Esophageal Acid Exposure Research Articles

The Role of the Transdiaphragmatic Pressure Gradient (TGP) in the Pathophysiology of Proximal Reflux

IntroductionAn increased transdiaphragmatic pressure gradient (TGP) is a main element for distal gastroesophageal reflux disease (GERD). The role of TGP for proximal reflux is still unclear. This study aims to evaluate the presence, severity, and importance of proximal reflux in relationship to the TGP, comparing healthy volunteers, obese individuals, and patients with chronic obstructive pulmonary disease (COPD). MethodsWe studied 114 individuals comprising 19 healthy lean volunteers, 47 obese individuals (mean body mass index 45 ± 7 kg/m2), and 48 patients with COPD. All patients underwent high-resolution manometry and dual-channel esophageal pH monitoring. Esophageal motility, thoracic pressure (TP), abdominal pressure (AP), TGP, DeMeester score, and % of proximal acid exposure time (pAET) were recorded. ResultsPathologic distal GERD was found in 0, 44, and 57% of the volunteers, obese, and COPD groups, respectively. pAET was similar among groups, only higher for obese individuals GERD + as compared to obese individuals GERD − and COPD GERD −. pAET did not correlate with any parameter in healthy individuals, but it correlated with AP in the obese, TP in the COPD individuals, and TGP and DeMeester score in both groups. When all individuals were analyzed as a total, pAET correlated with AP, TGP, and DeMeester score. DeMeester score was the only independent variable that correlated with pAET. ConclusionsOur results show that (a) TGP is an important mechanism associated with distal esophageal acid exposure and this fact is linked with proximal acid exposure and (b) obesity and COPD both seem to be primary causes for GERD but not directly for proximal reflux.

Minimally Invasive “3-Stitch” Modification of the Dor Fundoplication: Simple and Effective

A 180-degree anterior (Dor) fundoplication is usually paired with an esophagogastric myotomy in the surgical treatment of achalasia. The traditional technique, however, is not easily reversible and the execution is variable. This study examined a simplified ''3-stitch'' Dor fundoplication that addressed these challenges and presented the results. A prospectively collected, longitudinal surgical achalasia database was queried for patients undergoing a Heller myotomy with '3-stitch 180-degree fundoplication from 2008 to 2019. Preoperative and postoperative Eckardt score, postoperative DeMeester score (24- or 48-hour pH studies), and endoscopic evidence of esophagitis were collected and analyzed to determine the effectiveness and safety of the fundoplication. Length of stay and complications were also considered. The pH testing was performed in 296 patients, with 17% (50 of 296) demonstrating abnormal esophageal acid exposure. Of this group, only 8% (16 of 201) manifested clinical esophagitis on upper endoscopy. A total of 14% (7 of 50) of patients with abnormal esophageal acid exposure were symptomatic. Total postoperative Eckhardt scores for this cohort were 3 or lower in 92% of patients, with a dysphagia-specific score of 0 in 92%. The technical details of a modified 180-degree anterior fundoplication are described. The 3-stitch Dor fundoplication is an effective addition to a minimally invasive Heller myotomy, with good palliation of symptoms and an acceptable rate of acid reflux. The simplified construction anticipates the potential progression of esophageal dysmotility in patients with achalasia, and the modified technique is reproducible and readily teachable.

Evaluation and Management of Patients with PPI-Refractory Heartburn

To use recent insights on the causes and treatment of PPI-refractory heartburn to formulate an effective approach to patient management. PPI-refractory heartburn results from 5 major potential mechanisms: (1) PPIs have not normalized esophageal acid exposure; (2) PPIs have normalized esophageal acid exposure, but there is reflux hypersensitivity in which persistent “physiologic” reflux events evoke heartburn; (3) the sensation of heartburn is caused by an esophageal disorder other than GERD (e.g., eosinophilic esophagitis, achalasia); (4) the sensation of heartburn is caused by an extra-esophageal disorder (e.g., heart disease, pancreaticobiliary disease); or (5) heartburn is functional. A systematic work-up that includes careful medical history, endoscopy with esophageal biopsy, esophageal manometry, and esophageal impedance-pH monitoring can distinguish among these mechanisms. A systematic work-up will reveal that GERD is not the cause of PPI-refractory heartburn in the large majority of cases. In the minority of patients for whom the work-up establishes that PPI-refractory heartburn is reflux-related, however, antireflux surgery is superior to medical therapy.

Current Insights in the Pathophysiology of Gastroesophageal Reflux Disease.

The pathophysiology of Gastroesophageal reflux disease (GERD) is multifactorial determined and remains a matter of discussions between the involved medical subspecialties, mainly gastroenterologists and gastrointestinal surgeons, but also ear-nose-and-throat colleagues and pulmonologists. The purpose of this manuscript is an overview on the different pathophysiologic components of GERD, their influence as well as a certain weighing of their involvement in the disease. The lower esophageal sphincter (LES) represents together with the muscles and ligamentous structures of the diaphragm at the esophageal hiatus the antireflux barrier between esophagus and stomach. The crucial factor in GERD is an increased amount of gastric contents refluxing into the esophagus above the physiologic level. This creates pathologic esophageal acid exposure (EAE) to the mucosa, which may lead to symptoms and damage. The underlying pathophysiologic mechanisms are anatomical components such as LES and diaphragm, and functional components such as LES-incompetence, transient LES relaxations, impaired esophageal motility, gastroduodenal dysfunctions and alterations of the refluxate such as duodeno-gastro-esophageal reflux. The quantitative assessment of these components has been reported in a number of studies demonstrating the importance of LES-incompetence (incidence 80 %) and the role of hiatal hernia (incidence 80 %) in the severity of GERD indicated by excessive esophageal acid exposure and visible damage of the esophageal mucosa. All known pathophysiologic components of GERD can be investigated currently by diagnostic assessment, detecting a LES-incompetence or an increase in transient relaxations, detecting a hiatal hernia with increasing size, detecting increasing exposure to gastric contents in addition to other possible functional associated disorders such as an insufficient esophageal motility and or a delayed gastric emptying, which all can aggravate the disease and the patient's status.

Clinical spectrum and presentation of patients with absent contractility

BackgroundPrimary absent contractility is an uncommon finding on high-resolution manometry (HRM). The goal of this study was to describe the clinical spectrum and presentation of patients with primary absent contractility.MethodsWe queried a prospectively maintained esophageal testing registry to identify patients with absent contractility who presented between August 2016 and September 2018. Patients with poor quality studies and patients with insufficient clinical records as well as those with a history of previous foregut surgery or esophagram consistent with achalasia were excluded.ResultsA total of 2068 patients underwent HRM during the study period. Of these, 66 patients (3.2%) met the inclusion criteria and formed the study cohort; 52 patients in the cohort had an upper gastrointestinal contrast study, 50 had endoscopy, and 51 completed a foregut symptom questionnaire. Thirty-eight patients (57.6%) were women. The mean age was 56.6±13.86 years, and the mean body mass index was 26.37±5.7 kg/m2. Almost half of the patients (29/66, 43.9%) were undergoing lung transplant evaluation, and 22 patients (37.3%) had a history of autoimmune immune-mediated or myopathic diseases. On the symptom questionnaire, 42 of 51 patients (82.3%) reported heartburn, 24 of 51 (47.1%) reported dysphagia, and 23 of 51 patients (45.1%) reported both. On ambulatory pH monitoring, 23 of 37 patients (62.2%) had pathological esophageal acid exposure (acid exposure time >6%).ConclusionsAbsent contractility on HRM is uncommon and is frequently associated with connective tissue, myopathic or autoimmune disorders. The usual clinical presentation is reflux, dysphagia or both.

Diagnostic accuracy of multichannel intraluminal impedance-pH monitoring for gastroesophageal reflux-induced chronic cough

Objectives:To elucidate the accuracy and advantages of Multichannel intraluminal impedance-pH monitoring (MII-pH) in diagnosing gastroesophageal reflux-induced chronic cough (GERC).Methods:The patients with suspected GERC were recruited and underwent MII-pH, GERC was confirmed by subsequent anti-reflux treatment despite the findings of MII-pH. Its diagnostic accuracy in identifying GERC were evaluated by receiver operating characteristic (ROC) analysis and compared with that of 24-h esophageal pH monitoring.Results:Among 158 patients completing both MII-pH and anti-reflux therapy, GERC was diagnosed in 136 patients, including acid GERC in 96 patients (70.6%), non-acid GERC in 30 patients (22.0%), neither one of both GERC in 10 patients (7.4%). For the identification of GERC, MII-pH presented with the sensitivity of 92.6%, specificity of 63.6%, positive predictive value of 94.0%, negative predictive value of 58.3% and area under ROC curve of 0.863, which was totally superior to 24-h esophageal pH monitoring. As the essential criteria of MII-pH, esophageal acid exposure time and symptom associated probability had a limited diagnostic value when used alone, but improved greatly the diagnostic yield when used in combination, even with a suboptimal efficacy.Conclusion:MII-pH is a more sensitive test for identifying GERC, but with a suboptimal diagnostic efficacy.

Normal acid exposure time in esophageal pH monitoring in Asian and Western populations: A systematic review and meta-analysis.

Esophageal acid exposure time (AET) during 24h pH monitoring is reproducible and predictive outcomes of treatment for gastroesophageal reflux disease. Several small Asian studies have investigated the normal range of the AET; the range may be different from that in Western populations. We evaluated its normal range in healthy Asian compared to Western subjects. We searched PubMed, Embase, Cochrane Library, and KoreaMed for studies that reported pH monitoring parameters in healthy subjects. Studies that reported the AET values of healthy subjects were eligible for the analyses. The upper limit of normal of the AET was obtained from the 95th percentile of the available raw data or calculated as the mean value +2 standard deviations. Nineteen Asian and 49 Western studies were assessed. The estimated AET values were analyzed using a bootstrapping technique, weighted according to the sample size. The mean AET was 1.1% and 2.9% in the Asian and Western populations, respectively. The upper limit of the reference range was 3.2% (95% confidence interval [CI], 2.7-3.9%) and 8.2 (95% CI, 6.7-9.9) in the Asian and Western populations, respectively. The normal AET differed between the Asian and Western populations because the CI of the two groups did not overlap. The upper limit of normal of the AET in healthy Asian subjects was 3.2% (95% CI, 2.7-3.9%), which was lower than that of healthy Western subjects.

Simultaneous Laryngopharyngeal and Conventional Esophageal pH Monitoring.

In addition to typical reflux symptoms, many patients with gastroesophageal reflux disease (GERD) present with extraesophageal symptoms such as cough, hoarseness or asthma, which can be caused by laryngopharyngeal reflux (LPR). Due to their multifactorial origin, those symptoms can be a great diagnostic and therapeutic challenge. Esophageal pH-monitoring is commonly used to determine abnormal esophageal acid exposure and confirm the diagnosis of GERD. However, for better evaluation of acid exposure above the upper esophageal sphincter, a new laryngopharyngeal pH measurement system is now available and may lead to more reliable results in patients with predominantly extraesophageal symptoms. This article aims to present a standardized protocol for simultaneous pH measurement using esophageal and laryngopharyngeal pH probes in order to obtain acid exposure scores from both measurements.

Overlap of functional heartburn and reflux hypersensitivity with proven gastroesophageal reflux disease

AbstractBackgroundWhen esophageal acid exposure time (AET) is physiologic, ROME IV stratifies functional esophageal disorders into functional heartburn (FH, with negative reflux‐symptom association) and reflux hypersensitivity (RH, with positive reflux‐symptom association), and hypothesizes that FH/RH could overlap with proven gastroesophageal reflux disease (GERD). We compared conventional FH/RH diagnosed off antisecretory therapy with overlap FH/RH coexisting with proven GERD.MethodsAdult patients with heartburn underwent pH‐impedance testing on therapy (proven GERD) and off therapy (unproven GERD) and completed validated questionnaires defining symptoms (Reflux Diagnostic Questionnaire, RDQ), affective state (Hospital Anxiety and Depression Scale, HADS; Visceral Sensitivity Index, VSI), and functional diagnoses (irritable bowel syndrome, IBS; functional dyspepsia, FD on ROME diagnostic questionnaire). AET (pathologic: >6%, physiologic <4%) and mean nocturnal baseline impedance (MNBI) were calculated. Clinical, psychological, and functional profiles were compared between FH and RH and to a comparison cohort of non‐erosive reflux disease (NERD, AET > 6%).Key ResultsStudy patients included 19 with RH (10 with overlap RH), 60 with FH (31 with overlap FH), and 26 patients with NERD. Clinical, psychological, and functional profiles of conventional FH/RH were similar to overlap FH/RH. Compared with NERD, combined FH and RH cohorts had higher anxiety scores, and lower proportions with IBS. Compared with FH with low MNBI, FH defined using both normal AET and normal MNBI had higher depression scores (p = 0.008), and trended toward higher anxiety scores (p = 0.059).Conclusions and InferencesConventional and overlap FH and RH have similar clinical, psychological and functional profiles, thereby proving ROME IV hypotheses.

Prevalence of behavioral disorders in patients with vonoprazan-refractory reflux symptoms.

Behavioral disorders, such as supragastric belching (SGB) and rumination syndrome (RS), which may be treated by cognitive behavioral therapy, are common in patients with reflux symptoms refractory to proton pump inhibitors (PPI). Vonoprazan (VPZ) has been used as a new type of acid inhibitor in Japan since 2015. We herein investigated the prevalence of behavioral disorders in patients with VPZ-refractory reflux symptoms and attempted to identify predictive factors. We retrospectively analyzed esophagogastroduodenograms, high-resolution manometry, and 24-h multiluminal impedance pH-metry (MIIpH) in patients with VPZ-refractory reflux symptoms (heartburn or regurgitation) receiving 20mg VPZ who underwent these tests at our hospital between January 2015 and April 2020. Patients were divided as follows: non-erosive reflux disease with pathological esophageal acid exposure (NERD), functional heartburn (FH), reflux hypersensitivity (RH), excessive (> 13 per day) SGB, and possible RS based on MIIpH parameters. Among 49 patients, 6 (12.2%) had SGB, 4 (8.2%) possible RS, 29 (59.2%) FH, 9 (18.4%) RH, and 1 (2%) NERD. Possible RS patients had more postprandial non-acid reflux events than FH patients (p < 0.05). The multivariate logistic regression analysis did not identify any predictive factors with statistical significance. More than 20% patients with VPZ-refractory reflux symptoms had behavioral disorders. The use of HRM and MIIpH may be clinically relevant for a better diagnosis and more specific treatment.

Pathophysiological Mechanisms of Gastro-esophageal Reflux After Sleeve Gastrectomy.

To evaluate the mechanisms associated with reflux events after sleeve gastrectomy (SG). Gastro-esophageal reflux (GERD) post-SG is a critical issue due to symptom severity, impact on quality of life, requirement for reoperation, and potential for Barrett esophagus. The pathophysiology is incompletely delineated. Post-SG patients, stratified into asymptomatic and symptomatic, underwent protocolized nuclear scintigraphy (n = 83), 24-hour esophageal pH monitoring, and stationary manometry (n = 143) to characterize reflux patterns. Ten patients underwent fasting and postprandial concurrent manometry and pH for detailed analysis of reflux events. Baseline demographics between cohorts were similar: Age 47.2 ± 11.6 versus 44.1 ± 11.3 years ( P = 0.121); females 73.2% versus 90.8% ( P = 0.005); excess weight loss 53.8 ± 28.1% versus 57.4 ± 25.5% ( P = 0.422), follow-up duration 12.3 versus 7.4 months ( P = 0.503). Nuclear scintigraphy delineated bolus-induced deglutitive reflux events (29.6% vs 62.5%, P = 0.005) and postprandial reflux events [4 (IQR2) versus 4 (IQR 3) events, P = 0.356]. Total acid exposure was significantly elevated in the symptomatic population (7.7% vs 3.6%, P < 0.001), especially fasting acid exposure (6.0% vs 1.3%, P < 0.001). pH/manometry analysis demonstrated acute elevations of the gastro-esophageal pressure gradient (>10 mm Hg) underpinned most reflux events. Swallow-induced intragastric hyper-pressur-ization was associated with individual reflux events in most patients (90% in fasting state and 40% postprandial). We found reflux to be strongly associated with SG and identified 3 unique categories. Bolus-induced deglutitive and postprandial reflux occurred in most patients. Elevated fasting esophageal acid exposure mediated symptoms. Frequent, significant elevation in the gastro-esophageal pressure gradient was the mechanism of reflux and seemed to relate to the noncompliant proximal stomach.

Effect of electrical stimulation therapy of the lower esophageal sphincter in GERD patients with ineffective esophageal motility

BackgroundElectrical stimulation therapy (EST) of the lower esophageal sphincter (LES) is a novel technique in antireflux surgery. Due to the minimal alteration at the LES during surgery, LES-EST is meant to be ideal for patients with gastroesophageal reflux disease (GERD) and ineffective esophageal motility (IEM). The aim of this prospective trial (NCT03476265) is to evaluate health-related quality of life and esophageal acid exposure after LES-EST in patients with GERD and IEM.MethodsThis is a prospective non-randomized open-label study. Patients with GERD and IEM undergoing LES-EST were included. Follow-up (FUP) at 12 months after surgery included health-related quality of life (HRQL) assessment with standardized questionnaires (GERD-HRQL) and esophageal functional testing.ResultsAccording to the study protocol, 17 patients fulfilled eligibility criteria. HRQL score for heartburn and regurgitation improved from 21 (interquartile range (IQR) 15–27) to 7.5 (1.25–19), p = 0.001 and from 17 (11–23.5) to 4 (0–12), p = 0.003, respectively. There was neither significant improvement of esophageal acid exposure nor reduction of number of reflux events in pH impedance measurement. Distal contractile integral improved from 64 (11.5–301) to 115 (IQR 10–363) mmHg s cm, p = 0.249. None of the patients showed any sign of dysphagia after LES-EST. One patient needed re-do surgery and re-implantation of the LES-EST due to breaking of the lead after one year.ConclusionAlthough patient satisfaction improved significantly after surgery, this study fails to demonstrate normalization or significant improvement of acid exposure in the distal esophagus after LES-EST.

Safety and efficacy of peroral endoscopic myotomy with standard myotomy versus short myotomy for treatment-naïve patients with type II achalasia: a prospective randomized trial

Peroral endoscopic myotomy (POEM) has emerged as an effective endoscopic treatment modality for achalasia. However, there is no consensus regarding the length of muscle bundle dissection during POEM. The most commonly used approach is standard myotomy (about 10 cm). We herein compared the outcomes between standard myotomy versus short myotomy for the management of treatment-naïve patients with type II achalasia. This was a prospective, single-center, randomized trial in China. Previously untreated adults with a clinical diagnosis of type II achalasia, confirmed by manometric testing, were enrolled between February 2018 and February 2019. Patients were randomly assigned to POEM with standard myotomy or short myotomy. Clinical data on demographic characteristics, operative parameters, pre- and postoperative Eckardt scores, esophageal manometry results, 24-hour pH test, and adverse events were recorded and compared between the 2 groups. Of 100 randomized patients, 94 underwent treatment (48 in the standard myotomy group and 46 in the short myotomy group), and 91 (97%) completed the study. POEM was successfully accomplished in most patients (97.8%). The primary outcome of treatment success occurred in 45 of 48 patients (93.8%) in the standard myotomy group versus 44 of 46 (95.7%) in the short myotomy group, with no statistically significant difference between the 2 groups (P= .520). There were no significant between-group differences in postoperative esophageal manometry, Eckardt score, diameter of the esophageal lumen, quality of life, procedure-related adverse events, or reflux esophagitis (P > .05). Postoperative abnormal esophageal acid exposure occurred more often in the standard myotomy group than in the short myotomy group (21/48 patients [43.8%] vs 11/46 patients [23.9%], P= .042). Meanwhile, the short myotomy group showed a significant reduction in total procedure time compared with the standard myotomy group (31.2 ± 15.3 minutes vs 45.6 ± 16.2 minutes, respectively, P< .05). Among treatment-naïve patients with type II achalasia, standard and short POEM were comparable in terms of providing treatment efficacy and improving quality of life at 1 year, whereas short POEM is technically simpler to perform and requires less procedure time. Moreover, the short POEM approach resulted in fewer cases of postoperative abnormal esophageal acid exposure. (Clinical trial registration number: ChiCTR1800014989.).

S0448 Characterizing Regurgitation and Heartburn Symptoms in Patients Undergoing High Resolution Esophageal Manometry With Esophageal pH-Impedance Monitoring

INTRODUCTION: Studies that characterize GERD often fail to describe regurgitation as well as they do heartburn. The study aims to: 1) describe the frequency and severity of heartburn and regurgitation in patients referred for esophageal function evaluation; 2) describe the esophageal disorders with these symptoms; and 3) investigate the pathophysiology of these symptoms. METHODS: We retrospectively reviewed data from patients undergoing High Resolution Esophageal Manometry with Impedance (HREMI) and Esophageal pH Impedance monitoring (EpHI) between December 2019 and March 2020. Patients filled out the Reflux Disease Questionnaire (RDQ) and the Patient Assessment of Upper GI symptoms (PAGI-SYM). The RDQ evaluates both severity and frequency of heartburn, regurgitation, and dyspeptic symptoms. Mean symptom severity was calculated as (symptom frequency [days per week] x symptom intensity)/7 (scoring is from 0 to 3). RESULTS: Of the 171 patients (average age 55 ± 15 years; 69% female), 164 completed HREMI (7 were unable to tolerate procedure) and 108 completed EpHI. 74 were determined to have GERD by esophageal acid exposure time and/or impedance episodes. Regurgitation movement (RDQ score 0.8; present in 52%) and regurgitation taste (RDQ score 0.6; present in 48.5%) was more prevalent than substernal burning (RDQ score 0.5, present in 35.1%) and substernal pain (RDQ score 0.5, present in 35.1%). Regurgitation taste correlated with regurgitation movement (r = 0.50, P < 0.001), substernal burning (r = 0.53, P < 0.001), and substernal pain (r = 0.39, P < 0.001). Acid exposure time correlated with substernal burning (r = 0.22, P = 0.029) and dyspepsia burning (r = 0.26, P = 0.010). The presence/absence of a hiatal hernia (HH) did not affect regurgitation symptoms. Patients with GERD had similar LES pressures (P = 0.09), hiatal hernia sizes (P = 0.07), and RDQ symptoms. Regurgitation was present in 47% of patients with ineffective esophageal motility, 20% with absent contractility, 33% achalasia, and 39% with no abnormalities (P = 0.21). CONCLUSION: Regurgitation is correlated with heartburn and dyspepsia. It is a common symptom of patients undergoing HREMI and EpHI and is present in many disorders. Additionally, increasing acid exposure was related to substernal burning and dyspepsia burning but was not correlated to regurgitation.(image 3) These results suggest that although acid suppression therapy may be helpful for heartburn, it may not be helpful for treating regurgitation.Table 1Table 2Figure 1

Effects of Diaphragmatic Breathing on the Pathophysiology and Treatment of Upright Gastroesophageal Reflux: A Randomized Controlled Trial.

Uncontrolled results suggest that diaphragmatic breathing (DB) is effective in gastroesophageal reflux disease (GERD) but the mechanism of action and rigor of proof is lacking. This study aimed to determine the effects of DB on reflux, lower esophageal sphincter (LES), and gastric pressures in patients with upright GERD and controls. Adult patients with pH proven upright GERD were studied. During a high-resolution impedance manometry, study patients received a standardized pH neutral refluxogenic meal followed by LES challenge maneuvers (Valsalva and abdominal hollowing) while randomized to DB or sham. After that, patients underwent 48 hours of pH-impedance monitoring, with 50% randomization to postprandial DB during the second day. On examining 23 patients and 10 controls, postprandial gastric pressure was found to be significantly higher in patients compared with that in controls (12 vs 7 mm Hg, P = 0.018). Valsalva maneuver produced reflux in 65.2% of patients compared with 44.4% of controls (P = 0.035). LES increased during the inspiratory portion of DB (42.2 vs 23.1 mm Hg, P < 0.001) in patients and healthy persons. Postprandial DB reduced the number of postprandial reflux events in patients (0.36 vs 2.60, P < 0.001) and healthy subjects (0.00 vs 1.75, P < 0.001) compared with observation. During 48-hour ambulatory study, DB reduced the reflux episodes on day 2 compared with observation on day 1 in both the patient and control groups (P = 0.049). In patients, comparing DB with sham, total acid exposure on day 2 was not different (10.2 ± 7.9 vs 9.4 ± 6.2, P = 0.804). In patients randomized to DB, esophageal acid exposure in a 2-hour window after the standardized meal on day 1 vs day 2 reduced from 11.8% ±6.4 to 5.2% ± 5.1, P = 0.015. In patients with upright GERD, DB reduces the number of postprandial reflux events pressure by increasing the difference between LES and gastric pressure. These data further encourage studying DB as therapy for GERD.

High-resolution impedance manometry and 24-hour multichannel intraluminal impedance with pH testing before and after sleeve gastrectomy: de novo reflux in a prospective series.

Laparoscopic sleeve gastrectomy (SG) is increasingly popular but concern regarding its effect on gastroesophageal reflux disease remain. The current literature is conflicting, and there have been little objective data. To objectively and more accurately assess the impact of SG on esophago-gastric physiology. Centre of Excellence in Metabolic and Bariatric Surgery, Private Hospital, Australia. Prospective cohort study of 31 patients undergoing SG with high-resolution impedance manometry (HRM), 24-hour multichannel intraluminal impedance combined with pH testing (MII-pH), and Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS) questionnaire 1 month before and 6 months after SG. There were 31 patients that underwent SG, 20 with synchronous hiatal repair and fixation, and 6 that were excluded. HRM demonstrated significantly increased intragastric pressures (15.5-29.6 mm Hg) and failed swallows (3.1-7.5%) but no other change in esophageal motility. MII-pH did not demonstrate significant changes in acid exposure time (8.5%-7.5%) or number of reflux episodes, although the numbers of long reflux episodes (2.3-4.7) and weak acid reflux episodes were significantly increased (15.4-55.2). DeMeester and GSAS scores were not significantly changed. There was no significant difference in patients with preexisting reflux. However, for patients without preexisting reflux, acid exposure time increased significantly (1.3%-6.7%), as did DeMeester scores (5.8-24.5) and the numbers of long reflux episodes (.1-4.4) and weakly acidic episodes (22.1-89.2). SG was associated with increased intragastric pressures, without changes in esophageal motility or acid exposure. For patients without preexisting reflux, there were increases in acid exposure time, long reflux episodes, weakly acidic reflux episodes, and DeMeester score.

GERD for the nongastroenterologist: successful evaluation, management, and lifestyle-based symptom control.

Gastroesophageal reflux disease (GERD) is a complex disorder. Symptoms of heartburn can help find the disorder of GERD. pH testing is the mainstay of evaluation of symptoms, including 24-h and longer pH studies to detect pathologic acid exposure. The use of proton pump inhibitor (PPI) therapy for approved indications is helpful for both symptomatic relief and esophagitis healing in the majority of patients with abnormal acid exposure. PPI medications are safe in short- or long-term use. It is recommended not to maintain cirrhotic patients on PPI therapy without a meaningful indication. Dietary adjustment can provide benefit to some patients, but the data are mixed on how much benefit has been demonstrated from specific food avoidance. Reduction in weight improves reflux. Obesity has measurable effects on the esophageal acid exposure but fewer effects on the motility of the esophagus itself. Controlling weight and changing lifestyle can be helpful for improving GERD symptoms. For some patients in whom either the control of reflux with medications and lifestyle change is not sufficient or a hernia is contributing to symptom generation, surgical and endosurgical interventions can be considered to help manage reflux after a thorough workup with pH testing and manometry.

572 NUTRITIONAL PATTERNS MAY AFFECT ESOPHAGEAL ACID EXPOSURE, AND THE NUMBER AND TYPE OF GASTROESOPHAGEAL REFLUXES

Abstract The role of nutritional patterns on esophageal function testing parameters is not widely studied. Earlier published data focused on symptoms of GERD and their association with the food structure. Aim of the study was to assess the influence of nutritional patterns on esophageal acid exposure and types and number of gastroesophageal refluxes Methods The data of complete examination of 165 participants served as a source data for the study. Diagnosis of GERD was based on clinical data (heartburn and acid regurgitation at least once a week for not less than 6 month, actual during last 3 month, history of effective PPI treatment), GERD-Q questionnaire (≥8 points), endoscopic evaluation (Excera II, Olympus, Japan) and 24-hours esophageal pH-impedance studies (Ohmega, MMS, the Netherlands; 2 pH, 6 impedance catheters, UnisensorAG, USA). Food frequency questionnaire was used to analyse food structure. StatSoft (USA) software was used for correlation analysis. The work has been performed within RSF 19–76-30014. Results We enrolled 124 GERD patients and 41 controls. Significant (P &amp;lt; 0.05) correlation of AET was with energy value of the ration (Spearman rank R = 0.19), amount of fat (R = 0.2). Significant correlation of number of GERs was with energy values (R = 0.35), protein (R = 0.3), fat (R = 0.33), alcohol (R = 0.28) and dietary fibre (R = -0.22) consumption. Number of acid GERs correlated with calorie (R = 0.35), fat (R = 0.32), protein (R = 0.25), carbohydrates (R = 0.24) and alcohol (R = 0.24) consumption. Number of weak-acid GERs correlated with calories (R = 0.22), fat (R = 0.21), protein (R = 0.22), alcohol (R = 0.23) and dietary fibre (R = -0.24) consumption. High GERs correlated with fat (R = 0.3), protein (R = 0.22), alcohol (R = 0.25) and fibre (R = -0.25). Conclusion High energy value, consumption of fat and alcohol showed direct medium-strength correlation with esophageal acid exposure and the total number gastroesophageal refluxes. The total number of gastroesophageal refluxes, number of weak acid and high gastroesophageal refluxes had inverse correlation with the amount of dietary fibre consumed. Found trends are used to establish nutritional patterns for reflux events in GERD patients.

560 CORRELATION ANALYSIS OF TYPES AND NUMBER OF GASTROESOPHAGEAL REFLUXES WITH NUTRIENTS CONSUMPTION IN CHILDREN

Abstract Little is known about association of types and number of gastroesophageal refluxes with nutrients consumption in children. However this may be important for planning further research and from the practical point of view. The aim of the study was to perform a correlation analysis between the number and type of gastroesophageal refluxes (GER) with nutrients consumption in children and adolescents. Methods The data of the examination of 219 children served as the source for the study. The complex examination included the analysis of nutrients consumption (Validated language-specific food frequency questionnaire), esophageal pH-impedance recordings (Ohmega, MMS, the Netherlands) esophagogastroscopy (Olympus Excera II, Olympus, Japan). Spearman rank correlation analysis between types and number of gastroesophageal refluxes and level of nutrients consumption was performed with the use of Statistica 10 software (StatSoft Inc, USA). To analyze the data on actual nutrition of children of different age groups, the obtained direct values of were converted into a percentage deviation from the recommended daily allowance rates. Results Significant (P &amp;lt; 0.05) inverse correlation was found between AET and consumption of PUFAs (Spearman rank R = -0.33), ω-3 PUFA (R = -0.33), ω-6 PUFA (R = -0.3), vitamin A (R = -0.34), niacin (R = -0.28) and ascorbic acid (R = -0.37). The number of acid refluxes, was associated with energy values of the rations (R = 0.269), amount of protein (R = 0.279), total fat (R = 0.272), total carbohydrates (R = 0.152), and added sugar (R = 0.157) consumption. There was no correlation between number of weak-acid refluxes and diet. Nr of non-acid refluxes was associated with the 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) consumed. Conclusion We found that esophageal acid exposure time and number of different types of refluxes (but not weak-acid) may be associated with the consumption of some of the nutrients in children. This information may be of use for the diet correction as a component of treatment of children with GERD.

Evaluation of Gastroesophageal Reflux Disease 1 Year after Esophageal Atresia Repair: Paradigms Lost from a Single Snapshot?

To analyze the findings of both multichannel intraluminal impedance with pH (MII-pH) and endoscopy/histopathology in children with esophageal atresia at age 1year, according to current recommendations for the evaluation of gastroesophageal reflux disease (GERD) in esophageal atresia. We retrospectively reviewed both MII-pH and endoscopy/histopathology performed in 1-year-old children with esophageal atresia who were followed up in accordance with international recommendations. Demographic data and clinical characteristics were also reviewed to investigate factors associated with abnormal GERD investigations. In our study cohort of 48 children with esophageal atresia, microscopic esophagitis was found in 33 (69%) and pathological esophageal acid exposure on MII-pH was detected in 12 (25%). Among baseline variables, only the presence of long-gap esophageal atresia was associated with abnormal MII-pH. Distal baseline impedance was significantly lower in patients with microscopic esophagitis, and it showed a very good diagnostic performance in predicting histological changes. Histological esophagitis is highly prevalent at 1year after esophageal atresia repair, but our results do not support a definitive causative role of acid-induced GERD. Instead, they support the hypothesis that chronic stasis in the dysmotile esophagus might lead to histological changes. MII-pH may be a helpful tool in selecting patients who need closer endoscopic surveillance and/or benefit from acid suppression.