Esophageal pH-metry Research Articles

493. EFFECTIVENESS OF TRANSORAL INCISIONLESS FUNDOPLICATION (TIF) WITHOUT OR WITH HIATAL HERNIA REPAIR (CTIF) IN PATIENTS WITH GERD AND CHRONIC COUGH

Abstract Background GERD is a common cause of chronic cough. Although barrier therapy with laparoscopic fundoplication is highly effective for typical GERD symptoms, the response rates are variable for chronic cough. We hypothesized that transoral incisionless fundoplication (TIF) or TIF with hiatal hernia repair (cTIF) may be a suitable alternative for medically refractory cough associated with GERD. Aim We prospectively s studied the effectiveness and safety of TIF/cTIF in patients with chronic cough and proven GERD. Methods Patients with GERD and extra-esophageal symptoms from 10 academic and community medical centers (TIF Registry), elevated GERD-HRQL score +/- Reflux Symptom Index (RSI) >13 and pathologic reflux by esophageal pH-metry, or erosive esophagitis/Barrett’s esophagus were evaluated before and after a minimum 6 months post TIF/cTIF performed by gastroenterologists and surgeons. Patients with history of prior foregut/bariatric surgery, chronic obstructive or interstitial lung disease, or prior lung transplant were excluded. The primary outcome was improvement in RSI score at last follow-up compared to baseline. Secondary outcomes were: 1) normalization of RSI (<13), 2) improvement in cough sub-scores of RSI (decrease ≥ 2 points or to 0 on a 5-point scale), 3) GERD symptom improvement (>50% decrease in GERD-HRQL, or < 2 in all sub-scores) 4) discontinuation of proton pump inhibitor (PPI), and 5) overall patient satisfaction. We further analyzed response in patients with cough-predominant phenotype (chief complaint of cough and RSI troublesome cough subscore ≥2). Results 198 patients with cough and GERD successfully underwent TIF/cTIF (Table 1) without serious adverse events. Greater than 6-month follow-up was available for 177 patients at a median of 12 months [IQR 6,12]. Median RSI score decreased from 18 [IQR 13, 27] to 5 [IQR 2, 11] (p < 0.0001), median change 11 [IQR5,11]. 83% of patients with elevated baseline RSI normalized their scores. 75% of patients had improvement of cough when lying down (median: 1 point [IQR 0,3]), and 72% of patients had improvement of troublesome cough (median: 1 point [IQR 1,3]). 83% of patients successfully discontinued or decreased PPI to occasional use. Patient satisfaction improved from a baseline of 5.6% to 68.8% (p <0.0001). Compared to patients without cough-predominant symptoms, cough-predominant patients (n=108) experienced an additional 4.2-point decrease in in RSI score (p = 0.01) and 1.5-point decrease in troublesome cough sub-scores (p<0.0001). Patients with regurgitation phenotype were more likely to have a favorable cough response at 6 months (p<0.0001). In appropriately selected patients, cTIF and TIF were comparable for cough, GERD-HRQL, RSI, and PPI responses. Conclusion TIF/cTIF are effective and safe alternative barrier therapies for patients with pH-positive cough-predominant GERD.

Reflux Symptom and Sign Instrument: A New Instrument to Diagnose Pediatric Laryngopharyngeal Reflux

Abstract Introduction: Laryngopharyngeal reflux (LPR) is commonly found in children, usually connected to airway problems. LPR remains controversial as no standardized diagnostic instrument. Diagnostic tools available have been validated mostly in adults, i.e. Reflux Symptom Index (RSI) and reflux finding score (RFS). Objective: The objective of the study was to obtain a cost-effective, simple, convenient, noninvasive instrument with good diagnostic outcome. Methods: We compared RSI and RFS with esophageal double probe 24-h pHmetry results. A total of 29 children were recruited, aged 5–18 years. The inclusion criterion was phlegmy throat, frequent odynophagia, sensation of a lump in the throat, throat clearing, choking episodes, hoarseness, and chronic cough for at least 4 weeks. The subjects underwent nasopharyngolaryngoscopy and pHmetry insertion. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using three scenarios. Results: The Reflux Symptoms-Sign Instruments (RSII), consisting of frequent throat clearing, annoying cough, choking, vocal cords abnormalities, and subglottic edema has a cutoff score of 4 and demonstrated 75% sensitivity, 77% specificity, 80% PPV, and 71% NPV. Conclusions: The RSII has shown a good diagnostic result in diagnosing LPR in children.

Multidimentional assessment of voice quality in patients with laryngopharyngeal reflux disease.

<b><br>Introduction:</b> Gastroesophageal Reflux Disease (GERD) is a common disorder in world population. As a result of the regurgitation of acid content from the stomach to laryngopharynx and larynx, secondary damage of laryngeal mucosa occur, which is highly sensitive to hydrochloric acid, and morphological changes are observed. Symptomatology of laryngopharyngeal reflux is varied which makes differential diagnosis difficult.</br> <b><br>Aim:</b> The aim of the study was the assessment of voice quality, morphological changes in larynx as well as etiology of Laryngopharyngeal Reflux Disease.</br> <b><br>Material and method:</b> The severity of dysphonia was classified using perceptual and acoustic methods as well as RSI. Morphological control was performed using HSDI technique and RFS. Etiological factors were examined basing on barofunction of upper esophageal sphincter and 24-hour pH-metry of air exhaled expressed in Ryan score.</br> <b><br>Results:</b> In the majority of patients with Laryngopharyngeal Reflux, dysphonia was recognized, intensified especially in women (G3R2B0A0S3), which was confirmed in Yanagihara classification (type III) and parameters of acoustic analysis. Voice disorders were the most frequently the result of edema and congestion of interarytenoid area, aytenoids and vocal folds. Those symptoms were caused by the decrease of upper esophageal sphincter tension and acidity of exhaled air which was confirmed in 24-hour pHmetry.</br> <b><br>Conclusions:</b> It is important to educate physicians and patients about the possibilty of negative impact of reflux disease on the occurrence of voice quality disorders. Current diagnostic methods for dysphonia guarantee accurate recognition and therapeutic success improving the prognoses of patients with Laryngopharyngeal Reflux.</br&gt.

Salivary Pepsin versus Oesophageal PH Metry as a Diagnostic Test for Laryngopharyngeal Reflux Disease

Abstract Background Laryngopharyngeal reflux (LPR) is the retrograde movement of gastric contents (acid and enzymes such as pepsin) into the laryngopharynx leading to symptoms referable to the larynx/hypopharynx. Objective To evaluation of salivary pepsin as a non-invasive rapid test for diagnosis of laryngopharyngeal reflux versus oesophageal ph metry. Patients and Methods This was a prospective comparative study conducted on 50 subjects; to evaluate the salivary pepsin as a non-invasive rapid test for diagnosis of laryngo-pharyngeal reflux (LPR) versus oesophageal pH metry. Results The increase in age, laryngoscopic abnormality, and pH metry; had an independent effect on increasing salivary Pepsin; with significant statistical difference (p < 0.05 respectively). The increase in laryngoscopic abnormality; had an independent effect on increasing pH metry (% Time pH < 4); with significant statistical difference (p = 0.00002). The increase in pH metry (% Time pH < 4); had an independent effect on increasing the probability of LPR occurrence; with significant statistical difference (p < 0.005). Salivary Pepsin at a cutoff point (>5) predicted patients with LPR, with fair (77.9%) accuracy, sensitivity= 100% and specificity= 56% (p = 0.0001). PH metry (% Time pH < 4) at a cutoff point (>14) predicted patients with LPR, with good (87%) accuracy, sensitivity= 80% and specificity= 100% (p < 0.0001). Conclusion In this study we have shown that pepsin in saliva of patients with LPR is significantly higher than normal individuals, this may help as a diagnostic tool without using invasive methods for diagnosis of LPR.

Reliability of self-assessment of quality of life in patients with hiatal hernia associated with gastroesophageal reflux disease after videolaparoscopic anti-reflux surgery

This article aims to investigate the reliability of self-assessment of the quality of life in patients with hiatal hernia after undergoing videolaparoscopic anti-reflux intervention. To achieve this, the responses to a questionnaire were compared with the results of a study on the failure of the cardia anti-reflux mechanism.Materials and methods. A total of 213 patients who underwent videolaparoscopic oesophagus fundoplication were included in this study. The participants completed three questionnaires: GORD-HRQL, GIQLI, and SF-36. The responses obtained from the questionnaires were then compared with the results of a cardia anti-reflux mechanism study, which involved X-ray endoscopy of the oesophagus and stomach, daily oesophageal pH-metry, and oesophagogastric junction manometry. Based on the responses to the three questionnaires, the quality of life index was calculated for all patients. Additionally, a composite index of cardia anti-reflux mechanism failure was computed to assess the severity of pathological gastro-oesophageal reflux and describe the effectiveness of the cardia anti-reflux mechanism in preventing it.Results. The comparison of the components forming the integral quality of life index with the composite index of cardia anti-reflux mechanism failure before and after the operation revealed an inverse relationship: as the values of the integral quality of life index decreased, the values of the composite index of cardia anti-reflux mechanism failure increased.Conclusion. The self-assessment of the quality of life by patients with GORD-associated hiatal hernia after anti-reflux intervention, as assessed through GORD-HRQL, GIQLI, and SF-36 questionnaires, is accurate and can be effectively utilized for screening and diagnosing disease recurrence.

Esophageal Manometry and pHmetry Profile in Obese Patients Selected for Bariatric Surgery

Background: Obesity is a highly prevalent disease and risk factor for gastroesophageal reflux disease (GERD) which could predispose to esophageal motility disorders. Few studies exist regarding manometric and phmetric findings in patients with obesity who are candidates to bariatric surgery. The objective was to describe the preoperative profile of patients with obesity selected for bariatric surgery. Methods: Retrospective analysis of 338 patients with obesity, subjected to 24 hour-pHmetry with impedance and manometry prior to bariatric surgery between 2006 and 2021. Descriptive and analytical statistics were used for analysis. Results: The mean age and body mass index was 41.94 ± 0.70 years and 38.75 ± 0.37 kg/m2, respectively. GERD symptoms were present in 43.3% (139/321). A 24-hour pHmetry analysis showed a pathologic DeMeester index in 46.7% of patients, of which 64.3% (63/98) were symptomatic. Impedance was abnormal in 53.4%, of which 67% (73/109) were symptomatic. Manometry registered dysmotility in 22.7% (69/304) of patients, a mean lower esophageal sphincter (LES) pressure of 11.93 ± 0.43 mmHg and hypotensive LES in 38.5%. Mean gastric pressure was 9.79 ± 0.33 mmHg after deglutition and only 11.4% (34/299) presented abnormal gastroesophageal gradients. Conclusions: There is a high prevalence of dysmotility and GERD in candidates to bariatric surgery with obesity. Esophageal 24 hour-pHmetry with impedance and manometry should be considered within preoperative tests as pathologic results could guide appropriate procedure selection, at least in symptomatic patients.

Iron Deficiency Anemia in Pediatric Gastroesophageal Reflux Disease

(1) Background: Gastroesophageal reflux disease (GERD) can cause several complications as a result of the acidic pH over various cellular structures, which have been demonstrated and evaluated over time. Anemia can occur due to iron loss from erosions caused by acidic gastric content. In children, anemia has consequences that, in time, can affect their normal development. This study evaluates the presence of anemia as a result of pediatric gastroesophageal reflux disease. (2) Methods: 172 children were diagnosed with gastroesophageal reflux in the gastroenterology department of a regional children's hospital in northeast Romania by esophageal pH-metry and they were evaluated for presence of anemia. (3) Results: 23 patients with GERD from the studied group also had anemia, showing a moderate correlation (r = -0.35, p = 0.025, 95% confidence interval) and lower levels of serum iron were found in cases with GERD, with statistical significance (F = 8.46, p = 0.012, 95% confidence interval). (4) Conclusions: The results of our study suggest that there is a relationship between anemia or iron deficiency and gastroesophageal reflux due to reflux esophagitis in children, which needs to be further studied in larger groups to assess the repercussions on children's development.

Application of Wavelet Transform and Fractal Analysis for Esophageal pH-Metry to Determine a New Method to Diagnose Gastroesophageal Reflux Disease

In this paper, a new method for analysing gastroesophageal reflux disease (GERD) is shown. This novel method uses wavelet transform (WT) and wavelet-based fractal analysis (WBFA) on esophageal pH-metry measurements. The esophageal pH-metry is an important diagnostic tool supporting the physician’s work in diagnosing some forms of reflux diseases. Interpreting the results of 24-h pH-metry monitoring is time-consuming, and the conclusions of such an analysis can sometimes be too subjective. There is no strict procedure or reference values to follow when the impedance measurements are assessed. Therefore, an attempt was made to develop a point of reference for the assessment process, helping to distinguish healthy patients from GERD patients. In this approach, wavelet transform (WT) and wavelet-based fractal analysis (WBFA) were used to aid the diagnostic process. With this approach, it was possible to develop two efficient computer methods to classify healthy and sick patients based on the pH measurement data alone. The WT method provided a sensitivity value of 93.33%, with 75% specificity. The results of the fractal analysis confirmed that the tested signals have features that enable their automatic classification and assignment to a group of sick or healthy people. The article will be interesting for those studying the application of wavelet and fractal analysis in biomedical waveforms. The authors included in the work a description of the implementation of the fractal and wavelet analysis, the descriptions of the results of the analyses, and the conclusions drawn from them. The work will also be of interest to those who study the methods of using machine learning and artificial intelligence in computer-aided, automatic medical diagnostics.

Predictive value of dysplastic-dependent phenotypic and visceral manifestations in gastroesophageal refl ux disease associated with duodenogastroesophageal reflux

Purpose of the study : to identify and evaluate the prognostic role of phenotypic and visceral stigmas of connective tissue dysplasia in the formation of gastroesophageal refl ux disease (GERD) associated with duodenogastroesophageal refl ux (DHER). Materials and methods . In an analytical one-stage study 129 (42 men and 87 women) patients with GERD associated with DHER (GERD-DHER), verifi ed by the presence of refl ux esophagitis and the data of esophageal pH-metry, were examined to diagnose the presence / absence of a dysplastic- dependent phenotype and visceral signs of connective tissue dysplasia. Results . In the adult population of GERD-DHER patients, phenotypic and visceral manifestations of connective tissue dysplasia occur in 45,7% of cases. The chance of developing the disease in persons with a dysplastic- dependent phenotype in the presence of a hiatal hernia increases by 3,7 times, with a combination of a hiatal hernia and anomalies in the shape of the gallbladder — 4,3 times; in the presence of cardia insuffi ciency, anomalies in the shape of the gallbladder and their combination — by 1,4–1,6 times.

Fasting salivary pepsin level as a reliable non-invasive method of screening for laryngopharyngeal reflux in Egyptian patients

BackgroundLaryngopharyngeal reflux (LPR) is caused by the regurgitation of gastric contents above the upper esophageal sphincter. Diagnostic gold standard tests like multichannel intraluminal impedance (MII) and 24-h dual-probe pH-metry are invasive and expensive which limits their accessibility especially in resource-limited settings. Since pepsin is only produced in the stomach, detecting pepsin in the laryngopharynx would make it a specific marker for reflux.Therefore, in this study, we measured fasting salivary pepsin in patients with symptoms suggestive of LPR. We aimed to confirm the role of fasting salivary pepsin as a non-invasive diagnostic tool of LPR, to detect a cut-off value for it in Egyptian patients and to study predictors of changes in its level.MethodsWe conducted a prospective case control study at the gastroenterology clinic in Ain Shams University Hospitals. After testing with esophageal pH-metry, 25 symptomatic patients with confirmed LPR and 25 healthy controls were enrolled in the study. Patients diagnosed with organic upper gastrointestinal disorders, autoimmune diseases, diabetes, malignancy or organ failure were excluded. Patients on PPI were advised to stop 2 weeks before testing. All patients were tested for fasting salivary pepsin levels, esophageal pH-metry, and indirect laryngoscopy in addition to routine laboratory parameters.ResultsOut of the 25 LPR patients, 16% of patients had laryngoscope abnormality in the form of mucosal hyperemia and inflammation, and the average percentage of time pH < 4 in esophageal pH-metry testing was 29.14 ± 39.5%.Comparative study between the 2 groups revealed a significant increase in salivary pepsin in LPR group compared to control group (p < 0.001). By using ROC-curve analysis, salivary pepsin at a cut-off point > 5 ng/ml diagnosed patients with LPR, with fair (77.9%) accuracy, sensitivity = 100% and specificity = 56% (p = 0.0001) while pH-metry (% Time pH < 4) at a cut-off point > 14% diagnosed patients with LPR, with good (87%) accuracy, sensitivity = 80%, and specificity = 100% (p < 0.0001)ConclusionFasting salivary pepsin level at a cut-off value of > 5 ng/ml is a reliable, non-invasive method for detection of LPR especially in resource-limited settings.

The relationship between gastroesophageal reflux disease and recurrent wheezing in children.

Gastroesophageal reflux disease occurs when gastric contents flow back into the esophagus and produce symptoms. Recurrent wheezing affects the quality of life for the patient and family. The association of gastroesophageal reflux with recurrent wheezing is suggested by different studies. The purpose of this study was to explore this relationship and to evaluate the outcome after appropriate treatment.A retrospective study on 85 children with recurrent wheezing, admitted in a pediatric gastroenterology regional center in Romania was performed. 24-hour continuous esophageal pH monitoring was used to evaluate the presence of gastroesophageal reflux and the results were interpreted using the Boix Ochoa score. All patients with positive score received treatment with proton pump inhibitors and they were evaluated again after 2 months.Gastroesophageal reflux was present in 71 children (83.5%), while 14 (16.5%) had a negative score, with a statistic significance (χ2 = 6.88, P = .0086, 95% confidence interval). After 2 months treatment with proton pump inhibitors, the Boix Ochoa score was still positive in 15 patients (21.13%).Recurrent wheezing is a solid reason for evaluating the presence of gastroesophageal reflux by 24-hour continuous esophageal pH-metry. Adequate treatment of gastroesophageal reflux solves also the recurrent wheezing in the majority of patients.

GASTROESOPHAGEAL REFLUX DISEASE: A PRACTICAL APPROACH.

Gastroesophageal reflux disease (GERD) presents typical manifestations such as heartburn and/or regurgitation as well as atypical manifestations such as throat symptoms, laryngitis, hoarseness, chronic cough, asthma, and sleep alterations. There are two phenotypes of the disease: erosive GERD, when erosions are identified by upper digestive endoscopy, and non-erosive GERD, when the esophageal mucosa presents a normal endoscopic aspect. Relevant clinical findings are usually absent in the physical examination, but it should be highlighted that obesity is an important aggravating factor of reflux. The treatment is established based on clinical findings and, according to the clinical situation, on complementary exams such as upper digestive endoscopy. In dubious cases where a precise diagnosis is required, the indicated test is esophageal pHmetry or impedance-pHmetry. Clinical treatment is divided into behavioral/dietary measures and pharmacological measures. Most patients benefit from clinical treatment, but surgical treatment may be indicated in the presence of a larger hiatal hernia and complications of the disease.

GASTROESOPHAGEAL REFLUX DISEASE IN INFANTS WHO PRESENTED BRIEF RESOLVED UNEXPLAINED EVENT (BRUE).

The term brief resolved unexplained events (BRUE) is a description of the acute event occurring in infants less than 1-year-old that includes at least one of the following characteristics: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in tone or altered level of responsiveness. An investigative proceeding is required to identify the triggering phenomenon in those who are at high risk of complications. Prolonged esophageal pHmetry has been used as a tool in searching for gastroesophageal reflux disease (GERD) as one of the underlying etiologies. The study aims to verify the frequency of GERD in infants up to 1-year-old, when pHmetry has been performed for investigating high-risk BRUE (HR-BRUE) and to analyze if clinical characteristics or any particular symptom related by caregivers during BRUE could be correlated to GERD. It was performed a cross-sectional study. The data was collected retrospectively of patients less than 1-year-old, who had performed pHmetry in a tertiary hospital for investigating HR-BRUE between October 2008 and January 2018. For the analysis of medical records, a data collection protocol included: gender, age at the first HR-BRUE episode, age at the time of the pHmetry, gestational age, type of delivery (normal or caesarean) and birth weight and symptoms associated to HR-BRUE related by caregivers. Relation between variables were assessed using Fisher's exact test and Mann-Whitney test. The significance level was set at 0.05. A total of 54 infants were included (preterm 25, term 29), 62.9% males, median age at the HR-BRUE was 36 days, 53.7% HR-BRUE episodes had occurred during or right after feeding. According to pHmetry results: nine pHmetry results were considered inconclusive, physiological reflux (n=30) and GERD (n=15). The frequency of GERD diagnosed by pHmetry was 33%. GERD was not statistically related to gender (P-value=0.757), age at first HR-BRUE episode (P-value=0.960), age at the time of the pHmetry (P-value=0.720), prematurity (P-value=0.120) or type of delivery (P-value=0.738). GERD was statistically related to low birth weight (P-value=0.023). There was no association between symptoms reported by caregivers during HR-BRUE and GERD. GERD diagnosed by the pHmetry was found in one third of infants that experiencing a HR-BRUE, showing the importance of properly investigation. In half of infants BRUE occurred during or right after feeding. Besides low birth weight, it was not possible to select other data from the clinical history that suggest that these patients would be more likely to have GERD.

Gastrointestinal function testing model using a new laryngopharyngeal pH probe (Restech) in patients after Ivor-Lewis esophagectomy.

BACKGROUNDThere is no established correlation between 24-h esophageal pH-metry (Eso-pH) and the new laryngopharyngeal pH-monitoring system (Restech) as only small case series exist. Eso-pH was not designed to detect laryngopharyngeal reflux (LPR) and Restech may detect LPR better. We have previously published a dataset using the two techniques in a large patient collective with gastroesophageal reflux disease. Anatomically, patients after esophagectomy were reported to represent an ideal human reflux model as no reflux barrier exists. AIMTo use a human reflux model to examine our previously published correlation in these patients. METHODSPatients after Ivor Lewis esophagectomy underwent our routine follow-up program with surveillance endoscopies, computed tomography scans and further exams following surgery. Only patients with a complete check-up program and reflux symptoms were offered inclusion into this prospective study and evaluated using Restech and simultaneous Eso-pH. Subsequently, the relationship between the two techniques was evaluatedRESULTSA total of 43 patients from May 2016 - November 2018 were included. All patients presented with mainly typical reflux symptoms such as heartburn (74%), regurgitation (84%), chest pain (58%), and dysphagia (47%). Extraesophageal symptoms such as cough, hoarseness, asthma symptoms, and globus sensation were also present. Esophageal 24-hour pH-metry was abnormal in 88% of patients with a mean DeMeester Score of 229.45 [range 26.4-319.5]. Restech evaluation was abnormal in 61% of cases in this highly selective patient cohort. All patients with abnormal supine LPR were also abnormal for supine esophageal reflux measured by conventional Eso-pH. CONCLUSIONPatients following esophagectomy and reconstruction with gastric interposition can ideally serve as a human reflux model. Interestingly, laryngopharyngeal reflux phases occur mainly in the upright position. In this human volume-reflux model, results of simultaneous esophageal and laryngopharyngeal (Restech) pH-metry showed 100% correlation as being explicable by one of our reflux scenarios.

Transhiatal Migration After Laparoscopic Sleeve Gastrectomy: Myth or Reality? A Multicenter, Retrospective Study on the Incidence and Clinical Impact.

Only anecdotally reported, intrathoracic migration (ITM) represents an unacknowledged complication after sleeve gastrectomy (LSG) contributing to gastroesophageal reflux disease (GERD) development, both recurrent and de novo. The primary endpoint of this study was to evaluate the incidence of postoperative ITM ≥ 2 cm; the secondary endpoint was to determine the relationships between ITM, GERD, endoscopic findings, and percentage of patients requiring surgical revision. A retrospective, multicenter study on prospective databases was conducted, analyzing LSGs performed between 2013 and 2018. Inclusion criteria consisted of primary operation; BMI ranging 35-60 kg/m2; age 18-65 years; minimum follow-up 24 months; and postoperative UGIE, excluding concomitant hiatal hernia repair. Esophageal manometry and 24-h pH-metry were indicated, based on postoperative questionnaires and UGIE; patients with GERD due to ITM, and non-responders to medical therapy, were converted to R-en-Y gastric bypass (RYGB). An ITM ≥ 2cm was postoperatively diagnosed in 94 patients (7% of 1337 LSGs), after mean 24.16 ± 13.6 months. Postoperative esophagitis was found in 29 patients vs. 15 initially (p=0.001), while GERD was demonstrated in 75 (vs. 20 preoperatively, p< 0.001). Fifteen patients (16%) underwent revision to RYGB with posterior cruroplasty. Seventeen patients with severe GERD presented improvement of endoscopic findings and clinical symptoms as a result of conservative therapy. ITM after LSG is not a negligible complication and represents an important pathogenic factor in the development or worsening of GERD. Postoperative UGIE plays a fundamental role in the diagnosis of esophageal mucosal lesions.

Effectiveness of the Gerdq Questionnaire for Diagnosing Gastroesophageal Reflux Disease After Esophagectomy for Esophageal Cancer.

Gastroesophageal reflux disease (GERD) is a common complication after esophagectomy with gastric tube reconstruction. The GerdQ questionnaire was developed for diagnosing GERD in primary care patients. Its effectiveness in patients after esophagectomy remains unknown. In this study, we evaluated the usefulness of the GerdQ questionnaire for diagnosing GERD after esophagectomy for esophageal cancer. A total of 124 patients with esophageal cancer underwent right transthoracic esophagectomy with gastric tube reconstruction between January 2010 and December 2016. Esophagogastroduodenoscopy and 24-hour esophageal pH-metry were performed at 1 month, 1 year, and 2 years postoperatively. The GerdQ questionnaire was administered at the same postoperative time points. We assessed any correlation between the GerdQ scores and the endoscopy and pH-metry findings. The incidence rates of GERD at 1 month, 1 year and 2 years post-surgery were 31.6%, 46.9%, and 49.2%, respectively. The GerdQ questionnaire showed 77% sensitivity and 56% specificity for diagnosing GERD at 2 years after esophagectomy when the cutoff point was 7. However, the optimal cutoff points were different at each postoperative time, and the scores showed some imbalance between sensitivity and specificity. Regurgitation may be a useful indicator, as the frequency of regurgitation was significantly higher in patients with GERD than in patients without GERD at 1 year (P = 0.046) and 2 years postoperatively (P = 0.048). The GerdQ questionnaire is not a useful diagnostic tool for GERD in patients who have undergone esophagectomy for esophageal cancer.

Twenty-Four-Hour Esophageal pH Measurement in Mechanically Ventilated Children: A Prospective Cohort Study.

To assess the prevalence of gastroesophageal reflux in mechanically ventilated children using 24-hour esophageal pH-metry and its role as a risk factor for ventilator-associated pneumonia. Prospective cohort study. PICU of a tertiary care hospital from North India. Mechanically ventilated children 1-15 years old in PICU from July 2015 to June 2017, excluding those receiving acid suppressants, known cases of gastroesophageal reflux disease, having upper gastrointestinal bleed. Demographic details, baseline investigations, diagnosis, treatment details, and Pediatric Risk of Mortality III score were recorded at enrollment. Gastroesophageal reflux was evaluated using 24-hour esophageal pH-metry. Children were followed up for 7 days or 48 hours after extubation for development of ventilator-associated pneumonia using Centers for Disease Control and Prevention criteria. Pathologic acidic gastroesophageal reflux was defined as fall in esophageal pH less than 4 for more than 4% of total time, whereas pathologic alkaline gastroesophageal reflux as rise in esophageal pH greater than 7 for more than 17% of total time. Sixty-one children (median [interquartile range], age 73 mo [30-132 mo]; 44 boys [72%]) were enrolled. Median Pediatric Risk of Mortality III score was 10.0 (3-16). Median duration of ventilation was 6 days (3-9 d). Pathologic gastroesophageal reflux (acidic or alkaline) was present in 47 children (77%). Twelve children (19.7%) met criteria for pathologic acidic gastroesophageal reflux, whereas 44 children (72.1%) had pathologic alkaline gastroesophageal reflux; nine children (14.7%) had both pathologic acidic and alkaline gastroesophageal reflux. Of the enrolled children, 17 (27.9 %) developed ventilator-associated pneumonia. No patient had both pathologic acidic gastroesophageal reflux and ventilator-associated pneumonia. Of 17 children who developed ventilator-associated pneumonia, 12 (70.5%) had pathologic alkaline gastroesophageal reflux as compared to 32 children (72.7%) among the 44 children who did not develop ventilator-associated pneumonia (p = 0.87). The current study shows high incidence of gastroesophageal reflux on 24-hour esophageal pH-metry in mechanically ventilated children with medical diagnoses. The significance of this finding and its impact on ventilator-associated pneumonia and other ventilator-associated events need to be examined in larger studies.

Recommendations of the Russian Gastroenterological Association in Diagnosis and Treatment of Gastroesophageal Reflux Disease

Aim . Current recommendations of the Russian Gastroenterological Association are developed to acquaint medical practitioners with modern diagnostics, treatment and trends in rational drug therapy for gastroesophageal reflux disease (GERD). General provisions . Incidence rate of GERD in the Russian Federation varies from 11.3 to 23.6%. GERD is diagnosed with medical history and laboratory examination evidence. Esophagogastroduodenoscopy (EGDS) allows detection of reflux esophagitis of various severity and cylindrical epithelial metaplasia of esophagus. The refractory form of disease (lack of conclusive clinical and endoscopic remission during 4-8 weeks of standard-dose PPI therapy), presence of strictures and Barrett's esophagus require EGDS with esophageal biopsy and bioptic histological examination. Patients should be conclusively performed esophageal 24-hour pH-metry or pH-impedance monitoring, high-resolution manometry to thoroughly examine functionality of esophagus, esophagogastric junction and assess disease prognosis and therapy outcomes. Treatment of GERD should be personalised accounting for clinical manifestations and severity, as well as aimed at symptom improvement, lesion healing in erosive esophagitis, averting complications, Barrett's esophagus progression, dysplasia and esophageal adenocarcinoma. Proton pump inhibitors (PPIs) are most effective agents in primary (4-8 weeks) and maintenance anti-GERD therapy. Antacids are recommended in monotherapy for occasional nonerosive heartburn and complex anti-GERD settings for fast symptom improvement. Prokinetics can be used in combination with PPIs for their properties to recover normal functionality of esophagus through affecting pathogenetic mechanisms of GERD. Complicated patients (repeated bleedings, peptic esophageal strictures) are recommended anti-reflux surgery with prior examination of esophageal functionality using pH-impedance and high-resolution manometry. Conclusion . Current recommendations provide an up-to-date evidential medicial review of GERD and guidelines to advance special medical care and timely preventive measures.

Endoscopic Findings 5Years Following Sleeve Gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) has rapidly become increasingly popular in bariatric surgery. However, in the long-term follow-up, intractable severe gastroesophageal reflux disease (GERD) after primary LSG can necessitate further investigations. The purpose of this study was to evaluate the endoscopic results at 5-year follow-up, on a cohort of patients who underwent LSG, the correlation GERD-esophagitis, and the results of pH-metry studies. Forty-eight patients that underwent LSG (same surgeon) in our center between 2010 and 2015 were included. These patients were identified during the regular annual follow-up visit between January and July 2018 and systematic upper endoscopy was proposed. A pH-metry was carried out for the 13 patients who presented QoL altering GERD symptoms. Twenty-two patients (45.8%) with abnormal endoscopic results were identified at a mean follow-up of 62.4months following LSG. GERD symptomatology was identified for only 13 patients (27.1%) during the follow-up compared to 18 patients (37.5%) preoperatively. Esophageal pH-metry was performed for 13 patients (27.1%). Ten patients (20.8%) (one with esophagitis and nine with QoL altering GERD) had a pathological reflux with a DeMeester score of 47 ± 8 (30-70 interval). The other three patients had normal lower than 20 DeMeester scores. GERD symptomatology was related to weight loss failure for four patients. Fourteen patients (29.2%) in our series benefited from redo surgery, with subsequent RYGB conversion (four with BE, one with severe esophagitis, and nine with persistent QoL altering GERD symptomatology). One patient has been reoperated on at day 1 postoperatively for hemorrhage from jejuno-jejunal anastomosis. Mean hospital stay of 1.92days. Our study identified an important number of asymptomatic patients with different modifications on upper endoscopy. In case of discordance between endoscopic findings and clinical presentation, additional investigation tools like pH-impedancemetry should be used. Equally, the latter should be used in case of decision to conversion for patients with severe reflux to RYGBP in order to objectify the operative indication and to achieve a reference point for follow-up.

Evaluation of the Reflux Symptom Index and the Endolaryngeal Findings Scale after Treatment in Individuals with Laryngopharyngeal Reflux.

Introduction Laryngopharyngeal reflux (LPR) is a prevalent condition in outpatients visiting the otorhinolaryngological clinic, with many controversies regarding its diagnosis and follow-up. Therefore, there is a need for clinical instruments that can diagnose individuals and monitor the results of their treatment. Objective To evaluate the applicability of the scores translated and adapted to Brazilian Portuguese: Reflux Symptom Index (RSI) and Endolaryngeal Reflux Findings Scale (ERFS), as instruments for post-treatment follow-up of LPR. Method A total of 35 individuals with atypical symptoms of gastroesophageal reflux disease and with an objective diagnosis of LPR, confirmed by high digestive endoscopy and 24-hour esophageal pH-metry dual probe test were submitted to the RSI and ERFS questionnaires, used in the pre- and post-treatment of 90 days with a Proton Pump Inhibitor. Result The evaluation of RSI and ERFS in the pre- and post-treatment showed a reduction in the results of the two scores, with a higher drop in the RSI ( p < 0.001) than in the ERFS ( p = 0.014). Although there was an improvement in the values in 23.9% of the individuals in the ERFS, there was no change in the category ( p = 0.057), different from the RSI ( p < 0.001), where there was a 67.4% improvement in values, as well as change in category (score went from positive to negative). There was a correlation between RSI and ERFS, moderate in the pretreatment and strong in the post-treatment. Conclusion The RSI and ERFS scores, when translated and adapted for Brazilian Portuguese and applied simultaneously, can be considered a good tool for post-treatment LPR follow-up.