophageal time pH &lt; 4 (nl &lt; 4%) and impedance values (nl&lt; 53) were compared between the gastroparesis and control groups. Continuous variables were analyzed using independent 2-tailed t-test, while categorical values were evaluated using a chi squared analysis. RESULTS: Forty-two gastroparesis patients (9 men and 33 women, median age 46 years old, range 19-81 years old) underwent 24-hour ambulatory pH monitoring while off of PPI. When comparing total mean impedance events during pH testing, the gastroparesis cohort experienced significantly more episodes of distal esophageal reflux events, 61.27 ± 11.34 vs 45.81 ± 7.72 (P = 0.028), respectively. Mean percent total distal time for esophageal pH &lt; 4.0 was higher for the gastroparesis group when compared to controls, 4.79 ± 1.48% vs 3.31 ± 1.15% (P = 0.125), respectively. CONCLUSION: This pilot study demonstrates that patients meeting criteria for gastroparesis by gastric emptying study have significantly higher number of reflux episodes than those with normal gastric emptying. Trends toward a higher percentage of total distal esophageal acidity exposure time and a higher proportion of the gastroparesis group meeting diagnostic criteria for GERD were also seen. In the future, expanding sample sizes to better investigate these preliminary trends will be beneficial to better understand the association of GERD and gastroparesis.

What is the best method for calculating the optimal position of an esophageal pH probe in children?

In assessment of distal esophageal pH, the sensor of the probe should be placed above the upper border of the lower esophageal sphincter. There are several methods to estimate the distance from the nose where the probe should be fixed according to the patient's height. We studied the accuracy of these methods. Data of patients who underwent esophageal monitoring were collected prospectively. The esophageal pH electrode was set with the aid of fluoroscopy in all cases, considering the location recommended by the current guideline. Esophageal probe position and anthropometric data of each patient were recorded. We compared the actual esophageal pH electrode distance from the nose with that estimated by Nowak's, Strobel's, Staiano-Clouse's, and Moreau's formulae and the Great Ormond Street Hospital (GOSH) table. A total of 98 patients were included, with ages ranging from 2 months to 19years old. The highest success rate (67%) for all age groups was achieved by Nowak's formula (3.2+0.2×height in cm). Considering only children under 3 years old, the GOSH table reached the highest-yet probably overestimated-fraction of adequate predictions. A corrected Staiano and Clouse's formula (4.28+0.191×height in cm) had a slightly lower success rate than Nowak's due to a poorer performance in younger children. In conclusion, Nowak's formula is the most accurate regardless of age. It can help reduce radiation due to systematic fluoroscopy, as well as the subsequent manipulation of the esophageal probe. However, it still leads to pH sensor misplacements in more than one-third of children. In consequence, a confirmatory X-ray is advisable even after using the formula.

SWALLOWING IN PATIENTS WITH LARYNGITIS.

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

Involvement of the TLR4/NF-κB Signaling Pathway in the Repair of Esophageal Mucosa Injury in Rats with Gastroesophageal Reflux Disease

Numerous studies have highlighted the activation of NF-κB in the esophageal mucosa during the early stages of gastroesophageal reflux disease (GERD). The present study aimed to investigate the role of the TLR4/NF-κB signaling pathway in GERD rat models. Wistar rats (n = 60) were recruited to establish a GERD animal model. Distal esophageal pH was assessed, followed by determination of the contents of thiobarbituric acid-reactive species (TBARS) and reactive oxygen species (ROS) in esophageal mucosa homogenate. ELISA was employed to detect the levels of inflammatory factors (IL-6, IL-8, IL-10 and TNF-α) in esophageal mucosa. The expression of MMP-3, MPP-9, Cldn1 and Cldn4 was determined by immunohistochemistry. RT-qPCR and western blot analysis were applied to evaluate the protein expressions in TLR4/NF-κB signaling pathway, while TUNEL staining was utilized to examine the apoptosis rate in the esophageal mucosal tissues. Distal esophageal pH of the rats was higher in the GERD + PDTC group than in other groups. Levels of inflammatory factors in esophageal mucosal tissues were downregulated with the inhibition of NF-κB, which was determined to be associated with the decreased contents of TBARS and ROS. Moreover, decreased MMP-3 and MPP-9 in addition to elevated Cldn1 and Cldn4 were detected in the esophageal mucosa as a result of the inactivation of NF-κB. The TLR4/NF-κB signaling pathway-related proteins (TLR4, NF-κB and IκBα); the rate of apoptosis was demonstrated to be suppressed in the GERD + PDTC group, while inactivating NF-κB was found to alleviate the tissue damage observed in the esophageal mucosa. The key findings of the current study demonstrate that the inactivation of the TLR4/NF-κB signaling pathway alleviates oxidative stress injury and promotes the repair of esophageal mucosal injury among rats with GERD, highlighting a potential novel GERD mechanism.

Role of Ambulatory Distal Esophageal pH Monitoring in Patients With Laryngopharyngeal Reflux (LPR) and Gastroesophageal Reflux Disease (GERD)

Introduction: LPR is primarily a clinical diagnosis based on symptoms such as cough, globus, hoarseness and throat clearing thought to be due to reflux of gastric contents into larynx. Some of these patients do not have typical symptoms of heartburn and acid regurgitation which can make the diagnosis challenging. Though not 100% sensitive, the gold standard test for detection of reflux is distal esophageal pH monitoring with 24-hour pH or 48-hour pH testing. Therefore, our aim was to assess the role of distal esophageal pH testing in patients with LPR. Methods: The study group (Group A) consisted of the patients with a diagnosis of LPR who underwent either 24 pH test with a single probe transnasal catheter positioned 5 cm above gastroesophageal junction (GEJ) or 48 hour wireless bravo probe placed endoscopically 6 cm above the GEJ in our GI lab from 2006 to 2014. Group B consisted patients with the diagnosis of GERD only (heartburn or acid regurgitation more than two days a week) and group C comprised of patients with a diagnosis of GERD and LPR. In addition to pH testing, all groups had high resolution esophageal manometry (HREM) and otolaryngeal (ENT) evaluation. Variables such as age, gender, BMI and pH parameters including total acid exposure, supine and upright acid exposure, Symptom index (SI), Symptom sensitivity index (SSI) and symptom association probability (SAP) were noted. Results: A total of 239 patients underwent pH testing during the study period. There were 67 patients in Group A (LPR only), 107 patients in Group B (GERD only) and 68 patients in group C (GERD+ LPR). Only 43.3% in Group A, 50.5% in group B and 55.4% in group C had abnormal pH testing (Table 1). There were no significant differences in the three groups in terms of total, supine and upright acid exposure. SI, SSI and SAP were lower in group A than in group B and group C (although not statistically significant).Table 1: Esophageal pH Testing in LPR and GERDConclusion: Esophageal pH testing is normal in approximately half the patients with a clinical diagnosis of LPR, GERD or a combination. Hence, a diagnosis of LPR cannot be reliably made on the results of distal esophageal pH monitoring alone.

A bama minipig model of laryngopharyngeal reflux and the change of laryngopharyngeal mucosal ultrastructure.

Background/AimsTo establish an animal model of laryngopharyngeal reflux (LPR) and study the effect of LPR on the laryngopharyngeal mucosal ultrastructure.MethodsTen Bama minipigs were randomly divided into control group and stent group. Every pig underwent endoscope, and baseline pH was monitored for 4 hours at laryngopharynx and distal esophagus, then specimens from laryngopharyngeal mucosa were biopsied. For the control group, these procedures were repeated on the 14th day. In the stent group, a custom-designed esophageal stent suit was implanted into esophagus, laryngopharyngeal and distal esophageal pH monitoring lasted for 2 hours, then stent suit was removed 3 days later. At last, the same procedures were done as the control group on the 14th day. Specimens were observed under transmission electron microscope to measure the intercellular space and desmosome number.ResultsIn the control group, there was no laryngopharyngeal reflux on the first day and 14th day. Before the stent was implanted, there was also no laryngopharyngeal reflux in the stent group. In both 2 hours and 14 days after stent implantation, the num -ber of reflux, reflux time, and percentage time of pH < 4.0 were significantly increased (P < 0.05) in the stent group. There was no difference in intercellular space and desmosomes in the control group between baseline and 14th day. In the stent group, intercellular space of laryngopharyngeal mucosa was significantly increased (0.37 μm vs 0.96 μm, P = 0.008), and the number of desmosomes was significantly decreased (20.25 vs 9.5, P = 0.003).ConclusionsA Bama minipig model of LPR was established by implanting a custom-designed stent suit. LPR might destroy the laryngophar yngeal mucosal barrier.

High Prevalence of Esophageal Acid Exposure in Very Low Birth Weight Infants Presenting or Not Bronchopulmonary Dysplasia: A Prospective Cross-Sectional Study

Background: A high frequency of treatment for gastroesophageal reflux disease is observed in neonates with Bronchopulmonary Dysplasia (BPD). The association between these illnesses is controversial. Objective: To determine the prevalence of reflux index ≥ 10%, in very low birth weight infants, presenting or not BPD, using esophageal pH monitoring. Methods: A prospective cross-sectional study was conducted. Thirty-five newborns presenting BPD and 15 newborns not presenting BPD underwent distal esophageal pH monitoring during their stay in a university hospital neonatal unit. The frequency of symptoms and gastroesophageal reflux treatment was studied in both groups. Results: The prevalence of reflux index ≥ 10% did not differ between groups presenting (65.7%) and not presenting BPD (93.3%); p=0.075. Symptoms attributable to gastroesophageal reflux occurred in 91.4% of newborns presenting BPD and in 73.3% of the group not presenting BPD. Antireflux treatment was introduced to 80% of the subjects presenting BPD and to 20% of patients who were not presenting BPD; (p<0.001). Conclusions:There is a high prevalence of increased esophageal mucosal exposure to acid in very low birth weight infants presenting or not BDP. The symptoms attributable to gastroesophageal reflux are frequent in both groups; however, in very low birth weight infants, not presenting BPD, a clinical progression complicated by gastroesophageal reflux is less frequent. Nevertheless, BPD is associated with a higher frequency of gastroesophageal reflux treatment, the indication of any therapeutic modality must be cautious, and the laboratory investigation associated with a clinical evaluation may contribute to a reduction in the number of unnecessary treatment.

Pharyngeal pH alone is not reliable for the detection of pharyngeal reflux events: A study with oesophageal and pharyngeal pH-impedance monitoring.

Pharyngeal pH probes and pH-impedance catheters have been developed for the diagnosis of laryngo-pharyngeal reflux. To determine the reliability of pharyngeal pH alone for the detection of pharyngeal reflux events. 24-h pH-impedance recordings performed in 45 healthy subjects with a bifurcated probe for detection of pharyngeal and oesophageal reflux events were reviewed. Pharyngeal pH drops to below 4 and 5 were analysed for the simultaneous occurrence of pharyngeal reflux, gastro-oesophageal reflux, and swallows, according to impedance patterns. Only 7.0% of pharyngeal pH drops to below 5 identified with impedance corresponded to pharyngeal reflux, while 92.6% were related to swallows and 10.2 and 13.3% were associated with proximal and distal gastro-oesophageal reflux events, respectively. Of pharyngeal pH drops to below 4, 13.2% were related to pharyngeal reflux, 87.5% were related to swallows, and 18.1 and 21.5% were associated with proximal and distal gastro-oesophageal reflux events, respectively. This study demonstrates that pharyngeal pH alone is not reliable for the detection of pharyngeal reflux and that adding distal oesophageal pH analysis is not helpful. The only reliable analysis should take into account impedance patterns demonstrating the presence of pharyngeal reflux event preceded by a distal and proximal reflux event within the oesophagus.

Electrical Stimulation Therapy (EST) of the Lower Esophageal Sphincter (LES) Is Successful in Treating GERD: Long-term 2-year Results

Purpose: The aim of this open-label extension trial was to study long-term (2-year) safety and efficacy of LES-EST in GERD patients. Methods: We studied GERD patients at least partially responsive to PPI and had off-PPI GERD-HRQL> 20%, 24-hour esophageal pH<4.0 for >5%, hiatal hernia <3 cm and esophagitis < LA Grade-C. Bipolar stitch electrodes and an implantable pulse generator (EndoStim BV, the Hague, Netherlands) was laparoscopically implanted. EST at 20Hz, 220usec, 3-8mAmp in 6-12, 30 minute sessions was delivered. Patients were evaluated using GERD-HRQL, symptom-diaries, SF-12 and esophageal pH-testing. Stimulation sessions were optimized based on residual symptoms and esophageal pH at follow-up. Results: Twenty-five patients (mean (SD) age= 53 (12) years; men=14) were successfully implanted; 23 participated in the 2-year extension trial and 21 completed their 2-year evaluation. At 2-years, there was a significant improvement in their median GERD-HRQL on LES-EST compared to both their on-PPI (9 vs. 0, p=0.001) and off-PPI (23.5 vs. 0, p<0.001) scores. Median 24-hour distal esophageal pH improved from 10.1% at baseline to 4.7% (ITT analysis; p<0.001) and 4.1% (per-protocol analysis, p<0.001) at 2-years; 71% reported either normalization or >50% reduction in their esophageal pH. All except four patients reported complete cessation of PPI use. Over 2-years, 44 adverse events in 16 subjects were reported. There was 1 serious event -planned thyroid surgery -NOT device or procedure related. Of 43 non-serious events, 37 were not, 5 were possible/probably and 1 was definite device/procedure related. There were no unanticipated implantation- or stimulation-related adverse events, or untoward sensation due to stimulation. There was no new dysphagia reported with LES-EST and swallowing function assessed by HRM was also unaffected. Conclusion: LES-EST is safe and effective for treating GERD over long-term 2 year duration. There was a significant and sustained improvement in GERD symptoms, esophageal pH and elimination in PPI use. Further, LES-EST was not associated with any GI side-effects or adverse events and can be optimized to individual patient needs. Disclosure - L Rodriguez, P Rodriguez, B Gomez - Research Support: EndoStim E Soffer - Stockholder/Ownership Interest: EndoStim M Crowell - Consultant EndoStim. This research was supported by an industry grant from EndoStim Inc.Figure

An oropharyngeal pH monitoring device to evaluate patients with chronic laryngitis

Diagnostics for gastro-esophageal reflux disease (GERD) are suboptimal because of limited sensitivity. We performed in vitro and in vivo studies to systematically assess the performance characteristics of an oropharyngeal pH probe. In vitro studies compared the oropharyngeal probe with a standard pH catheter in liquid and aerosolized solutions, pH 1-7. The accuracy of measurements, deviation from target pH, and time to equilibrium pH were determined. Simultaneous distal esophageal pH measurements were obtained in 11 patients with GERD. Oropharyngeal and distal esophageal reflux parameters were measured for controls (n = 20), patients with GERD (n = 17), and patients with chronic laryngitis (n = 10). In the liquid phase, at pH 4-5, the oropharyngeal probe had less deviation from the target value than the standard catheter; deviation in the vapor phase was similar (0.4 pH units). Median (interquartile) time to reach equilibrium pH was significantly (P < 0.001) faster with the oropharyngeal than the standard probe. In comparing simultaneous distal esophageal pH characteristics, 96% of recordings with the new and standard probes were in agreement to within ± 1.0 pH unit; 71% of recordings were in agreement within ± 0.5 pH units. Patients with chronic laryngitis had significantly higher levels of oropharyngeal acid exposure at pH <4, <5, and <6, in the upright position than patients with GERD or controls (P < .001). Oropharyngeal pH monitoring appears to be more sensitive than traditional pH monitoring in evaluation of patients with extraesophageal reflux. It is a promising tool in evaluation of this difficult group of patients.

Wireless pH capsule – yield in clinical practice

Wireless pH monitoring is one of the recent technologies that focus on improving the diagnosis of gastroesophageal reflux disease (GERD). The capsule, which is fixed within the esophagus, transmits data via telemetry to an external receiver. The capsule is usually inserted 6 cm above the squamocolumnar junction during an upper endoscopy. The standard recording duration is 48 hours but this can be extended to 96 hours. The wireless capsule has been shown to be at least as accurate as the conventional catheter for the monitoring of esophageal pH. Normal pH values have been established in three different series. The use of a wireless capsule provides an increased diagnostic yield for GERD compared with the conventional catheter. The increased yield is the result of higher sensitivity to detect both abnormal acid esophageal exposure and positive symptom-reflux association. This may be related both to the prolonged recording duration and to fewer dietary modifications and restrictions on activities. Several studies have shown that the pH capsule was better tolerated by patients than the conventional pH catheter. Mild-to-moderate chest pain represents the main side effect of the pH capsule: severe chest pain requiring endoscopic removal of the capsule is rare. The main indication for wireless capsule application is monitoring of distal esophageal pH for diagnostic purpose, particularly in patients with a normal endoscopic examination. The capsule technique has some limitations: costs are higher than conventional pH monitoring, misplacement may occur, and the sampling rate is lower. Finally, compared with pH-impedance monitoring, only acid reflux events can be evaluated.

Evaluation of Histologic Criteria for the Diagnosis of Gastroesophageal Reflux Disease

Background. Standardized criteria for the histologic assessment of gastroesophageal reflux disease (GERD) were recently developed and evaluated by an international working group, and showed promising levels of intraand inter-assessor agreement1. To gain clinical acceptance these criteria require appropriate validation2.Aim. To evaluate new criteria for histologic markers of GERD in a well characterized primary care population. Methods. The study included primary care patients from the Diamond study3 (ClinicalTrials.gov: NCT00291746) who had not previously taken proton pump inhibitors and who had upper gastrointestinal symptoms ≥ 2 times a week for ≥ 4 weeks, and at least mild symptoms on ≥ 3 days in the week before biopsy. GERD was diagnosed as any of the following: Los Angeles grade reflux esophagitis; distal esophageal pH 5.5% of 24 hours; ≥ 95% symptom association probability. Biopsies were collected at 0.5 cm and 2.0 cm above the Z-line and data were analyzed in a single-blind manner by one pathologist (MV). Variables assessed included total epithelial thickness (TET), papillary length (PL), basal cell thickness (all in μm), presence of dilated intercellular spaces (severity score: 0-2)1, number of inflammatory cells (in one high powered field), presence of necrosis, and presence of active or healed erosions. Logistic regression analysis of the histologic variables was performed for GERD versus non-GERD. Cut-off values for sensitivity, specificity, and predictive power (positive and negative) were calculated, and the receiver operating characteristic (ROC) curve was analyzed. Results. The analysis included 258 subjects: 138 (53%) GERD and 120 (47%) non-GERD. TET and PL (μm) at 0.5 cm and 2.0 cm were both significant predictors of GERD (p < 0.005), as was the presence of eosinophils at 2.0 cm (p < 0.05). The optimal efficiency based on the ROC analysis was observed for TET at 0.5 cm, with sensitivity and specificity values of 77% and 52%, and positive and negative predictive values of 65% and 66%, based on a cut-off of 390 μm. TET and PL were significant (p < 0.05) predictors of both reflux esophagitis and of pathologic esophageal pH. TET and PL were also significant predictors (p < 0.05) of non-erosive reflux disease versus non-GERD. Conclusions. Potential new criteria for the histologic evaluation of GERD showed good diagnostic properties when assessed in a well-characterized primary care population with upper gastrointestinal symptoms.

Research on the relationship between obstructive sleep apnea hypopnea syndrome and gastroesophageal reflux

To study the relationship between obstructive sleep apnea and nocturnal gastroesophageal reflux (GER). Seventy-six patients with obstructive sleep apnea hypopnea syndrome (OSAHS) underwent polysomnography (PSG) and nocturnal distal esophageal pH monitoring, to assess the prevalence of GER in OSAHS patients. Among these patients, thirty-two OSAHS patients with GER disease had been operated on. Surgical treatment included uvulopalatopharyngoplasty (UPPP), inferior turbinate reduction, nasal septoplasty et al. After 6 months of surgical treatment, the PSG and pH probe testing were rechecked. The pre and post operative apnea-hypopnea index (AHI), micro-arousal index (MAI), lowest artery oxygen saturation (LSaO2), acidified index of distal esophagus (pHI) and percentage of acid contact time of esophagus were compared. The correlation analysis was also employed. The AHI of 76 OSAHS patients was (38.6 +/- 29.5)/h (average +/- s), GER was present in 48 patients (63.2 %). The pre and post operative AHI, MAI, LSaO2, pHI and percentage of ACT in 32 OSAHS patients associated with GER were (51.2 +/- 23.1)/h and (17.3 +/- 10.3)/h, (38.3 +/- 21.4 )/h and (14.5 +/- 10.0)/h, 0.698 +/- 0.107 and 0.858 +/- 0.076, (12.5 +/- 6.6)/h and (6.3 +/- 4.2)/h, (10.3 +/- 5.2)% and (4.5 +/- 2.9)%. The differences were statistically significant by matching t test (t were 10.95, 7.82, 15.97, 6.12, 7.62 respectively, P < 0.001). There were positive relationships between the reductions of AHI, MAI and the reductions of pHI (r were 0.775, 0.764, P < 0.001). The improved levels of AHI and MAI were correlated with the reduction of the percentage of ACT (r were 0.607, 0.730, P < 0.001). GER is prevalent in OSAHS patients. Surgical treatment of OSAHS has significant reduction in AHI, MAI as well as marked improvement in the GER, which suggests that nocturnal gastroesophageal reflux is correlated with the disorder of sleep respiration and the sleep disturbances.

Hiatal Hernia, Lower Esophageal Sphincter Incompetence, and Effectiveness of Nissen Fundoplication in the Spectrum of Gastroesophageal Reflux Disease

Background and AimsGastroesophageal reflux disease (GERD) is a spectrum of disease that includes nonerosive reflux disease (NERD), erosive reflux disease (ERD), and Barrett’s esophagus (BE). Treatment outcomes for patients with different stages have differed in many studies. In particular, acid suppressant medication therapy is reported to be less effective for treating patients with NERD and Barrett’s esophagus. The aims of this study were to investigate (1) the role of mechanical factors including hiatal hernia and lower esophageal sphincter (LES) competence in the spectrum of GERD and (2) outcomes of Nissen fundoplication. MethodsFrom the records of patients who had undergone laparoscopic Nissen fundoplication after an abnormal pH study, we identified 50 symptomatic consecutive patients with each of the GERD stages: (1) NERD, (2) mild ERD, defined as esophagitis that was healed with acid suppression therapy, (3) severe ERD, defined as esophagitis that persisted despite medical therapy, and (4) BE. Exclusion criteria were normal distal esophageal acid exposure, esophageal pH monitoring performed elsewhere, antireflux surgery less than 1 year previously or previous fundoplication, and a named esophageal motility disorder or distal esophageal low amplitude hypomotility. Patients who could not be contacted for the study were also excluded. All patients completed a detailed preoperative questionnaire; underwent preoperative upper gastrointestinal endoscopy, stationary manometry, and distal esophageal pH monitoring; and were interviewed at least 1 year after operation. ResultsOne hundred sixty patients meeting the entry criteria were studied. The mean follow-up period was 36.7 months. The only significant preoperative symptom difference was that patients with BE had more moderately severe or severe dysphagia compared to patients with NERD. Patients with severe ERD or BE had a significantly higher prevalence of hiatal hernia, lower LES pressures, and more esophageal acid exposure. Hiatal hernia and hypotensive LES were present in most patients with severe ERD or BE but in only a minority of patients with NERD or mild ERD. Surgical therapy resulted in similarly excellent symptom outcomes for patients in all GERD categories. ConclusionsCompared to mild ERD and NERD, severe ERD and BE are associated with significantly greater loss of the mechanical antireflux barrier as reflected in the presence of hiatal hernia and LES measurements. Restoration of the antireflux barrier and hernia reduction by laparoscopic Nissen fundoplication provides similarly excellent symptom control in all patients.

Clinical predictors of abnormal esophageal pH monitoring in preterm infants

Risk factors for gastroesophageal reflux disease in preterm neonates have not been yet clearly defined. To identify factors associated with increased esophageal acid exposition in preterm infants during the stay in the neonatal unit. A case-control study in preterm infants who had undergone prolonged monitoring of distal esophageal pH, following clinical indication. Eighty-seven preterms with reflux index (percentage of total time of esophageal pHmetry) > or = 10% (cases) and 87 unpaired preterms were selected with reflux index <10% (controls). Demographic variables, signs and symptoms, main diagnoses and some aspects of treatment were studied. Simple and multiple logistic regression analysis adjusted for birthweight and postconceptional age at the pH study were used. The factors associated with a greater chance of reflux index > or = 10% in preterms were: vomiting, regurgitation, Apnea, female gender. The variables that were associated with a lower frequency of increased reflux index were: volume of enteral intake at the onset of symptoms > or = 147 mL/kg/day, and postnatal corticoid use. Vomiting, regurgitation, apnea, female gender and acute respiratory distress during the first week of life were variables predictive of increased esophageal acid exposition in preterm infants with birthweight <2000 g. Bronchopulmonary dysplasia and use of caffeine were not associated with reflux index > or = 10%.

Oropharyngeal pH Monitoring for the Detection of Liquid and Aerosolized Supraesophageal Gastric Reflux

The association between gastroesophageal reflux disease (GERD) and extraesophageal symptoms is poorly understood and difficult to document. pH monitoring in this group of patients has resulted in conflicting data due to lack of diagnostic sensitivity. Recently, a new sensitive pH device for detection of liquid and aerosolized droplets in the oropharynx (The Dx-pH Measurement System [Dx-pH]) has become available. Our hypothesis is that we will be able to improve our ability to identify and understand this group of patients with this device. The aim of this preliminary observation study was to compare the results of this new device to the standard esophageal and pharyngeal pH probes in a small group of patients with extraesophageal symptoms. Patients with suspected extraesophageal GER symptoms underwent traditional 24-hour esophago-pharyngeal pH monitoring (24pH) simultaneous with Dx-pH monitoring in the oropharynx. Tracings were reviewed for comparison and correlation between the two probes, with an event in the Dx-pH Probe being defined as a rapid drop >3 standard deviation from baseline. Fifteen patients (10 females, 5 males) with mean age of 57.5 years (range, 25-75) were studied. The predominant chief complaint included 12/15 chronic cough, 2/15 asthma; and 1/15 throat clearing. All Dx-pH events were preceded and associated with distal esophageal pH drops in a progressive ante grade manner. Ten patients had 1-13 abnormal oropharyngeal pH events as measured by Dx-pH monitoring with a total of 48 events. The median pH of reflux events had a statistically significant increase from 3.1 at the distal esophageal probe to 5.2 at the pharynx and 5.6 at the oropharynx, the latter being 80% higher than the distal esophageal probe (P<0.001). The percentage of acid events decreased in a cephalad manner from 66.7% at distal esophagus to 25% at the pharynx and only 6.25% at the oropharyngeal Dx-pH Probe, with the remaining events being weakly acidic. Dx-pH Probe is a new sensitive oropharyngeal pH device whose values correlate well with the gold-standard 24-hour pH device, and appears to accurately detect pH events that begin at the distal esophagus and travel upward to the oropharynx. This device suggests that supraesophageal events manifest themselves as rapid pH drops (>10%), which are likely not to be identified using the standard criteria of pH <4 due to the gradient of increasing pH from the lower esophagus to the oropharynx.

Diagnosis and management of supraesophageal complications of reflux disease

Supraesophageal reflux disease may manifest in numerous ways, including reflux laryngitis, long-term cough, long-term sinusitis, and dental enamel loss. The mechanisms of pharyngeal and laryngeal reflux are not clearly defined, and standard reflux testing does not consistently demonstrate supraesophageal reflux. The diagnosis is usually based on clinical suspicion when other causes of symptoms are not found and on the patient’s response to empiric acid suppression. With the development of dual-and triple-probe pH monitoring, through which proximal esophageal pH can be assessed along with distal esophageal pH, the physician may be able to correlate reflux with patient symptoms. Therapy consists primarily of behavioral modifications and aggressive acid suppression, though some alternative therapies do exist.

High Prevalence of Proximal and Distal Gastroesophageal Reflux Disease in Advanced COPD

Gastroesophageal reflux disease (GERD) is common in a variety of chronic respiratory diseases, but little is known about GERD in the setting of COPD. The aims of this study were to determine the prevalence, presentation, and predictors of GERD based on proximal and distal esophageal pH monitoring in patients with severe COPD. Forty-one COPD patients with a mean FEV1 of 24% of predicted underwent dual-probe 24-h esophageal pH monitoring, and 1 patient underwent esophagogastroduodenoscopy. The prevalence of GERD was 57%. Elevated distal and proximal reflux were present in 41% and 46% of patients undergoing esophageal pH studies, respectively. Fifteen percent of these patients had abnormal proximal reflux despite having normal distal probe results. Most patients with GERD were not receiving acid blockers at the time of their referral, and only one third reported heartburn and/or acid regurgitation during the pH study. Only higher body mass index was predictive of reflux on regression analysis (odds ratio, 1.2; 95% confidence interval, 1.0 to 1.5; p = 0.05). GERD is common in advanced COPD. Patients are often asymptomatic and have a relatively high prevalence of isolated abnormal proximal reflux. Dual-probe monitoring is therefore well suited for detecting GERD in patients with advanced COPD.

Exclusion of pH Artifacts is Essential for Hypopharyngeal pH Monitoring

Published yields of pH monitoring for suspected laryngopharyngeal reflux (LPR) vary greatly. Hypopharyngeal pH artifacts may be responsible for these inconsistencies. To determine the impact of potential artifacts on pH monitoring of the hypopharynx and esophagus. Patients with suspected LPR were prospectively studied. Single-catheter, triple-sensor pH monitoring was performed off antireflux therapy. Subjects recorded meal times and marked liquid swallows outside of meals on the data recorder. Results were analyzed by excluding six potential pH artifacts individually and all together. Positive pH test was defined as three or more reflux episodes in hypopharynx, total percent of time pH less than 4 was 1.0% or greater in the proximal esophagus, and total percent of time pH less than 4 was 4.2% or greater in the distal esophagus. Wilcoxon rank sum and chi-square tests were used. Thirty-eight subjects (24 females; median age, 47 yr) completed the study. A total of 2,225 hypopharyngeal pH drops less than 4 were identified; 48% were short pH drops at less than 5 seconds, 17% within meal periods, 16% liquid swallows outside of meals, 16% isolated proximal pH drops, 12% pH out of range, and 5% pH drift. Eighty percent of the hypopharyngeal pH drops were at least one of the potential pH artifacts. The yield of the hypopharyngeal sensor was reduced by 45% (from 92% to 47%) after all potential pH artifacts were excluded. Yields of proximal and distal esophageal pH sensors were reduced by 19% and 8%, respectively, significantly less than the hypopharyngeal sensor (P < .01). Patients should record all liquid swallows outside of meals. It is essential to exclude all potential artifacts for hypopharyngeal pH monitoring in patients with suspected LPR.