Gastroesophageal Reflux Events Research Articles

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

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

Acute administration of fructans increases the number of transient lower esophageal sphincter relaxations in healthy volunteers.

Dietary measures are often advised to patients with gastro-esophageal reflux disease (GERD). Fermentable Oligo-, Di-, Mono-saccharides and Polyols (FODMAPs) induce lower gastrointestinal (GI) symptoms. However, their effects on esophageal motility, including transient lower esophageal sphincter relaxations (TLESRs), reflux events and GERD symptoms are unknown. We investigated the effect of acute administration oftwo FODMAPs, fructose, and fructans, on the number of TLESRs, reflux episodes and symptom perception in healthy volunteers (HVs). After an overnight fast, 20 HVs (10 males; 32.6±2.8years) underwent a high-resolution impedance manometry. The number of TLESRs and reflux episodes was quantified during five hours after consumption of a high-caloric meal (740kcal) enriched with 40g of either fructose, fructans or glucose (as placebo). Results were analyzed using mixed models. There was a trend for a change in the number of TLESRs between the three conditions (P=.06). Post hoc analysis revealed a trend toward a higher number of TLESRs in the fructan condition compared with placebo (Pcorr =.06). Acute administration of fructose did not influence the number of TLESRs. The total number of reflux events was not affected by either FODMAP condition. Lower esophageal sphincter (LES) pressures dropped significantly in the first postprandial hour to recover slowly back to baseline values (P<.0001), without any difference in LES pressure between the three conditions. Ingestion of fructans increased the number of TLESRs slightly compared with placebo. The effect of FODMAPs such as fructans or a low FODMAP diet on reflux parameters in GERD patients remains to be investigated.

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

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

Liquid Gastroesophageal Reflux Characterization by Investigating Multichannel Intraluminal Impedance-pH Monitoring Data.

Multichannel Intraluminal Impedance-pH (MII-pH) monitoring is designed to detect intraluminal bolus movement without the use of radiation and allows for detection of Gastroesophageal reflux (GER). Automatic analysis of MII-pH data are available however since the recordings are complex and filled with artifacts; a thorough and time-consuming review of the recordings, episode by episode, is still required. The proposed method was designed to segment GER events in a set of 100 episodes of two minutes interval of MII data based on a decision tree approach. An amount of 24 hours of MII-pH data belonging to eight patients were recorded, digitized and stored along with standardized timings of GER events that had been characterized by two gastroenterologist experts. The performance of the algorithm was evaluated using 100 individual GER events. The algorithm has been shown to perform correctly in over 95% of cases.

Correlation between cardiorespiratory events and gastro-esophageal reflux in preterm and term infants: Analysis of predisposing factors

BackgroundThe association between cardiorespiratory events (CRE) and gastro-esophageal reflux (GER) among neonates is still controversial. AimsTo test such an association in preterm and term infants. Study designProspective observational study. SubjectsForty-seven infants with suspected GER and recurrent CRE admitted at a neonatal intensive care unit, who underwent simultaneous and synchronized 24-hour recording of heart rate (HR), peripheral oxygen saturation (SpO2) and pH-impedance monitoring (MII-pH). HR/SpO2 data were filtered to avoid artefactual episodes of hypoxia and hypoperfusion. Outcome measuresThe main outcome measure was the symptom association probability (SAP), with a 2-minute time window. Infants with positive (>95%) and negative (≤95%) SAP index tests were compared by univariate and multivariate statistics. ResultsMedian gestational age at birth was 294/7 weeks, median age at study 36 days. We recorded 3341 GER events and 4936 CRE (4710 desaturations, 226 bradycardias); 609/4936 (12%) CRE were temporally associated with GER episodes: 338 preceded and 271 followed GER events. The SAP index was significant in 5/47 (11%) patients. The SAP index including only CRE following GER events was significant in 3/47 (6%). There was no significant difference in the number of acid, weakly acid, non-acid, pH-only events preceding or following CRE between infants with SAP-positive and SAP-negative tests. Infants with positive SAP-index tests compared to those with SAP-negative tests had lower weight gain in the three days preceding the test and tended to have lower birth weight. ConclusionsGER and CRE were associated in <11% of patients. The evaluation of ponderal growth might be helpful in predicting such an association.

Esophageal Impedance-pH Monitoring and Pharyngeal pH Monitoring in the Diagnosis of Extraesophageal Reflux in Children.

Various clinical symptoms are attributed to extraesophageal reflux disease (EERD). Multichannel intraluminal impedance-pH monitoring (MII-pH) is considered to correlate symptoms with acid and nonacid gastroesophageal reflux (GER) events. Pharyngeal pH monitoring (Dx-pH) is considered to correlate the decrease in the pH level in the oropharynx with reported symptoms and to diagnose supraesophageal reflux. We aimed to assess the correlation between acid reflux episodes recorded by Dx-pH and GER detected via MII-pH in children with suspected EERD. The study enrolled 23 consecutive children (15 boys and 8 girls; median age 8.25 [range 3-16.5] years) with suspected EERD. MII-pH and Dx-pH were conducted concurrently in all patients. A total of 1228 reflux episodes were recorded by MII-pH. With the antimonic sensor placed inside the impedance probe, 1272 pH-only reflux episodes were recorded. Of these, 977 (76.81%) were associated with a retrograde bolus transit. Regarding GER, 630 full-column episodes extended to the most proximal pair of impedance sensors; 500 (83.33%) demonstrated an acidic character. The following acid reflux numbers were determined by the Dx-pH system: for pH < 4, n = 126; pH < 4.5, n = 136; pH < 5, n = 167; and pH < 5.5, n = 304, and for a decrease in pH > 10% relative to the baseline, n = 324. There was no significant correlation between the number of pharyngeal reflux episodes detected by Dx-pH and that of GERs identified by MII-pH. The proportion of oropharyngeal pH events that were temporally related to a GER episode increased with the extended pH criteria. The highest proportion was observed for a pH decrease of ≥10% from the baseline and did not exceed 5.2%. The application of the extended pH criteria in the Dx-pH system resulted in an increase in the number of diagnosed laryngopharyngeal refluxes; most were not temporally associated with GER episodes confirmed by MII-pH. Thus, the efficacy of the exclusive application of Dx-pH for supraesophageal gastric reflux diagnosis is uncertain.

Erythromycin and Reflux Events in Premature Neonates: A Randomized Clinical Trial.

Gastroesophageal reflux disease (GERD) in premature neonates may manifest as apnea, bradycardia, growth failure, aspiration, or feeding intolerance. Erythromycin ethylsuccinate (EES), is often used as a pro-kinetic in the management of GERD, despite lack of evidence or safety from randomized controlled trials. We sought to study the efficacy of enteral EES at a dose of 50 mg · kg · day in decreasing the frequency of gastroesophageal reflux events as determined by pH-multichannel intraluminal impedance (pH-MII) monitoring. In a randomized, double-blind, placebo-controlled trial, eligible premature neonates with clinical signs of GERD underwent 24-hour pH-MII monitoring. If >5 reflux events were identified on pH-MII, then subjects were randomized to receive either EES or placebo. Repeat 24-hour pH-MII was performed on day 7 of study treatment and compared to initial pH-MII. Forty-three premature neonates were enrolled. Of those, 31 neonates were randomized, 15 to EES and 16 to placebo with a median (IQR) pretreatment total reflux events per 24 hours of 23 (16-40) and 29 (12-40), respectively. Day 7 total events per 24 hours decreased by 4 events in the EES group to 19 (15-33) and by 10 events in the placebo group to 19 (11-26) (P = 0.09). There were no differences in pretreatment and day 7 acidic and nonacidic reflux, proximal reflux, total or percent reflux time, median or longest bolus clearance time, or nurse-reported apnea events between groups. Enteral EES did not decrease reflux events on 24-hour pH-MII at the dose studied. Therefore, it may be ineffective in the treatment of GERD in premature neonates.

Temporal relationship between arousal from sleep and night‐time gastroesophageal reflux events

Temporal relationship between arousal from sleep and night‐time gastroesophageal reflux events

Laparoscopic magnetic sphincter augmentation versus double-dose proton pump inhibitors for management of moderate-to-severe regurgitation in GERD: a randomized controlled trial

GERD patients frequently complain of regurgitation of gastric contents. Medical therapy with proton-pump inhibitors (PPIs) is frequently ineffective in alleviating regurgitation symptoms, because PPIs do nothing to restore a weak lower esophageal sphincter. Our aim was to compare effectiveness of increased PPI dosing with laparoscopic magnetic sphincter augmentation (MSA) in patients with moderate-to-severe regurgitation despite once-daily PPI therapy. One hundred fifty-two patients with GERD, aged≥21 years with moderate-to-severe regurgitation despite 8 weeks of once-daily PPI therapy, were prospectively enrolled at 21 U.S. sites. Participants were randomized 2:1 to treatment with twice-daily (BID) PPIs (N= 102) or to laparoscopic MSA (N= 50). Standardized foregut symptom questionnaires and ambulatory esophageal reflux monitoring were performed at baseline and at 6 months. Relief of regurgitation, improvement in foregut questionnaire scores, decrease in esophageal acid exposure and reflux events, discontinuation of PPIs, and adverse events were the measures of efficacy. Per protocol, 89% (42/47) of treated patients with MSA reported relief of regurgitation compared with 10% (10/101) of the BID PPI group (P< .001) at the 6-month primary endpoint. By intention-to-treat analysis, 84% (42/50) of patients in the MSA group and 10% (10/102) in the BID PPI group met this primary endpoint (P< .001). Eighty-one percent (38/47) of patients with MSA versus 8% (7/87) of patients with BID PPI had ≥50% improvement in GERD-health-related quality of life scores (P< .001), and 91% (43/47) remained off of PPI therapy. A normal number of reflux episodes and acid exposures was observed in 91% (40/44) and 89% (39/44) of MSA patients, respectively, compared with 58% (46/79) (P< .001) and 75% (59/79) (P= .065) of BID PPI patients at 6 months. No significant safety issues were observed. In MSA patients, 28% reported transient dysphagia; 4% reported ongoing dysphagia. Patients with GERD with moderate-to-severe regurgitation, especially despite once-daily PPI treatment, should be considered for minimally invasive treatment with MSA rather than increased PPI therapy. (Clinical trial registration number: NCT02505945.).

Cardiorespiratory events in infants with gastroesophageal reflux symptoms: Is there any association?

Cardiorespiratory (CR) events (apnea, bradycardia, oxygen desaturation) and gastroesophageal reflux (GER) symptoms often coexist in infants admitted to Neonatal Intensive Care Unit, leading to over-prescription of drugs and delayed discharge. We aimed to evaluate the relationships between CR and GER events. The temporal associations between CR and GER events were analyzed in symptomatic infants who underwent synchronized CR and pH-impedance monitoring. The symptom association probability (SAP) index was used to identify infants with a significant number of temporal associations. Gastroesophageal reflux characteristics and the chronological sequence of CR and GER events occurring within 30seconds of each other were evaluated according to SAP index. Of the 66 infants enrolled, aged 29 (18-45) days, 58 had CR events during monitoring. From these 58 patients, a total of 1331 CR events and 5239 GER (24% acidic) were detected. The SAP index was positive in seven (12%) infants. These infants had greater GER frequency, duration, and proximal extent (P<.05). The number of temporal associations was 10 times greater in the positive SAP group. Gastroesophageal reflux events preceded CR events in 83% of these associations. These GER events had a higher proximal extent (P=.004), but showed no differences in pH values. The simultaneous evaluation of CR and GER events could be useful to identify infants with severe GER and significant temporal associations between these events. Treatment of GER could be indicated in these infants, but as the GER events involved are mainly non-acidic, empirical treatment with antacids is, often, inappropriate.

Correlation of Gastroesophageal reflux disease Assessment Symptom Questionnaire to impedance-pH measurements in children.

Background:Esophageal multichannel intraluminal impedance-pH monitoring has become one of the preferred tests to correlate observed reflux-like behaviors with esophageal reflux events. The Gastroesophageal reflux disease Assessment Symptom Questionnaire is a validated tool used to distinguish infants with gastroesophageal reflux disease from healthy children. The aim of this study was to determine whether the Gastroesophageal reflux disease Assessment Symptom Questionnaire composite symptom scores and individual symptom scores correlate with outcomes in esophageal multichannel intraluminal impedance-pH monitoring.Methods:A total of 26 patients with gastroesophageal reflux disease–associated symptoms, aged 0–2 years, for whom both esophageal multichannel intraluminal impedance-pH monitoring and Gastroesophageal reflux disease Assessment Symptom Questionnaire survey results were available were included in the study. Gastroesophageal reflux disease Assessment Symptom Questionnaire score data were collected from a 7-day recall of parent’s responses about the frequency and severity of gastroesophageal reflux disease symptoms, which determined the individual symptom scores. The composite symptom scores is the sum of all individual symptom scores. Multichannel intraluminal impedance-pH study results were compared to Gastroesophageal reflux disease Assessment Symptom Questionnaire data using Pearson correlation.Results:Among 26 patients, a total number of 2817 (1700 acid and 1117 non-acid) reflux episodes and 845 clinical reflux behaviors were recorded. There were significant correlations between the reflux index and the individual symptom scores for coughing/gagging/choking (r2 = 0.2842, p = 0.005), the impedance score and individual symptom scores for coughing/gagging/choking (r2 = 0.2482, p = 0.009), the reflux symptom index for acid reflux-related coughing/gagging/choking and the individual symptom scores for coughing/gagging/choking (r2 = 0.1900, p = 0.026), the impedance score and individual symptom scores for vomiting (r2 = 0.1569, p = 0.045), and the impedance score and the composite symptom scores (r2 = 0.2916, p = 0.004). However, there were no significant correlations between fussiness, irritability, or abdominal pain–related multichannel intraluminal impedance-pH results and the individual symptom scores for abdominal pain.Conclusion:The impedance scores from multichannel intraluminal impedance-pH studies correlate with coughing/gagging/choking and vomiting in infants with gastroesophageal reflux disease. There are no significant correlations among the reflux index and impedance score versus the Gastroesophageal reflux disease Assessment Symptom Questionnaire scores for abdominal pain. We conclude that in infants with gastroesophageal reflux disease, multichannel intraluminal impedance-pH studies are more likely to demonstrate an association between gastroesophageal reflux disease and symptoms of coughing, gagging, or choking compared to an association between gastroesophageal reflux disease and pain in infants.

Nasogastric Feeding Tubes May Not Contribute to Gastroesophageal Reflux in Preterm Infants.

The objective was to determine if the presence of a nasogastric (NG) feeding tube is associated with increased gastroesophageal reflux (GER) and acid exposure in preterm infants. This is a retrospective study on preterm infants [gestational age (GA) <37 weeks] who were evaluated by multichannel intraluminal impedance and pH monitoring (MII-pH) between October 2009 and March 2016. Infants were divided into two groups, NG tube present and no feeding tube. GER events per hour and the percent of time with pH <4 during a 24-hour period were then compared. Eighty-three infants were included, 41 had an NG tube present and 42 did not. The group without an NG tube had significantly more reflux events per hour (2.3 ± 2.9 vs. 1.3 ± 0.8, p < 0.05) even after adjusting for differences in birth weight, GA, corrected GA, and total fluid intake. There was no significant difference in acidic events per hour and acid exposure time between the two groups. The presence of a 5-French NG tube is not associated with an increase in GER or acid exposure in preterm infants. In fact, it appears that infants fed through an NG tube have fewer episodes of GER.

Upper esophageal sphincter augmentation reduces pharyngeal reflux in nasogastric tube–fed patients

Aspiration of gastric refluxate is one of the most commonly observed complications among long-term nasogastric tube (NGT) fed patients. The upper esophageal sphincter (UES) pressure barrier is the main defense mechanism against pharyngeal reflux of gastric contents. Our objective was to investigate the efficacy and safety of the UES assist device (UES-AD) in preventing gastric reflux through the UES in long-term NGT-fed patients. Self-Controlled Case series. We studied 10 patients (mean age = 90.6 ± 3.4 years, four females) with dysphagia caused by stroke or dementia who were fed for 0.5 to 5 years (median = 3 years) by NGT. External pressures of 20 to 30 mm Hg were applied by using a handmade UES-AD, which was started 2 hours after the beginning of NGT infusion and was alternated between periods of 2 hours on and 2 hours off, for a total of 12 hours. Placement of the impedance sensors within the UES was guided by high-resolution manometry. Trans-UES and intraesophageal reflux events were recorded by using 24-hour combined pH-impedance measurements. No aspiration pneumonia events were noted in the period 1 month before or during the study in any of the cohort. Baseline UES pressure averaged 17.5 ± 9.4 mm Hg and was increased to 38.9 ± 11.9mm Hg after application of the UES-AD. Overall frequency of trans-UES reflux decreased significantly with the UES-AD compared to without (0.8 ± 0.9 vs. 3.3 ± 2.8, P < .05 for the 12-hour study period). There was no effect of the UES-AD on esophageal reflux events (7.4 ± 4.4 vs. 6.4 ± 3.0, P > .05). UES-AD significantly decreases the number of trans-UES reflux events and can potentially reduce the aspiration risk associated with NGT feeding. 4. Laryngoscope, 128:1310-1315, 2018.

Mo1005 - Analysis of Proximal Esophageal Reflux Events in Unmedicated Patients with Typical and Atypical Symptoms of GERD

Mo1005 - Analysis of Proximal Esophageal Reflux Events in Unmedicated Patients with Typical and Atypical Symptoms of GERD

The binomial symptom index for the evaluation of temporal association between cardiorespiratory symptoms and gastroesophageal reflux in neonates

Abstract Introduction The evaluation of symptom association between gastroesophageal reflux and cardiorespiratory events in preterm infants remains unclear. This paper describes a conservative approach to decision-making of anti-reflux surgery through symptom association analysis. Methods Forty-three neonates with potentially reflux-related cardiorespiratory symptoms underwent synchronized esophageal impedance-pH and cardiorespiratory monitoring. Three indices were considered to evaluate symptom association, the symptom index (SI), the symptom sensitivity index (SSI) and the symptom association probability (SAP). A conservative strategy was adopted regarding the decision of anti-reflux surgery, and therefore, patients were scheduled for laparoscopic Nissen fundoplication if the three indices showed a positive assessment of symptom association. Retrospectively, these indices and the binomial symptom index (BSI) were contrasted against the decision of anti-reflux surgery using different windows of association. Results Thirteen patients showed positive symptom association but only two underwent anti-reflux surgery. The SI and the SSI showed an increasing trend with the width of the window of association. The SAP was affected randomly by slightly altering the windowing parameters. The BSI showed the best performance with the two-minute window (κ = 0.78). Conclusions The pathology under study is known to improve with maturity. However, the severity of cardiorespiratory symptoms may threaten the neonate's life and therefore, on some occasions, invasive treatments must be considered to protect life. The BSI provides a good prediction of a combination of positive SI, SSI and SAP, which may improve clinical decisions. However, further clinical studies are required to prove the BSI as an optimal predictor of clinical outcomes.

Liquid-containing Refluxes and Acid Refluxes May Be Less Frequent in the Japanese Population Than in Other Populations: Normal Values of 24- hour Esophageal Impedance and pH Monitoring.

Background/AimsTwenty-four-hour esophageal impedance and pH monitoring allows detection of all types of reflux episodes and is considered the best technique for identifying gastroesophageal refluxes. However, normative data for the Japanese population are lacking. This multicenter study aimed to establish the normal range of 24-hour esophageal impedance and pH data both in the distal and the proximal esophagus in Japanese subjects.MethodsForty-two healthy volunteers (25 men and 17 women) with a mean ± standard deviation age of 33.3 ± 12.4 years (range: 22–72 years) underwent a combined 24-hour esophageal impedance and pH monitoring. According to the physical and pH properties, distal or proximal esophageal reflux events were categorized.ResultsMedian 45 reflux events occurred in 24 hours, and the 95th percentile was 85 events. Unlike previous reports, liquid-containing reflux events are median 25/24 hours with the 95th percentile of 62/24 hours. Acidic reflux events were median 11/24 hours with the 95th percentile of 39/24 hours. Non-acidic gas reflux events were median 15/24 hours with the 95th percentile of 39/24 hours. Proximal reflux events accounted for 80% of the total reflux events and were mainly non-acidic gas refluxes. About 19% of liquid and mixed refluxes reached the proximal esophagus.ConclusionsUnlike previous studies, liquid-containing and acidic reflux events may be less frequent in the Japanese population. Non-acidic gas reflux events may be frequent and a cause of frequent proximal reflux events. This study provides important normative data for 24-hour impedance and pH monitoring in both the distal and the proximal esophagus in the Japanese population.

Effect of Severity of Esophageal Acidification on Sleep vs Wake Periods in Infants Presenting with Brief Resolved Unexplained Events

To describe the pattern of gastroesophageal reflux (GER) events in wake and sleep states with increasing acid reflux index (ARI) in neonates and to test the hypothesis that GER-related symptoms are frequent in ARI >7% in wake state. Infants underwent 24-hour pH-impedance studies with 6-hour concurrent video-polysomnography studies. Data were stratified based on the 24-hour ARI (% duration that esophageal pH is <4) into ARI < 3% (normal), ARI 3 ≥ to ≤7% (intermediate), and ARI >7% (abnormal). GER frequency, clearance mechanisms, and symptoms were distinguished during wake state and sleep state. Total wake and sleep duration was similar (P ≥ .2) in all ARI groups. Acidic events were frequent with increasing ARI in wake state vs sleep state (P ≤ .03). The symptom index increased with increasing ARI (P ≤ .02) in both wake state and sleep state. Acid clearance time increased with increasing ARI in wake state (P ≤ .02). In ARI > 7% vs ARI ≤ 7%, frequency of acidic GER events was higher (P ≤ .02) in wake state and sleep state; proximal migration of acid (P = .03) and acid clearance time were higher in wake state (P = .0005) only. Symptom index was higher in ARI >7% vs ARI ≤ 7% in wake state (P < .0001), comparable in normal vs intermediate (P = .4), and higher in abnormal vs intermediate (P = .0004) groups. Severe esophageal acid exposure (ARI >7%) is associated with increased reflux-associated symptoms in wake state. Sleep state appears to be protective regardless of ARI, likely because of greater chemosensory thresholds. Attention to posture and movements during wake state can be helpful. Scrutiny for non-GER etiologies should occur for infants presenting with life-threatening symptoms.

Prospective Controlled Study of Gastroesophageal Reflux in Dogs with Naturally Occurring Laryngeal Paralysis.

To determine the frequency, nature, and magnitude of gastroesophageal reflux (GER) in dogs with laryngeal paralysis (LP). Prospective comparative clinical study. Client-owned dogs with LP and healthy client-owned dogs (n = 6 each). Dogs underwent sedated laryngeal examination for diagnosis and grading of bilateral LP and for placement of a nasoesophageal dual pH/impedance probe. Endoscopy was used to confirm probe location and evaluate the distal esophagus. Data were recorded continuously. GER was defined as pH<4 or >7.5 lasting >2 seconds reaching a magnitude of 2 impedance sensors proximally. The median total number of GER events per hour was 0.64 (range, 0.44-1.6) for the LP group and 0.53 (range, 0.38-1.0) for the control group (P = 0.259; power = 0.50). The median total number of alkaline regurgitation events per hour was 0.37 (range, 0.17-0.93) for the LP group and 0.46 (range, 0.25-1.0) for control group (P = 0.575; power = 0.57). The median total number of acidic regurgitation events per hour was 0.22 (range, 0-0.70) and 0.0 (range, 0-0.14) for the LP and control groups, respectively (P = 0.025). Acidic reflux events reached the proximal pH sensor in 2 dogs in the LP group for a total of 4 reflux events and in 1 dog in the control group for a total of 3 reflux events (P = 0.673). Based on the limited number of dogs studied, it appears that dogs with naturally occurring LP have increased acidic reflux events compared to clinically normal dogs. GER can reach the most proximal part of the esophagus.

The impact of the speed of food intake on gastroesophageal reflux events in obese female patients.

Obesity increases the risk of gastroesophageal reflux disease (GERD). The majority of the reflux attacks occur postprandially. The influence of the speed of food intake on gastroesophageal reflux events is unclear in obese patients. To determine the influence of the speed of food intake on intraesophageal reflux events in obese patients with and without GERD. A total of 26 obese female patients were recruited. The patients underwent esophageal manometry to evaluate the upper limit of the lower esophageal sphincter and subsequently placement of a Multichannel intraluminal impedance-pH (MII-pH) catheter. All patients were asked to eat the same standard meal (double cheeseburger, 1 banana, 100g yogurt and 200mL water; total energy value, 744kcal; 37.6% carbohydrates, 21.2% proteins and 41.2% lipids) within 5 or 30minutes under observation in a random order on two consecutive days. All reflux episodes over a 3-hour postprandial period were manually analyzed and compared. The mean age was 46 ± 12 (18-66) years. The mean body mass index (BMI) was 39.9 ± 8.4kg/m2. There was no difference between the fast- and slow-eating group in the number of refluxes within the 3-postprandial hours. The patients were divided into 2 groups according to the 24-hour MII-pH monitoring results, that is, 16 subjects with normal MII-pH monitoring and 10 patients with pathologic MII-pH monitoring. There was no effect of the speed of food intake in either the patients with or without GERD. In contrast to the general belief, this study suggested that the speed of food intake does not influence the number of refluxes in obese female patients with or without GERD.

Association between respiratory events and nocturnal gastroesophageal reflux events in patients with coexisting obstructive sleep apnea and gastroesophageal reflux disease

BackgroundLiterature has addressed the increased prevalence of gastroesophageal reflux disease (GERD) in obstructive sleep apnea (OSA). Significant improvement of GERD has been found after OSA treatment. However, precise mechanisms underlying this correlation remain unclear. We examined the association between nocturnal gastroesophageal reflux (GER) and sleep events in patients with coexisting OSA and GERD. MethodsA case-crossover study among 12 patients with coexisting moderate–severe OSA and GERD was conducted. Participants underwent simultaneous polysomnography and esophageal impedance and pH monitoring. GER subtypes (ie, acid reflux, non-acid reflux) were defined as outcomes. Respective control time points were selected in all eligible control periods. Each sleep event was assessed individually. Estimated odds ratios (ORs) and 95% confidence intervals (CIs) were analyzed. A p-value of < 0.05 was considered significant. ResultsPatients were determined as moderate to severe OSA (respiratory disturbance index of 42.66 [±22.09]). There were a total of 50 GER episodes, 22 acid reflux and 28 non-acid reflux. Arousals and awakenings were significantly associated with subsequent GER events. The OR for GER following an arousal was 2.31 (95% CI 1.39–3.68; p < 0.001) and following an awakening was 3.71 (95% CI 1.81–7.63; p < 0.001). GER events were significantly less likely to occur after other respiratory events (OR 0.38 [95% CI 0.18–0.82]; p = 0.01). No sleep events followed GER events (p > 0.05). ConclusionsBoth awakening and arousal appear to precipitate any subtype of GER events in patients with coexisting GERD and moderate to severe OSA. However, GER events were significantly less likely to occur after other respiratory events and did not appear to cause sleep-related events.