Esophageal pH-metry Research Articles

A proof-of-concept study evaluating the effect of ADX10059, a metabotropic glutamate receptor-5 negative allosteric modulator, on acid exposure and symptoms in gastro-oesophageal reflux disease

Background:In preclinical models, antagonism of metabotropic glutamate receptor 5 (mGluR5) reduces transient lower oesophageal sphincter relaxations (TLOSRs) and increases LOS pressure. This study evaluated the effect of ADX10059, a potent,...

S1872 Acid-Induced Injury Does Not Enhance Local Changes of Eosinophilic Esophagitis: An Analysis of 11 Histologic Findings

Introduction: Refractory GERD describes those patients who continue to have symptoms despite treatment with proton-pump inhibitors (PPI)1. The participation of eosinophilic esophagitis (EE) in the refractory GERD has been scarcely studied. When both disorders are simultaneously present, the clinical, endoscopic and histologic findings may be nonspecific and as such the overlap of refractory GERD and EE has been matter of debate. Aim: To study the occurrence of EE in patients with refractory GERD. Methods: Upper digestive endoscopies (UDE) were performed, obtaining mucosal biopsies of distal, middle and lower esophagus and stomach (body and antrum) in 97 adult consecutive patients. Erosive esophagitis was classified according to Los Angeles classification. Seventy three (75.3%) were female, with mean age of 44,4 (+ 9.09) of years. Eighty seven patients (89.6%) were submitted to esophageal manometry and pHmetry. The patients (82, 84%) have been receiving high doses of PPI (40 mg omeprazol b.i.d.) for at least 6 weeks. The main complaint was heartburn and regurgitation. The diagnosis of GERD was based on UDE and pHmetry. The diagnosis of EE was based on the presence of ≥20 eosinophils per high power field (eo/hpf) in the esophageal biopsies. Results: UDE was normal in 78 patients (81%). Erosive esophagitis (grade A in 9, B in 2 and C in 2 of LA) was found in 13 (13%) patients. All the others 6 (6%) were classified as non-erosive esophagitis (NERD). One patient ( 1 %) presented > 20 eo/hpf. In 25 (27.8%) patients the pHmetry was altered during PPI treatment (80 mg/day). The manometry showed hypomotility before the treatment for EE and, inespecific motor disturbances after the decreasing of eosinophils post the appropriate treatment. Conclusions: There was a very low prevalence of EE in patients with refractory GERD. (1) Spechler SNat Clin Pract Gastroenterol Hepatol, 2007

S1870 Low Prevalence of Eosinophilic Esophagitis in Patients with Refractory Gastroesophageal Reflux Disease. a Prospective Study

Introduction: Refractory GERD describes those patients who continue to have symptoms despite treatment with proton-pump inhibitors (PPI)1. The participation of eosinophilic esophagitis (EE) in the refractory GERD has been scarcely studied. When both disorders are simultaneously present, the clinical, endoscopic and histologic findings may be nonspecific and as such the overlap of refractory GERD and EE has been matter of debate. Aim: To study the occurrence of EE in patients with refractory GERD. Methods: Upper digestive endoscopies (UDE) were performed, obtaining mucosal biopsies of distal, middle and lower esophagus and stomach (body and antrum) in 97 adult consecutive patients. Erosive esophagitis was classified according to Los Angeles classification. Seventy three (75.3%) were female, with mean age of 44,4 (+ 9.09) of years. Eighty seven patients (89.6%) were submitted to esophageal manometry and pHmetry. The patients (82, 84%) have been receiving high doses of PPI (40 mg omeprazol b.i.d.) for at least 6 weeks. The main complaint was heartburn and regurgitation. The diagnosis of GERD was based on UDE and pHmetry. The diagnosis of EE was based on the presence of ≥20 eosinophils per high power field (eo/hpf) in the esophageal biopsies. Results: UDE was normal in 78 patients (81%). Erosive esophagitis (grade A in 9, B in 2 and C in 2 of LA) was found in 13 (13%) patients. All the others 6 (6%) were classified as non-erosive esophagitis (NERD). One patient ( 1 %) presented > 20 eo/hpf. In 25 (27.8%) patients the pHmetry was altered during PPI treatment (80 mg/day). The manometry showed hypomotility before the treatment for EE and, inespecific motor disturbances after the decreasing of eosinophils post the appropriate treatment. Conclusions: There was a very low prevalence of EE in patients with refractory GERD. (1) Spechler SNat Clin Pract Gastroenterol Hepatol, 2007

S1873 True/False: Eosinophilic Esophagitis (EoE) Responds to Acid Suppression

Introduction: Refractory GERD describes those patients who continue to have symptoms despite treatment with proton-pump inhibitors (PPI)1. The participation of eosinophilic esophagitis (EE) in the refractory GERD has been scarcely studied. When both disorders are simultaneously present, the clinical, endoscopic and histologic findings may be nonspecific and as such the overlap of refractory GERD and EE has been matter of debate. Aim: To study the occurrence of EE in patients with refractory GERD. Methods: Upper digestive endoscopies (UDE) were performed, obtaining mucosal biopsies of distal, middle and lower esophagus and stomach (body and antrum) in 97 adult consecutive patients. Erosive esophagitis was classified according to Los Angeles classification. Seventy three (75.3%) were female, with mean age of 44,4 (+ 9.09) of years. Eighty seven patients (89.6%) were submitted to esophageal manometry and pHmetry. The patients (82, 84%) have been receiving high doses of PPI (40 mg omeprazol b.i.d.) for at least 6 weeks. The main complaint was heartburn and regurgitation. The diagnosis of GERD was based on UDE and pHmetry. The diagnosis of EE was based on the presence of ≥20 eosinophils per high power field (eo/hpf) in the esophageal biopsies. Results: UDE was normal in 78 patients (81%). Erosive esophagitis (grade A in 9, B in 2 and C in 2 of LA) was found in 13 (13%) patients. All the others 6 (6%) were classified as non-erosive esophagitis (NERD). One patient ( 1 %) presented > 20 eo/hpf. In 25 (27.8%) patients the pHmetry was altered during PPI treatment (80 mg/day). The manometry showed hypomotility before the treatment for EE and, inespecific motor disturbances after the decreasing of eosinophils post the appropriate treatment. Conclusions: There was a very low prevalence of EE in patients with refractory GERD. (1) Spechler SNat Clin Pract Gastroenterol Hepatol, 2007

M1882 Response to Air Insufflation in Patients with Non-Erosive Gastroesophageal Reflux Disease (NERD) - Including Assessment Under a Rabeprazole Load

Gastro-esophageal reflux disease (GERD) is a multifactorial condition whose main pathogenetic factor is represented by Transient Lower Esophageal Sphincter Relaxations (TLESRs). Many hypotheses have been proposed to identify the mechanisms underlying the onset of TLESRs. One evidence suggested that colonic fermentation of indigestible carbohydrates (fructooligosaccharides, FOS) increases the rate of TLESRs and the number of acid reflux episodes. Alpha-galactosidase is an enzyme allowing better digestion of food rich in FOS that is commonly used to control symptoms of patients affected by Irritable Bowel Sindrome. Aim of our study was therefore to test the possible effect of the assumption of alphagalactosidase on esophageal pH profile in GERD patients. Patients and methods: 9 patients with low-grade esophagitis and typical GI symptoms underwent a basal 24-hour esophageal pH-metric recording. Once confirmed the GERD diagnosis, patients were instructed to assume 1 tablet of alpha-galactosidase 300 GalU (n=5) or placebo (n=4) before meals for the following four weeks. At the end of treatment a second 24-h esophageal pH-metry was performed. Heartburn and regurgitation were also scored (score: intensity x duration) at baseline and after 4 weeks. Results: Patients receiving alpha-galactosidase showed a reduced number of acid reflux episodes/24 hours as compared to baseline (60±25 vs 118±40, p<0.01); percentage of time with pH<4 was also reduced in such patients as compared to baseline values (4.2±1.7 vs 6.7±2.7, p<0.05); no difference was detected in the group receiving placebo. Heartburn was reduced in patients assuming alpha-galactosidase as compared to baseline (1.2±0.4 vs 2±0.6, p<0.05) with no differences in the placebo group. Regurgitation showed a trend toward a decrease after alpha-galactosidase which did not reach statistical significance (1.2±0.4 vs 1.5±0.3, n.s.). Summary and Conclusions: chronic assumption of alpha-galactosidase is associated to a decreased amount of gastro-esophageal reflux episodes in GERD patients. Such patients also experienced an initial improvement in clinical features of the disease. It seems likely that this change in esophageal pH pattern could depend on the modulation of TLESRs due to the reduced fermentation of FOS in the colon.

W1832 Improved Reflux-Symptom Association Analysis to Predict PPI Treatment Outcome in Patients with Chronic Cough

Background: Patients with unexplained chronic cough are often treated empirically with PPI, based on clinical suspicion of increased acid GER. The success rate of such approach is only 50-60%, probably due to poor patient selection. Furthermore, the predictive value of standard esophageal pHmetry for PPI treatment outcome is low. Analysis of the temporal association reflux-cough might be more relevant. However the predictive value of the Symptom Index (SI) and Symptom Association Probability (SAP) is still uncertain because a) were developed for acid reflux, heartburn and chest pain, b) consider a reflux-related cough when the patient presses an event marker within a time window of 5 or 2 min respectively, c) do not consider non-acid reflux and d) are not based on objective cough detection. We aimed to improve the assessment of reflux-cough association in order to better predict PPI treatment outcome in patients with chronic cough. Methods: 31 patients with chronic unexplained cough [19 men, age 50.5(18-71)] underwent 24h impedance-pH monitoring “off” PPI. Cough was recorded using a) by the patient (event marker) and b) objectively (pressure pattern in simultaneous gastro-esophageal manometry). After reflux monitoring patients received PPI treatment (20mg OME BID) for 8 weeks. Positive response to PPI was defined as ≥50% cough improvement. Symptom association analysis was performed considering acid or all reflux (acid+non-acid), using either the event marker or objective cough detection and SI and SAP were calculated using different time windows (0.5-6min). Results: 14/31 patients were classified as responders to the PPI. 8/14 responders and 6/17 non-responders had cough + typical GER symptoms. 9/14 responders and 4/17 non-responders had increased esophageal acid exposure (p< 0.02). The number of acid reflux events was higher in responders [34(21-58) vs. 14(8-35), p<0.05]. The best symptom association analysis was obtained using all reflux (acid+non acid), objective cough detection and a 4 min time window. Conclusion: Combined ambulatory impedance-pH-manometry allows better selection of patients with unexplained chronic cough for PPI treatment. Patients are less likely to respond to PPI if they have a negative SAP for total reflux (acid + non-acid), using a 4 minutes time window and an objective technique for cough recording.

W1835 Gastroesophageal Reflux (Acid and Non-Acid) and Unexplained Chronic Cough in Children. Symptom Association Analysis Using Objective Cough Detection

Background: Patients with unexplained chronic cough are often treated empirically with PPI, based on clinical suspicion of increased acid GER. The success rate of such approach is only 50-60%, probably due to poor patient selection. Furthermore, the predictive value of standard esophageal pHmetry for PPI treatment outcome is low. Analysis of the temporal association reflux-cough might be more relevant. However the predictive value of the Symptom Index (SI) and Symptom Association Probability (SAP) is still uncertain because a) were developed for acid reflux, heartburn and chest pain, b) consider a reflux-related cough when the patient presses an event marker within a time window of 5 or 2 min respectively, c) do not consider non-acid reflux and d) are not based on objective cough detection. We aimed to improve the assessment of reflux-cough association in order to better predict PPI treatment outcome in patients with chronic cough. Methods: 31 patients with chronic unexplained cough [19 men, age 50.5(18-71)] underwent 24h impedance-pH monitoring “off” PPI. Cough was recorded using a) by the patient (event marker) and b) objectively (pressure pattern in simultaneous gastro-esophageal manometry). After reflux monitoring patients received PPI treatment (20mg OME BID) for 8 weeks. Positive response to PPI was defined as ≥50% cough improvement. Symptom association analysis was performed considering acid or all reflux (acid+non-acid), using either the event marker or objective cough detection and SI and SAP were calculated using different time windows (0.5-6min). Results: 14/31 patients were classified as responders to the PPI. 8/14 responders and 6/17 non-responders had cough + typical GER symptoms. 9/14 responders and 4/17 non-responders had increased esophageal acid exposure (p< 0.02). The number of acid reflux events was higher in responders [34(21-58) vs. 14(8-35), p<0.05]. The best symptom association analysis was obtained using all reflux (acid+non acid), objective cough detection and a 4 min time window. Conclusion: Combined ambulatory impedance-pH-manometry allows better selection of patients with unexplained chronic cough for PPI treatment. Patients are less likely to respond to PPI if they have a negative SAP for total reflux (acid + non-acid), using a 4 minutes time window and an objective technique for cough recording.

W1833 Mechanism of the Effects of Esophageal Acidification On the Production and Secretion of Airway Mucus

Background: Patients with unexplained chronic cough are often treated empirically with PPI, based on clinical suspicion of increased acid GER. The success rate of such approach is only 50-60%, probably due to poor patient selection. Furthermore, the predictive value of standard esophageal pHmetry for PPI treatment outcome is low. Analysis of the temporal association reflux-cough might be more relevant. However the predictive value of the Symptom Index (SI) and Symptom Association Probability (SAP) is still uncertain because a) were developed for acid reflux, heartburn and chest pain, b) consider a reflux-related cough when the patient presses an event marker within a time window of 5 or 2 min respectively, c) do not consider non-acid reflux and d) are not based on objective cough detection. We aimed to improve the assessment of reflux-cough association in order to better predict PPI treatment outcome in patients with chronic cough. Methods: 31 patients with chronic unexplained cough [19 men, age 50.5(18-71)] underwent 24h impedance-pH monitoring “off” PPI. Cough was recorded using a) by the patient (event marker) and b) objectively (pressure pattern in simultaneous gastro-esophageal manometry). After reflux monitoring patients received PPI treatment (20mg OME BID) for 8 weeks. Positive response to PPI was defined as ≥50% cough improvement. Symptom association analysis was performed considering acid or all reflux (acid+non-acid), using either the event marker or objective cough detection and SI and SAP were calculated using different time windows (0.5-6min). Results: 14/31 patients were classified as responders to the PPI. 8/14 responders and 6/17 non-responders had cough + typical GER symptoms. 9/14 responders and 4/17 non-responders had increased esophageal acid exposure (p< 0.02). The number of acid reflux events was higher in responders [34(21-58) vs. 14(8-35), p<0.05]. The best symptom association analysis was obtained using all reflux (acid+non acid), objective cough detection and a 4 min time window. Conclusion: Combined ambulatory impedance-pH-manometry allows better selection of patients with unexplained chronic cough for PPI treatment. Patients are less likely to respond to PPI if they have a negative SAP for total reflux (acid + non-acid), using a 4 minutes time window and an objective technique for cough recording.

Demographic, Clinical, and Psychological Characteristics of the Heartburn Groups Classified Using the Rome III Criteria and Factors Associated with the Responsiveness to Proton Pump Inhibitors in the Gastroesophageal Reflux Disease Group

Background/Aims: The diagnostic criteria for nonerosive reflux disease (NERD) and functional heartburn (FH) have been changed. We investigated demographic, clinical, and psychological characteristics of the heartburn groups classified using the Rome III criteria and factors associated with the responsiveness to proton pump inhibitors (PPIs) in the gastroesophageal reflux disease (GERD) group. Methods: Ninety-five patients with heartburn underwent endoscopy, 24-hour esophageal pH-metry and then a PPI test. NERD was diagnosed when % time with pH <4 was >4%, a symptom index (SI) ≥50% or a positive PPI test in patients without erosive esophagitis. Patients without such findings were classified as FH. Results: Thirty-six patientshad erosive reflux disease (ERD), 36 had NERD, and 23 had FH. The proportion of males was significantly higher in ERD than in FH. Atypical symptoms and IBS were more prevalent in FH than in ERD. Anxiety was more prevalent in FH than in NERD. The prevalence of pathologic acid reflux, a positive SI and a positive PPI test was similar between ERD and NERD patients. In the ERD and NERD groups, depression was independently associated with nonresponsiveness to PPIs. Conclusions: FH is a different entity from ERD or NERD, particularly in terms of gender, acid reflux patterns, psychological profiles, and the responsiveness to PPIs.

Obesity Is Associated With Increased 48-h Esophageal Acid Exposure in Patients With Symptomatic Gastroesophageal Reflux

Obesity has been associated with gastroesophageal reflux disease (GERD) but the relationship between body mass index (BMI) and esophageal acid exposure remains poorly understood. We hypothesized that overweight (OW) and obese (OB) patients with GER symptoms would have a higher degree of esophageal acid exposure than with normal weight (NW) patients. 157 patients separated in groups according to BMI were studied for 48h while off antisecretory medications using ambulatory wireless capsule pH-metry. The pH capsule was appropriately positioned and esophageal pH data were collected. Appropriate univariate and multivariate statistical methods were used. Groups did not differ in age, but more women were in the NW group. OB patients had a fivefold increase in odds for abnormal total acid exposure compared with NW (OR=5.01; 95% CI 2.94, 12.95). Total acid exposure time (AET) was elevated in OB (8.7%+/-5.1%) compared with NW (5.3%+/-5.2%; P<0.05). AET was highest during awake, upright periods. The DeMeester score was higher in OB (31.7+/-19.2) and OW (26.0+/-16.8) groups compared with the NW (19.8+/-17.6) group (P<0.001). AET increased from day 1 to day 2 in the OB group only. This is the first study to report a positive relationship between BMI and esophageal acid exposure time using prolonged, continuous wireless esophageal pH-metry. Abnormal AET was more frequent in OB patients. Variability in AET increased from day 1 to day 2 in the OB group, supporting the use of more prolonged pH studies in subsets of patients.

Gastroesophageal reflux in mechanically ventilated pediatric patients and its relation to ventilator-associated pneumonia

IntroductionThe objective was to determine the frequency of gastroesophageal reflux (GER) in mechanically ventilated pediatric patients and its role as a risk factor for ventilator-associated pneumonia (VAP), which may be enhanced among those patients.MethodsThe study is a prospective cohort study of mechanically ventilated pediatric patients in the pediatric intensive care unit (PICU) of Ain Shams University Children's Hospital. It was conducted in 24 mechanically ventilated patients (16 of them developed VAP and 8 did not, with mean age of 16.6 +/- 20.5 and 18.6 +/- 22.4 months respectively). Esophageal 24-hour pH-metry beside clinical and laboratory evaluation of their underlying problem and severity of their condition were carried out.ResultsAll VAP patients had GER (50% alkaline reflux, 12.5% acidic reflux and 37.5% combined reflux) compared to 75% of non-VAP ones (100% alkaline reflux). The mean total reflux time was significantly longer among VAP (50 minutes) versus non-VAP (3 minutes) patients. There was significant increase in acidic reflux parameters among non-survivors versus survivors (P < 0.001). For VAP mortality, total acidic reflux at a cut-off value of 28.6 minutes is found to be a mortality predictor with a sensitivity of 100% and a specificity of 100%.ConclusionsGER is a constant incident in mechanically ventilated pediatric patients, with alkaline reflux being more common than acidic reflux. Both acidic and alkaline refluxes were found to be associated with the development of VAP and total reflux time was found to be a reliable predictor of VAP. Moreover, acidic reflux was found to be more related to mortality than alkaline reflux.

Esofagomanometria e pHmetria esofágica de 24 h em uma ampla amostra de pacientes com manifestações respiratórias

To determine the prevalence of gastroesophageal reflux disease (GERD) and to evaluate the esophageal motor profile of patients with respiratory symptoms referred to a digestive motility referral center for esophageal function testing. The results of esophageal manometry and 24-h esophageal pH-metry were analyzed.The inclusion criterion was presenting respiratory symptoms, with or without accompanying digestive symptoms. Of the 1,170 patients included in the study, 602 (51.5%) reported having digestive and respiratory symptoms (DRS group), and 568 (48.5%) reported having only respiratory symptoms (RS group). Asthma was diagnosed in 142 patients in the RS group (RS-A subgroup) and in 201 of those in the DRS group (DRS-A). Of the 346 cases of esophageal dysmotility, hypomotility was found in 175 (14.3% and 15.6% in the DRS and RS groups, respectively), and lower esophageal sphincter (LES) hypotonia was found in 411 (40.3% and 30.2%, respectively). Hypotonia correlated with GERD. Exposure of the distal esophagus to acid was markedly abnormal in the supine position. The prevalence of GERD in the sample as a whole, the RS-A/DRS-A subgroups and the RS-A subgroup alone was 39.8%, 44.0% and 35.2%, respectively Hypotonic LES was the most common abnormality and correlated with GERD. Although GERD was more evident in the DRS group, approximately one third of the patients in the RS group also presented GERD (silent GERD). The findings suggest that GERD can be an extrapulmonary cause of chronic respiratory symptoms unresponsive to conventional therapy.

Cough and gastroesophageal reflux: From the gastroenterologist end

Gastroesophageal reflux (GER) is one of the three most common causes of chronic unexplained cough. Diagnosing GER-related cough is challenging since many patients do not have esophagitis or an increased esophageal acid exposure during 24 h esophageal pH-metry. A significant time association between acid reflux and cough can be demonstrated in a subgroup of patients, even if the total esophageal acid exposure is normal. Establishing an exact time relationship between reflux and cough requires objective measurements of both cough and reflux episodes. A variety of techniques for cough assessment are available, including sound recordings and continuous measurement of gastroesophageal pressures. The Symptom Association Probability (SAP) has been suggested as the most reliable algorithm to establish the non-chance association between GER and cough. Although the relationship between acid reflux and cough is generally accepted, the response rate of patients with chronic unexplained cough to proton pump inhibitor treatment (PPI) is poorer compared to that in patients with typical GERD symptoms. Combined impedance-pH recordings, a new technique for the measurement of all types of reflux, have recently shown that not only acid but also weakly acidic GER may be associated with cough. Moreover, measurements in patients “on” PPI therapy demonstrated that weakly acidic reflux may persist during PPI treatment and may be associated with cough. Aspiration of gastric contents into the lungs and a vagally mediated reflex arc, originating from the distal esophagus, have been proposed as pathophysiological mechanisms in GER-related cough. More recently, reflux induced bronchial hypersensitivity has been proposed as a third underlying mechanism. Treatment of GER-related cough remains challenging. So far, long term PPI treatments produce unsatisfactory results. In patients not responding to PPI, weakly acidic GER might still be the cause of cough. In these patients other therapeutic strategies i.e. abolishing all types of GER might need to be considered. Antireflux surgery has been performed successfully in a group of patients with GER-related cough. However, controlled, prospective outcome studies are necessary to confirm the role of antireflux treatments in the management of GER-related cough.

Prevalência de refluxo gastroesofágico em pacientes com doença pulmonar avançada candidatos a transplante pulmonar

To assess the esophageal function profile and the prevalence of gastro-esophageal reflux (GER) in lung transplant candidates. From July of 2005 to November of 2006, a prospective study was conducted involving 55 candidates for lung transplantation at the Santa Casa de Misericórdia Hospital in Porto Alegre, Brazil. Prior to transplantation, patients underwent outpatient stationary esophageal manometry and 24-h esophageal pH-metry using one and two electrodes. Abnormal esophageal manometry was documented in 80% of the patients, and 24% of the patients presented pathological acid reflux. Digestive symptoms presented sensitivity and specificity for GER of 50% and 61%, respectively. Of the patients with chronic obstructive pulmonary disease, 94% presented abnormal esophageal manometry, and 80% presented lower esophageal sphincter hypotonia, making it the most common finding. Patients with bronchiectasis presented the highest prevalence of GER (50%). In patients with advanced lung disease, GER is highly prevalent. In the population studied, digestive symptoms of GER were not predictive of pathological acid reflux. The role that GER plays in chronic rejection should be examined and clarified in future studies.

Clinical predictors of abnormal esophageal pH monitoring in preterm infants

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

Lap-Band Impact on the Function of the Esophagus

The laparoscopic adjustable gastric band (LAGB) has been widely used to treat morbid obesity. There is conflicting data on its long-term effect on esophageal function. Our aim was to assess the long-term impact of the LAGB on esophageal motility and pH-metry in patients who had LAGB who had normal and abnormal esophageal function at baseline. Consecutive patients referred for bariatric surgery were prospectively enrolled. A detailed medical history was obtained, and esophageal manometric and 24-h pH evaluations were performed in standard fashion preoperatively and 6 and 12 months postoperatively; patients served as their own controls. Twenty-two patients completed manometric evaluation. Ten patients had normal manometric parameters at baseline; at 6 months, mean lower esophageal sphincter (LES) residual pressure increased significantly from baseline (3.9 +/- 2 vs. 8.9 +/- 4 mmHg, p = 0.014). At 12 months, the mean peristaltic wave duration increased from 3.6 +/- 1 at baseline to 6.8 +/- 2 s, p = 0.025 and wave amplitude decreased during the same period (98.7 +/- 22 vs. 52.3 +/- 24, p = 0.013). LES pressure and percent peristalsis did not differ significantly pre- and post-LAGB. Twelve patients had one or more abnormal manometric findings at baseline; at 12 months, LES pressure in these 12 patients decreased significantly (31.1 +/- 10 vs 23.6 +/- 7, p = 0.011) and wave amplitude was significantly reduced (125.9 +/- 117 vs 103 +/- 107, p = 0.039). LES residual pressure did not change significantly pre- and post-LAGB. Twenty-two individuals were evaluated for impact of Lap-Band on esophageal acid exposure. Sixteen of these patients had normal esophageal pH-metry values at baseline and had no significant changes in 12 months in any pH-metry measurement. Six patients had abnormal pH-metry values at baseline. Among these patients, time with pH < 4.0 and Johnson/DeMeester score did not change significantly during follow-up. There was a significant decrease in the number of reflux episodes from baseline to 6 months (159 +/- 48 vs. 81 +/- 61, p = 0.016). Abnormal manometric findings are frequently encountered post-LAGB. Increases in LES residual pressure and peristaltic wave duration were the most significant changes. LAGB is not associated with an increase in total esophageal acidification time. Further evaluation of the clinical significance of manometric abnormalities is warranted.

Diagnostic value of the dual channel esophageal pH-metry in supraesophageal manifestations of gastroesophageal reflux disease

Aim: To compare the value of 24-h dual channel pH-metry in the diagnosis of GERD associated respiratory complications with symptom analysis, endoscopy, esophageal manometry and distal pH-monitoring. Patients, methods: 117 patients (pts) with GERD (43 pts with asthma, 44 pts with chronic hoarseness and 30 pts without supraesophageal manifestation) were submitted to detailed symptom analysis, upper gastrointestinal endoscopy, esophageal manometry and 24-h dual channel esophageal pH-monitoring. Results: Silent GERD was observed more frequently among asthma pts (21%) and pts with hoarseness (18%) than in pts without respiratory symptoms (3%). The endoscopic score based on Los Angeles classification (NERD=0, LA-A=1, LA-B=2, LA-C=3, LA-D=4) was not significantly different between the 3 pts groups (0.6±0.14 in asthma, 0.7±0.17 in hoarseness and 0.6±0.17 in pts without supraesophageal manifestations). No differences were observed in the results of LES manometry between pts with or without respiratory complaints (LES pressure: 15.3±1.49, 12.0±0.98 and 14.5±2.18 Hgmm). 5cm above LES the pH parameters were less pathological in pts with supraesophageal manifestations as compared with respiratory symptom free pts (DeMeester score: 14.5±1.98, 12.4±1.37 vs. 22.2±5.16, p<0.05; fraction time below pH 4: 3.5±0.61% and 2.7±0.40% vs. 9.9±2.25%, p<0.05). In contrast to the distal esophageal parameters, pH-monitoring 20cm above LES showed significantly pronounced reflux activity in pts with airway symptoms as compared with pts without supraesophageal manifestations (fraction time below pH 4: 0.7±0.18%, 0.5±0.14% vs. 0.3±0.08%, p<0.05). Conclusions: Symptom analysis, endoscopy, manometry and conventional distal pH-metry were not able to separate the GERD pts with airway complications from respiratory symptom free GERD subjects, only proximal pH-monitoring was able to select GERD pts with supraesophageal manifestations. Our results evidence the diagnostic value of routine dual channel pH-monitoring in the diagnosis of GERD induced respiratory complications.

Nutcracker oesophagus: Association with chest pain and dysphagia controlling for gastro-oesophageal reflux

Background The association between nutcracker oesophagus, gastro-oesophageal reflux and their symptoms is controversial. Aim To evaluate the association of nutcracker oesophagus with chest pain and dysphagia controlling for gastro-oesophageal reflux. Methods From a database of 935 consecutive patients investigated with oesophageal manometry and pH-metry, we selected all patients with nutcracker oesophagus including diffuse and segmental patterns. Patients with normal oesophageal peristalsis served as controls. Symptoms assessment, manometry testing and 24 h oesophageal pH monitoring off acid-suppressive medications were performed following a standardized protocol. The associations between nutcracker oesophagus and symptoms were assessed by logistic regression analysis. Results Nutcracker oesophagus was found in 60 patients (6.4%), of which 30 had diffuse nutcracker oesophagus and 30 had segmental nutcracker oesophagus. The control group was composed by 656 patients with normal oesophageal peristalsis. Diffuse nutcracker oesophagus was associated with chest pain (odds ratio 4.3; 95% CI 1.9–9.9; P < 0.0001) and dysphagia (odds ratio 5.3; 95% CI 2.3–12.2; P < 0.0001), whereas segmental nutcracker oesophagus was associated with chest pain (odds ratio 2.8; 95% CI 1.1–6.9; P = 0.026), controlling for total oesophageal acid exposure, age, sex and lower oesophageal sphincter (LOS) pressure. Conclusion This study suggests that both diffuse and segmental nutcracker oesophagus should be regarded as meaningful abnormalities and not mere manometric curiosities.

The Role of Esophageal pH-metri Test on Gastro-Esophageal Reflux Disease Diagnosis

Gastro-esophageal reflux disease is a pathological condition of esophagus which is caused by gastric content reflux into esophagus. There is an increased prevalence of gastro-esophageal reflux disease. The roles of esophageal pH-metry in clinical application include looking for abnormal acid exposure on esophagus with no abnormality found in endoscopy; evaluating patients following the anti-reflux surgery who are being suspected for abnormal esophageal reflux; evaluating patients with normal endoscopic result but still having refractory reflux symptoms against proton pump inhibitor medication; detecting refractory reflux in patients chest pain following the heart evaluation; evaluating patients with otolaryngologic manifestations (laryngitis, pharyngitis, chronic cough) of the esophageal reflux disease after therapeutic failure of 4-weeks proton pump inhibitor treatment; and looking for correlation between adult onset gastro-esophageal reflux disease and non-allergic asthma. Keywords : gastro-esophageal reflux disease, esophagus pH-metry, symptoms-reflux correlation

Esophageal impedance–pH monitoring

Classical techniques like endoscopy and esophageal pH-metry are routinely used to study patients with symptoms related to gastroesophageal reflux disease (GERD). Although these techniques have been useful over the years both for diagnosis and therapeutic guidance, there are still many patients with typical or atypical GERD symptoms with normal endoscopy and pH-metry that do not respond adequately to antisecretory therapy. Ambulatory esophageal impedance-pH monitoring is a new technique that can be used to evaluate all types of gastroesophageal reflux, achieving higher rates of sensitivity and specificity than standard techniques. This review describes esophageal impedance-pH monitoring, summarizing the current literature on validation studies and clinical application.