Gastroesophageal Reflux Episodes Research Articles

Infant gastroesophageal reflux disease management consensus.

Infant gastroesophageal reflux is mostly benign; however, when associated with complications like failure to thrive, it may be indicative of gastroesophageal reflux disease. There are currently several unmet needs pertaining to the management of infant gastroesophageal reflux (disease). Reflux in infants is mostly composed of breast milk or formula, so this population is significantly different to older children and adults. The objective of this Delphi consensus was to establish recommendations based on published literature and the experience of clinical experts in paediatric gastroenterology in the context of infant gastroesophageal reflux (disease). The Delphi methodology was used to obtain a consensus on 18 statements relating to clinical aspects of infant gastroesophageal reflux (disease). The expert panel comprising paediatric gastroenterology clinical specialists reached a consensus for all statements by means of an online, anonymised voting system. It was highlighted that there is generally low awareness of or adherence to guidelines in clinical practice and that acid suppression therapy should not be indicated for non-acid reflux, which constitutes a significant proportion of total gastroesophageal reflux episodes among infants. Furthermore, it was emphasised that there is an unmet medical need for therapy for some symptomatic infants with non-acid reflux disease.

Prediction of gastroesophageal reflux episodes by smooth muscle electromyography: A translational study in rats and adolescents

AimsOur aim was to measure the myoelectric modifications during gastric acid secretion along with the gastric pH in a rat model and to detect the gastrointestinal (GI) myoelectric changes in adolescents suffering from gastroesophageal reflux disease (GERD) along with the esophageal pH measurement. Main methodsIn anesthetized rats, gastric acid secretion was initiated with intragastric histamine (50 mg/kg), and gastric pH, GI myoelectric activity and mechanical GI contractions were measured with intragastric pH electrode, subcutaneously implanted smooth muscle electromyography (SMEMG) electrodes and organ implanted strain gauges, respectively. In the clinical study, esophageal pH and GI myoelectric activity were measured in adolescents suffering from GERD with intraesophageal pH electrode and SMEMG electrodes placed on the abdominal surface, respectively. The SMEMG records were analyzed by fast Fourier transformation (FFT) and power spectrum density maximum (PsDmax) values were calculated for the GI segments. Key findingsIn rats, histamine initiated an immediate increase in gastric PsDmax, which preceded the significant reduction in gastric pH by 75 min. The myoelectric change was independent of mechanical GI contractions. In adolescents, the GERD episodes were preceded by a significant increase in gastric PsDmax 45 min earlier. These changes were independent of motion or meals. SignificanceIncreased gastric myoelectric activity during histamine stimulation or GERD might be linked to the enhanced activity of the gastric proton pump, indicating a link between gastric acid secretion and GERD episodes. It is supposed that SMEMG might be a tool for predicting forthcoming reflux episodes in GERD.

Magnetic sphincter augmentation: paradigm change or just another device in the surgeon's toolbox?

The common denominator for virtually all episodes of gastroesophageal reflux in health and disease is the loss of the barrier that confines the distal esophagus to the stomach. Factors important in maintaining the function of the barrier are its pressure, length and position. In early reflux disease, overeating, gastric distention and delayed gastric emptying led to a transient loss of the barrier. A permanent loss of the barrier occurs from inflammatory injury to the muscle allowing free flow of gastric juice into the esophageal body. Corrective therapy requires augmentation or restoration of the barrier referred to more commonly as the lower esophageal sphincter.

Change of Sleep Stage during Gastroesophageal Reflux in Infants.

This study intended to explore the existence of a temporal association of changes of sleep stage and gastroesophageal reflux (GER) in infants. Documentation of sleep stage and GER was conducted via the use of synchronized polygraphic recording combined with impedance-pH-metry in 15 infants. The total recording-time (Rt) was divided into GER-"window-time" (five seconds before and after the onset of a GER episode), "remaining GER time", and "GER-free time", and analyzed for changes of sleep stage. a total of 462 GER episodes were identified during Rt (151.1 h) in all infants. During 1.3 h of window-time; 61 changes of sleep stage (47/h); during 5.9 h of Remaining GER-time, 139 changes of sleep stage (24/h); and during 143.9 h of GER-free time, 4087 changes of sleep stage (28/h) were documented. Change of sleep stage was strongly associated with the onset of GER (p < 0.02 and p < 0.05, respectively). There is a strong temporal association between sleep irregularities, i.e., changes of sleep and episodes of GER in infants. When dealing with disturbed sleep in infants, GER should be considered by caregivers.

Effect of the reverse Trendelenburg position on the incidence of gastroesophageal reflux in dogs anesthetized for elective stifle surgery

ObjectiveTo determine if a 15° reverse Trendelenburg position decreases the incidence of gastroesophageal reflux (GER) compared with a horizontal position in dogs anesthetized for stifle surgery. Study designProspective, randomized parallel-arm study. AnimalsA total of 44 healthy client-owned dogs were enrolled and data from 36 dogs were analyzed. MethodsDogs requiring preoperative radiographs under anesthesia, or with a history of gastrointestinal signs or administered gastroprotectant therapy within 1 month of surgery were excluded. Anesthesia protocol was standardized to include hydromorphone, dexmedetomidine, ketamine, propofol and isoflurane. Dogs were randomly assigned at enrollment to be positioned in a 15° reverse Trendelenburg or a horizontal position for surgery. Continuous pH monitoring was documented throughout the procedure with a 6.4 Fr (2.13 mm) esophageal pH probe positioned in the distal esophagus via the oral cavity. GER was defined as pH < 4.0 (acidic) or > 7.5 (alkaline) for more than 30 seconds. The proportions of dogs developing GER were compared between groups using Fisher’s exact test. Time to reflux was compared using survival curves and the Gehan–Breslow–Wilcoxon test. Statistical significance was set as p < 0.05. ResultsAn episode of GER occurred in 11/36 (30%) dogs. Reflux was alkaline in two dogs and acidic in nine dogs. The proportion of dogs with GER was 5/18 (28%) and 6/18 (33%) for dogs in the reverse Trendelenburg position and horizontal position, respectively, and was not statistically significant (p > 0.99). Median (range) time until reflux was 44 (23–135) and 44.5 (9–56) minutes when dogs were positioned in reverse Trendelenburg position and horizontal position, respectively (p = 0.66; two-tailed Mann–Whitney U test). Conclusions and clinical relevancePositioning the surgery table in a 15° rostral elevation for dogs anesthetized for elective stifle surgical procedures did not decrease the incidence of GER.

Is there a direct relationship between hiatal hernia size, esophageal body hypomotility and symptomatic perception of gastroesophageal reflux episodes?

The esophagogastric junction (EGJ) is classified into 3 anatomical subtypes according to lower esophageal sphincter-crural diaphragm (LES-CD) separation. We aimed to assess their relationship to esophageal motility, reflux characteristics, and symptom perception. We analyzed data from 1740 consecutive patients with typical reflux symptoms, who underwent high resolution manometry and a 24-h pH-impedance study during a 13-year period. A diagnosis of gastroesophageal reflux disease (GERD) was made if acid exposure time (AET) was >6%. EGJ types were classified as 1, 2, or 3, if LES-CD separation was up to 1 cm, 1-3 cm, or ≥3 cm, respectively. EGJ type distribution was 72.2%, 22.1% and 5.7%, for types 1, 2 and 3, respectively. GERD was diagnosed in 31.2% and was more common among patients with EGJ type 2/3 vs. 1 (P<0.001). Length of LES-CD separation significantly correlated with AET and number of reflux episodes. Patients with type 2 or 3 EGJ more often showed ineffective or absent peristalsis compared with type 1 (P=0.008 and P<0.001 respectively). In the multivariate analysis, EGJ type 2/3 correlated with AET (P=0.001) and reflux episodes (P=0.041) but not with positive symptomatic markers or with ineffective/absent peristalsis. Our study confirms that EGJ anatomical morphology is a strong risk factor for GERD and correlates with both AET and the number of reflux events, though the length of separation is more important than the type. The multivariate analysis revealed that EGJ type 2 or 3 was not correlated with symptom perception or esophageal hypomotility.

Characteristics of gastroesophageal reflux disease in children with interstitial lung disease.

Childhood interstitial lung disease (chILD) is a rare group of respiratory tract disorders. One of the factors suggested to be associated with its etiopathogenesis is microaspiration related to gastroesophageal reflux disease (GERD). The aim of the present study was to determine the frequency and characteristics of GERD in children with chILD, with a particular focus on proximal GER episodes. This was a prospective cross-sectional study. Consecutive patients with chILD underwent 24-h multichannel intraluminal pH-impedance monitoring. Different types of gastroesophageal reflux episodes (GER) were recorded and compared with regard to the GERD diagnosis. Sixty-two children (median age of 1.22 years) were included. GERD was diagnosed in 20 (32.3%) of them. The GERD (+) and GERD (-) subgroups differed mainly in their esophageal exposure to acid content (2.9 vs. 1.0%, p = 0.02) and bolus exposure (3.0 vs. 1.4%, p < 0.0001), as well as total number of GER (72.5 vs. 42.0 p = 0.0004), acid GER (35.5 vs. 15.0 p = 0.004), and acid proximal GER (21.0 vs. 12.0 p = 0.02). There were no differences in the number of proximal GER comparing GERD (+) and GERD (-) subgroups. The frequency of GERD seems to be relatively high in the population of children with chILD used in this study. However, it has not demonstrated an association between proximal GER and GERD diagnosis in chILD, which casts uncertainty over the microaspiration theory proposed to link the two diseases. The latter conclusion, however, needs to be confirmed using more accurate aspiration assessment methods.

652. EVOLUTION OF BARRETT’S ESOPHAGUS IN PATIENTS WHO UNDERWENT UPPER DIGESTIVE TRACT SURGERY: RETROSPECTIVE STUDY AT HIGH VOLUME CENTER

Abstract Continuous episodes of Gastroesophageal reflux (GER) attack the esophageal mucosa and may lead to the unusual replacement of the squamous cell epithelium for the glandular columnar cell epithelium, with goblet cells. The intestinal metaplasia, in the esophageal mucosa characterizes Barrett's Esophagus (BE). BE occurs in 10 to 15% of chronic and long-term reflux patients. In addition, BE's epithelium is susceptible to chronic inflammation with risks for dysplasia and adenocarcinoma. We analyzed the impact of unconventional techniques on the evolution of Barrett's esophagus extension, as: Antrectomy (n = 1), Roux-en-Y Bypass (n = 5), Cardiomyotomy (n = 6), Esophagectomy (n = 10), Gastrectomy (n = 12), Lind fundoplication (n = 12). For this purpose, a retrospective study with BE patients treated at our service was carried out, evaluating the extension of Barrett's epithelium between the first and the last endoscopy of each patient. The greatest mean absolute regression of the BE extension was seen in esophagectomy, equivalent to 2.87 cm; esophagectomy combined with gastrectomy, 1.15 cm; and gastrectomy, with 0.97 cm. Antrectomy and procedures involving Roux-en-Y, in our series, did not reduce the extent of the columnar epithelium, actually showing progression or formation of Barrett's Esophagus. It is worth mentioning that Lind fundoplication, once the main treatment for GERD, obtained a mean regression of 0.37 cm in the BE extension, however it was not the treatment with the best result, and 17% of the evaluated patients showed lesion progression. The majority of evaluated procedures as alternative procedures for the treatment of reflux in patients with BE can be effective in controlling the evolution and even contributing to its regression.

Randomized, blinded, controlled clinical trial to assess gastroesophageal reflux and regurgitation in dogs undergoing general anesthesia after hydromorphone premedication with or without acepromazine or dexmedetomidine.

To investigate whether premedication with hydromorphone alone or combined with acepromazine or dexmedetomidine affects the incidence of gastroesophageal reflux (GER) and regurgitation in dogs undergoing general anesthesia for elective orthopedic surgery. 39 healthy client-owned dogs undergoing general anesthesia for elective orthopedic surgery between November 2016 and November 2018. For this prospective, randomized, controlled, blinded clinical trial, dogs were randomly assigned to be premedicated with hydromorphone (0.1 mg/kg, IM) alone (group H [control group]) or with either acepromazine (0.05 mg/kg, IM; group AH) or dexmedetomidine (6 μg/kg, IM; group DH) before undergoing general anesthesia induced with propofol and maintained with isoflurane. A pH sensor-tipped probe was used to identify episodes of GER (esophageal pH < 4 or > 7.5 for ≥ 30 seconds). Results for GER, regurgitation, vomiting, propofol dose, and durations of food withholding and anesthesia were compiled and compared across groups. There were 13 dogs in each group, and no meaningful differences were detected in age, body weight, sex, breed, or durations of anesthesia or food withholding across groups. Overall, 16 of the 39 (41%) dogs developed GER: 9 in group H, 6 in group AH, and 1 in group DH. The incidence of GER was significantly lower for group DH versus group H. Six of the 39 (15%) dogs regurgitated: 4 in group H and 2 in group AH. The combined use of dexmedetomidine and hydromorphone as premedication may be a better choice to reduce GER in healthy dogs undergoing orthopedic surgery than would the use of hydromorphone with or without acepromazine. Additional research is warranted.

The inability to belch syndrome: A study using concurrent high-resolution manometry and impedance monitoring.

IntroductionAlthough inability to belch has previously been linked to dysfunction of the upper esophageal sphincter (UES), its underlying pathogenesis remains unclear. Our aim was to study mechanisms underlying inability to belch and the effect of UES botulinum toxin (botox) injections in these patients.MethodsWe prospectively enrolled consecutive patients with symptoms of inability to belch. Patients underwent stationary high‐resolution impedance manometry (HRIM) with belch provocation and ambulatory 24‐h pH‐impedance monitoring before and 3 months after UES botox injection.ResultsEight patients (four males, age 18–37 years) were included. Complete and normal UES relaxation occurred in response to deglutition in all patients. A median number of 33(15–64) gastroesophageal gas reflux episodes were observed. Despite the subsequent increase in esophageal pressure (from −4.0 [−7.7–4.2] to 8 [3.3–16.1] mmHg; p < 0.012), none of the gastroesophageal gas reflux events resulted in UES relaxation. Periods of continuous high impedance levels, indicating air entrapment (median air presence time 10.5% [0–43]), were observed during 24‐h impedance monitoring. UES botox reduced UES basal pressure (from 95.7[41.2–154.0] to 29.2 [16.7–45.6] mmHg; p < 0.02) and restored belching capacity in all patients. As a result, esophageal air presence time decreased from 10.5% (0–43.4) to 0.7% (0.1–18.6; p < 0.02) and esophageal symptoms improved in all patients (VAS 6.0 [1.0–7.9] to 1.0 [0.0–2.5]; p < 0.012).ConclusionThe results of this study underpin the existence of a syndrome characterized by an inability to belch and support the hypothesis that ineffective UES relaxation, with subsequent esophageal air entrapment, may lead to esophageal symptoms.

Investigation of the frequency of application of physiotherapy in infants with gastroesophageal reflux

Introduction: Gastroesophageal reflux (GER) is defined as the reflux of gastric and/or intestinal contents into the esophagus. It is a common phenomenon, seen in 40-65% of infants and is due to transient relaxations of the lower esophageal sphincter.Many infants have daily episodes of GER, of short duration after meals, during sleepeven while awake. Its early diagnosis helps towards early intervention and successful treatment of complications. Furthermore, it contributes to improving the infant’s and the family’s quality of life. Physiotherapy as an adjunctive therapeutic intervention seems to be able to contribute significantly to the improvement of GER in infants. The goal is to improve movement, body posture, cardiorespiratory function and coordination in order to limit the phenomenon. Aim:The main purpose of this study was to investigate whether infants with GER, in addition to dietary and other instructions and any pharmaceutical intervention, also undergo physical therapy treatment to improve their symptoms. Additional objectives were to record the infant’s and the family’s quality of life, and to explore parents’ expectations of a physical therapy program. Patients and methods:Thirty infants with GER participated in the study. The research was conducted in Thessaloniki, Greece, in a regular pediatric gastroenterology clinic. The questionnaire was given to the parents and completed under the supervision of the researcher in case of need for clarification. Results:None of the 30 infants studied was following a physical therapy program. In addition, GER was found to have a great impact on parents’ quality of life, since 80% answered that they were significantly affected, not knowing how to manage the condition. Regarding the need for physical therapy intervention and informing parents, 70% answered that they would like to have information and help from a physical therapist. A percentage of 80% of parents were in favor of a physical therapy program that could contribute to the reductioneven the elimination of their children’s medication. Conclusions:Gastroesophageal reflux affects a large percentage of infants. In severe cases, if not treated in time, it can affect the health of young infants and the families’ quality of life. Most parents seem to trust a physical therapy program to improve their children’s health for the fastest recovery from GER. This research can be a pilot for further studies, in the context of a more holistic intervention by doctors and physical therapists in infants with GER symptoms.

Oesophageal pH-Impedance for the Diagnosis of Gastro-Oesophageal Reflux Disease: Validation of General Population Reference Values in Children with Chronic Neurological Impairments.

Diagnosis of gastro-oesophageal reflux disease (GORD) in children with chronic neurological impairment (NI) remains a clinical challenge. The study aimed to validate the relevance of the reference values used to assess gastro-oesophageal reflux (GOR) in children with NI and to determine the optimal cut-off level of the pH-impedance parameter with the best predictive value for outcomes associated with endoscopic assessments of the oesophagus. Sixty-seven children (32 male, 35 female; age: interquartile range, 5 years 6 months–14 years 10 months; median, 11 years 3 months) with NI were prospectively recruited for the study. The exclusion criteria were previous fundoplication and lack of consent for the study. All patients underwent evaluations for GOR disease, including pH-impedance and gastroscopy. Based on endoscopy, oesophagitis was diagnosed in 22/67 children (32.8%); 9/67 (13.4%) were classified as having Hetzel–Dent grade III or IV. GOR was present in 18/67 children (26.9%), as determined by pH-impedance. Patients with endoscopic lesions had a significantly higher number of total reflux (p = 0.0404) and acidic episodes (p = 0.0219). The total number of reflux episodes, with a cut-off level of 44 episodes, was the pH-impedance parameter most strongly predictive of the presence of lesions in gastroscopy (specificity: 50%, sensitivity: 73%). These findings suggest that endoscopic lesions may be present in children with chronic NI with a low number of GOR episodes, as recorded by pH-impedance. The use of standardised reference norms determined for the general population may underestimate GOR episodes in this group of patients.

Nutrients Consumption Affect the Number of Gastroesophageal Refluxes and Oesophageal Acidity in Children

ObjectivesTo evaluate the correlation between types and number of gastroesophageal refluxes and nutrients consumption in children and adolescents. MethodsThe study was approved by IEC. The data of examination of 219 children (7–17 y.o.), 147 with GERD and 72 controls served as a source for the study. The amount and types of GER were determined using 24-hours esophageal pH-impedansometry (Ohmega, MMS, The Netherlands). Food frequency questionnaire was used to evaluate level of nutrients consumption. To make possible comparison of data obtained in different age and sex groups of children, direct levels of nutrients consumption were converted to a percentage deviation from the recommended daily allowance rates. Spearman rank correlation analysis was performed with the use of Statistica 10 (StatSoft Inc., USA) to reveal association between usual nutrition and number of gastroesophageal reflux episodes, their acidity and duration in children. ResultsStatistically significant (p < .05) correlation of Acid exposure time was found with amounts of PUFA (Spearman R = –0.334), ω-3 (R = –0.33), ω-6 (R = –0.3); retinols (R = –0.34), niacin (R = –0.28) and ascorbic acid (R = –0.37) consumption. The number of acid refluxes correlated with energy values of the ration (R = 0.269), amount of total protein (R = 0.279), total fat (R = 0.272), total carbohydrates (R = 0.152), and added sugar (R = 0.157) consumption. The number of weak-acid refluxes was not correlated with any of the parameters of actual nutrition. We found significant correlation between the number of non-acid refluxes and amount of PUFAs (R = 0.19), ω-6 (R = 0.151), ω-3 (R = 0.19); sodium (R = 0.158), phosphorus (R = 0.166), vitamin B1 (R = 0.17), niacin (R = 0.19), and ascorbic acid (0.23). ConclusionsWe found that types and number of gastroesophageal refluxes, as well as acidification of the lower part of oesophagus may be associated with diet in children. Our results may mean that different nutrients have different impact on esophageal motility in children. The results may have practical outcome for planning non-pharmacological intervention in children with GERD Funding SourcesMinistry of Science and Hiigher Education of Russia, research project #0529–2019-0055.

La impedanciometría multicanal con pHmetría de 24 h: una herramienta útil para estudiar lactantes con eventos de aparente amenaza a la vida

Infants with events of apparent threat to life should be hospitalized for evaluation. Gastroesophageal reflux is one of the possible etiologies. Multichannel intraluminal impedanciometry – 24-hour pHmetry is a diagnostic tool that assesses the behavior of pH-independent reflux. Objectives. To describe the parameters of the gastroesophageal reflux measured by multichannel intraluminal impedanciometry – 24-hour pHmetry in infants with events of apparent threat to life. Identify if there are differences between those with positive symptomatic correlation with drowning compared to those without symptomatic correlation. Method. Descriptive, comparative, retrospective and observational study realized between 2005 and 2015. The population were infants under seven months hospitalized by events of apparent threat to life in thepediatrics sector of the Hospital Italiano who underwent multichannel intraluminal impedanciometry – 24-hour pHmetry due to suspected gastroesophageal reflux. Results. 125 patients were evaluated. The median age was 55,7 days of life (range 6-209 days). It was divided into two groups: GI: infants with symptomatic correlation with choking: (32,8% N = 41) and GII: without symptomatic correlation (67,2%, N = 84). Significant statistical differences were observed in: total number of gastroesophageal reflux episodes, episodes that reached proximal channels; clearance time, but not with number of acidic, non-acidic episodes and pHmetry score. Conclusion. Infants with episodes of events of apparent threat to life represent a diagnostic challenge. Gastroesophageal reflux is a potential trigger. The information obtained with the multichannel intraluminal impedanciometry – 24-hour pHmetry in this cohort was useful to better understand the mechanisms involved in this clinical association and thus choose the most appropriate therapy.

The Role of Combined Multichannel Intraluminal Impedance-pH Monitoring in Infants with Brief, Resolved, Unexplained Events.

PurposeData on the relationship between gastroesophageal reflux (GER) and brief resolved unexplained events (BRUE) in infants is scarce. The aim of this study was to identify the characteristics of combined multichannel intraluminal impedance-pH (MII-pH) monitoring in infants who have experienced BRUE.MethodsWe conducted a prospective study of infants who were hospitalized on account of BRUE and required 24-hour MII-pH monitoring.ResultsTwenty-one infants (mean age, 4.7 months; range, 0.9–8.9 months; male/female, 11/10) participated in this study. BRUE symptoms associated with GER were found in 10 infants (47.6%). Based on the RI on pH-metry alone, only 7 (33.3%) infants were diagnosed with GERD. More than 100 GER episodes detected by MII were found in 10 (47.6%) infants. Nineteen percent of infants were diagnosed with GERD based on both pH and MII.ConclusionBoth acid and non-acid reflux seem to play a significant role in the pathogenesis of GER-related BRUE in infants.

Analysis of the effect of noninvasive positive-pressure ventilation with simultaneous detection of Dx-pH monitoring in oropharynx and esophagus for 48 hours in patients with moderate and severe OSA

Objective:To investigate the effect of noninvasive positive-pressure ventilation（NPPV） on the related indexes of gastroesophageal reflux（GER） and laryngopharyngeal reflux（LPR） in patients with moderate and severe obstructive sleep apnea（OSA）. Method:This was a retrospective study of 23 cases with moderate or severe OSA and suspected laryngopharyngeal reflux disease （LPRD）. The results of 48h-pH monitoring of oropharynx and esophagus, polysomnography（PSG） and NPPV were analyzed to explore the relationship between reflux related parameters and sleep disordered respiratory. To analyze the impact of NPPV on reflux, the data related to nocturnal reflux with or without NPPV treatment was compared. Result:On the first day of Dx-pH, 5 cases of LPRD were diagnosed with a positive Ryan score rate of 21.7%. There were 19 cases（82.6%） with more than one nocturnal reflux event with pH6.0 as the threshold. Ten cases of GERD were diagnosed with a positive DeMeester score rate of 43.5%. The lowest pH value of oropharynx and esophagus was negatively correlated with the obstructive apnea index（OAI）. The total number of reflux episodes falling below pH thresholds of 6.0 and the duration of the longest episode of gastroesophageal reflux were positively correlated with AHI and OAI（P<0.05）. On the night of NPPV treatment, the lowest pH value in the oropharynx increased, while the total number of reflux episodes below pH6.0 and the percentage time below pH5.0 decreased（P<0.05）. Similar significant difference was found in the GER parameters（P<0.05）. Conclusion:OSA patients were associated with a higher incidence of GER at night and a certain degree of LPR. NPPV treatment can not only effectively improve GER, but also reduce LPR to a certain extent.

The mechanisms associated with reflux episodes in ambulant subjects with gastro-esophageal reflux disease.

The mechanisms associated with gastro-esophageal reflux (GER) episodes were studied using combined High-resolution Impedance Manometry (HRIM) and pH monitoring in ambulant subjects with different patterns of GERD. Sixteen subjects with mild-moderate esophagitis (Los Angeles (LA) grade A&B) (group A) and 11 subjects with severe esophagitis (LA grade C&D) or Barrett's esophagus (BE) were studied before and after a meal, resting, while walking, and during standardized exercise, using a HRIM and a pH probe. Post-prandial acid GER episodes were more common in group B (median 10 range (3-18) vs A (6.5 (0-18), p=0.048). Postprandial acid clearance time was much longer in group B (median 0.71( 0.07-2.66min) vs A (0.17 (0.04-2.44 min), p=0.02). Transient lower esophageal sphincter relaxation (TLESR) was the most frequent mechanism associated with GER episodes in both groups. Post-prandial TLESRs with GER were more common in group B (median 17 (9-24) vs A 13.5 (7-34), p=0.014), particularly during exercise (B 8 (6-9) vs A 6 (5-6.8), p=0.007). Post-prandially TLESR with acid reflux increased during exercise in both groups (A rest median 2.4 (0-6.4) per hour vs exercise 4.7 (0-17.3), p=0.005 and B 4 (0.8-9.6) vs 5.3 (2.7-13.3) per hour, p=0.045). TLESR was the most common mechanism associated with reflux episodes in all subjects. Acid reflux episodes were more common in subjects with severe esophagitis or BE and esophageal acid clearance was much slower. Post-prandial exercise increased TLESR with acid reflux and GERD patients should be encouraged to avoid exercise immediately after a meal.

Incidence of Gastroesophageal Reflux in Dogs Undergoing Orthopaedic Surgery or Endoscopic Evaluation of the Upper Gastrointestinal Tract.

Gastroesophageal reflux (GER) is a common event during general anaesthesia but is often underdiagnosed in veterinary medicine. The oesophageal pH in anaesthetised dogs undergoing endoscopic evaluation of the upper gastrointestinal tract (END group; n = 12) or orthopaedic surgery (ORT group; n = 12) was measured using an oesophageal probe. The dogs were sedated with acepromazine or with methadone or butorphanol, and anaesthesia was induced with propofol and maintained with isoflurane. Of the 24 dogs in this study, 21 (87.5%) had an episode of GER during anaesthesia. The incidence of GER, as well as the first, the minimum, and the maximum pH values, did not differ significantly between the groups. The mean maximum difference versus the first pH value was higher for dogs in the END group (−2.6 ± 3.5) as compared with those in the ORT group (−0.7 ± 2.5), although they were not statistically significant (p = 0.25). The administration of methadone or butorphanol had no significant effect on the development of acidic reflux or biliary reflux. In the acepromazine-sedated dogs, the incidence of GER did not differ significantly between patients undergoing an endoscopic procedure and those undergoing orthopaedic surgery; however, during endoscopy, fluctuations in the oesophageal pH can be expected, even without any clinical signs of GER.

Postprandial proximal gastric acid pocket and its association with gastroesophageal acid reflux in patients with short-segment Barrett's esophagus.

To determine the characteristics of postprandial proximal gastric acid pockets (PPGAPs) and their association with gastroesophageal acid reflux in patients with Barrett's esophagus (BE). Fifteen patients with BE (defined by columnar lined esophagus of ≥1 cm) and 15 healthy individuals that were matched for age, gender, and body mass index, were recruited. The fasting intragastric pH and the appearance time, length, lowest pH, and mean pH of the PPGAP were determined using a single pH electrode pull-through experiment. For BE patients, a gastroesophageal reflux disease questionnaire (GerdQ) was completed and esophageal 24-h pH monitoring was carried out. The PPGAP was significantly longer (5 (3, 5) cm vs. 2 (1, 2) cm) and the lowest pH (1.1 (0.8, 1.5) vs. 1.6 (1.4, 1.9)) was significantly lower in patients with short-segment BE than in healthy individuals. The PPGAP started to appear proximally from the gastroesophageal pH step-up point to the esophageal lumen. The acidity of the PPGAP was higher in the distal segment than in the proximal segment. In short-segment BE patients, there were significant correlations between the acidity and the appearance time and length of the PPGAP. The length and acidity of the PPGAP were positively associated with gastroesophageal acid reflux episodes. The acidity of the PPGAP was associated with the DeMeester scores, the GerdQ scores, and the fasting intragastric pH. In patients with short-segment BE, a PPGAP is commonly seen. Its length and acidity of PPGAP are associated with gastroesophageal acid reflux, the DeMeester score, and the GerdQ score in patients with short-segment BE.

Transient Lower Esophageal Sphincter Relaxations and Mechanical Incompetence of the Lower Esophageal Sphincter – Is There a Relationship?

Introduction: The detailed process of a gastroesophageal reflux event is still under controversial discussion. Gastroenterologists have developed and favor the concept of Transient Lower esophageal Sphincter Relaxations (TLESR`s) as the major cause of gastroesophageal reflux episodes. TLESR`s are related with reflux episodes both in healthy individuals and patients with GERD. Another concept around the functional mechanism of the antirefluxbarrier is a more mechanical interpretation of the Lower Esophageal Sphincter (LES), developed by surgeons. The aim of this study is to investigate this relationship between TLESR`s and the mechanical failure of the LES by investigating these criteria in the same individuals. Methods: In a referral center for esophageal and gastric functional disease at the University Hospital in Würzburg, Germany, we investigated healthy volunteers and patients with proven GERD. The assessment of the LES consisted of the overall length, the intraabdominal length, and the end-expiratory pressure of the LES. The manometry was performed in a station-to-station-pull-through technique. The changing LES pressure and the TLESRs were measured with a sleeve catheter according to the protocol published by Dent and Schoeman. The presence of pathologic reflux in patients was evaluated by 24h pH monitoring. Results: In total, 8 healthy volunteers were investigated (median age: 26 years (22-34)). In addition, 21 patients with GERD were evaluated (median age: 49 years (25-68)). The frequency of TLESR´s was quite low in volunteers and patients with 0,4 TLESR`s/h and 0,6 TLESR`s/h respectively. While the frequency of TLESR`s was not different between volunteers and GERD-patients, the percentage of reflux-associated TLESR`s was significantly higher in GERD-patients with mechanically incompetent LES (20,8%), compared to the percentage in GERD-patients with intact LES (6,8%) and also compared to the percentage in healthy volunteers (7,8%) (p<0,001). Conclusion: The present analysis shows a relationship between a mechanically incompetent LES and an increased number of reflux-associated TLESR`s, suggesting that the two mechanisms are not mutually exclusive, but may be instead different measurements of the same condition - a functionally and mechanically defective LES.