Severity Of Gastroesophageal Reflux Research Articles

Radionuclide Diagnosis of Esophageal Dysmotility and Gastroesophageal Reflux in Patients with Systemic Sclerosis

Objective: to evaluate the possibilities of dynamic scintigraphy for the diagnosis of esophageal dysmotility (ED) and gastroesophageal reflux (GER) in patients with systemic sclerosis (SS).Material and methods. The study group included 77 patients with established SS of different disease duration (from several months to 30 years) who underwent Technephyt 99mTc dynamic esophageal scintigraphy using two-stage protocol. During the first stage, the esophageal transport function was evaluated; during the second stage, the presence and severity of GER were assessed. Scans were analyzed using visual assessment, quantitative estimation of time/activity curves, and a proposed three-point scale for evaluating ED and GER severity. The control group consisted of 19 practically healthy individuals who underwent a routine examination to exclude digestive system and gastrointestinal tract diseases, the algorithm of which included dynamic scintigraphy.Results. ED was found in 74 of 77 patients (96%). According to three-point scale, severe ED (3 points) was registrated in 41 (55%) patients, moderate ED (2 points) in 15 (21%), and mild ED in 18 (24%). GER was diagnosed in 35 of 77 cases (45%): mild GER in 13 (37%), moderate GER (2 points) in 22 (63%), and none of the patients was found to have severe GER (3 points). A significant relationship between the presence of GER and the severity of ED was not obtained, but a direct correlation was established between ED and GER severity.Conclusion. Most SS patients demonstrated ED of varying severity associated with mild and moderate GER in nearly 45% of the cases. The study results confirm the practical significance of dynamic scintigraphy for assessing the esophageal transport function and GER in SS patients.

Effect of conventional multilevel brachycephalic obstructive airway syndrome surgery on clinical and videofluoroscopic evidence of hiatal herniation and gastroesophageal reflux in dogs.

To evaluate the effect of conventional multilevel surgery (CMS) for brachycephalic obstructive airway syndrome (BOAS) on associated sliding hiatal hernia (SHH) and/or gastroesophageal reflux (GER). Prospective clinical trial. Sixteen client-owned dogs with clinical signs consistent with BOAS and associated SHH and GER. All dogs were treated with 1 or more components of CMS including soft palate resection, laryngeal ventriculectomy, and alaplasty. A standardized Dog Swallowing Assessment Tool (Dog SAT) questionnaire was completed by owners preoperatively and postoperatively. Videofluoroscopic swallow studies (VFSS) were used to evaluate esophageal motility, gastroesophageal reflux, and hiatal herniation preoperatively, and in a subset of dogs postoperatively. Upper gastrointestinal endoscopic studies were performed to document esophagitis and lower esophageal sphincter pathology. All dogs were discharged from the hospital. One dog experienced aspiration pneumonia immediately postoperatively. Owner-assigned clinical scores improved in scores related to regurgitation after eating and regurgitation (P=.012) during increased activity/exercise (P=.002) between preoperative and postoperative time points. However, no improvement was detected in masked assessment of preoperative and postoperative VFSS studies in terms of GER frequency (P=.46) or severity (P=.79), SHH frequency (P=.082) or severity (P=.34) scores. Owners of dogs treated with CMS perceived an improvement in clinical signs of SHH and GER that was not confirmed by VFSS studies. Conventional multilevel surgery in dogs with BOAS does not appear to consistently resolve SHH and GER, although clinical signs may improve.

Antacid Medication and Antireflux Surgery in Patients with Idiopathic Pulmonary Fibrosis: A Systematic Review and Meta-Analysis.

Rationale: Idiopathic pulmonary fibrosis (IPF) is a fibrosing interstitial pneumonia with impaired survival. Previous guidelines recommend antacid medication to improve respiratory outcomes in patients with IPF. Objectives: This systematic review was undertaken during the development of an American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and Asociación Latinoamericana del Tórax guideline. The clinical question was, "Should patients with IPF who have documented abnormal gastroesophageal reflux (GER) with or without symptoms of GER disease 1) be treated with antacid medication or 2) undergo antireflux surgery to improve respiratory outcomes?" Methods: Medline, Embase, the Cochrane Central Register of Controlled Trials, and the gray literature were searched through June 30, 2020. Studies that enrolled patients with IPF and 1) compared antacid medication to placebo or no medication or 2) compared antireflux surgery to no surgery were selected. Meta-analyses were performed when possible. Outcomes included disease progression, mortality, exacerbations, hospitalizations, lung function, respiratory symptoms, GER severity, and adverse effects/complications. Results: For antacid medication, when two studies were aggregated, there was no statistically significant effect on disease progression, defined as a 10% or more decline in FVC, more than 50-m decline in 6-minute walking distance, or death (risk ratio [RR], 0.88; 95% confidence interval [CI], 0.76-1.03). A separate study that could not be included in the meta-analysis found no statistically significant effect on disease progression when defined as a 5% or more decline in FVC or death (RR, 1.10; 95% CI, 1.00-1.21) and an increase in disease progression when defined as a 10% or more decline in FVC or death (RR, 1.28; 95% CI, 1.08-1.51). For antireflux surgery, there was also no statistically significant effect on disease progression (RR, 0.29; 95% CI, 0.06-1.26). Neither antacid medications nor antireflux surgery was associated with improvements in the other outcomes. Conclusions: There is insufficient evidence to conclude that antacid medication or antireflux surgery improves respiratory outcomes in patients with IPF, most of whom had not had abnormal GER confirmed. Well-designed and adequately powered prospective studies with objective evaluation for GER are critical to elucidate the role of antacid medication and antireflux surgery for respiratory outcomes in patients with IPF.

Clinical and videofluoroscopic outcomes of laparoscopic treatment for sliding hiatal hernia and associated gastroesophageal reflux in brachycephalic dogs.

To describe a laparoscopic technique for treatment of sliding hiatal hernia (SHH) and associated gastroesophageal reflux (GER) in brachycephalic dogs and document clinical and videofluoroscopic outcomes postoperatively. Prospective clinical trial. Eighteen client-owned dogs. A three-port laparoscopic approach was used. Intracorporeal suturing was used for hiatal plication and esophagopexy, and left-sided laparoscopic or laparoscopic-assisted gastropexy was performed. A standardized canine dysphagia assessment tool (CDAT) questionnaire was completed by owners pre- and postoperatively. Videofluoroscopic swallow studies (VFSS) were used to evaluate esophageal function, and impedance planimetry was used to assess lower esophageal sphincter geometry preoperatively and in a subset of dogs postoperatively. Median age was 27.5 (range 5-84) months. Conversion to open surgery was necessary in 1 (5.5%) of 18 dogs. Regurgitation after eating, and associated with activity/exercise, improved significantly when comparing pre- and postoperative CDAT assessments. Hiatal hernia and GER severity scores improved significantly between pre- and postoperative VFSS assessments, whereas SHH and GER frequency scores did not. One dog developed pneumothorax intraoperatively, underwent cardiopulmonary arrest, and died. Minor complications included splenic (n=6) and hepatic lacerations (n=3) that did not require specific therapy. A laparoscopic approach to treatment of SHH and GER led to improvements in clinical and VFSS indices in the majority of brachycephalic dogs. However, a subset of dogs still demonstrated some clinical signs postoperatively. In experienced hands, laparoscopic treatment of SHH and GER offers a minimally invasive alternative to open surgery.

Impact of gastroesophageal reflux and delayed gastric emptying on pediatric lung transplant outcomes

Gastroesophageal reflux disease is thought to predispose to adverse lung allograft outcomes. However, little is known about the burden of gastroesophageal reflux (GER) and gastroparesis in pediatric patients. In this study we describe the burden of reflux and gastroparesis in children undergoing lung transplant, and evaluates their impact on allograft survival and rejection incidence. This study is a retrospective analysis of pediatric lung transplant recipients who had combined pH and multichannel intraluminal impedance testing (pH-MII) and gastric-emptying scans (GES). Hazard ratios with 95% confidence intervals (CIs) estimated from Cox proportional hazard models were used to examine the associations between reflux parameters and adverse allograft outcomes. Covariates considered in the multivariate analysis included abnormal pH-MII testing, abnormal GES and Nissen fundoplication status. Kaplan-Meier curves were created, with log-rank testing employed to assess differences between groups. Thirty lung transplant recipients, aged 1 to 21 years, were identified. Eight of 30 patients (27%) had abnormal reflux by impedance, and 12 (40%) had abnormal pH-metry. Of 19 patients tested, 5 (26.3%) had evidence of gastric dysmotility; however, the severity of GER did not trend with delays in gastric emptying. Neither reflux burden by pH-MII testing nor fundoplication status impacted survival or rejection. However, delayed gastric emptying appeared significantly linked to the development of chronic lung allograft dysfunction, independent of GER. In children, reflux burden and fundoplication status do not impact lung transplant outcomes, but gastric dysmotility may be linked to allograft dysfunction in children.

Gastrointestinal symptom severity in irritable bowel syndrome, inflammatory bowel disease and the general population.

Irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) patients report similar gastrointestinal (GI) symptoms, yet comparisons of symptom severity between groups and with the general population (GP) are lacking. We compared Patient-Reported Outcomes Measurement Information System (PROMIS® ) GI symptom scales measuring gastro-esophageal reflux (GER), disrupted swallowing, diarrhea, bowel incontinence, nausea/vomiting, constipation, belly pain, and gas/bloating in: (i) USA GP sample, (ii) IBS patients, and (iii) IBD patients from tertiary care and community populations. Symptom severity scores were based on T-score metric with mean 50±10 (standard deviation) relative to the GP. Of 1643 patients enrolled, there were 253 IBS patients (68% F, mean age 45±15years), 213 IBD patients (46% F, mean age 41±14years), and 1177 GP subjects (57% F, mean age 46±16years). IBS patients reported greater severity of GER, disrupted swallowing, nausea/vomiting, belly pain, gas/bloating, and constipation symptoms than their IBD counterparts (all P<.05). Compared to the GP, IBD patients had worse belly pain, gas/bloating, diarrhea, and bowel incontinence, but less severe GER and disrupted swallowing (all P<.05), and IBS patients had more severe nausea/vomiting, belly pain, gas/bloating, and constipation (all P<.05). Women had more severe belly pain and gas/bloating than men, whereas men had more severe bowel incontinence (all P<.05). IBS and IBD are associated with more severe GI symptoms compared to the GP excluding esophageal symptoms. Unlike IBD, IBS is not characterized by observable GI inflammation but patients report more severe upper and lower GI symptoms.

Reflux characteristics of 113 GERD patients with abnormal 24-h multichannel intraluminal impedance-pH tests.

To analyze reflux parameters by means of combined multichannel intraluminal impedance and pH (MII-pH) monitoring in patients with gastroesophageal reflux disease (GERD) symptoms off medication, and to find the reflux characteristics of Chinese GERD patients and the influences of gender, age, body posture, and body mass index (BMI) on gastroesophageal reflux (GER). Between Dec. 2008 and May 2014, 125 patients with typical GERD symptoms were subjected to 24-h MII-pH monitoring. Twelve patients with normal MII-pH profiles were not considered for analysis. The reflux parameters of 113 GERD patients with abnormal MII-pH results were analyzed. (1) DeMeester scores were above the normal range in 46.90% (53/113) of GERD patients. Weakly acidic refluxes were prevalent in GERD patients, and the frequency of abnormal weakly acidic reflux was 75.22% (85/113). The frequencies of abnormal symptom index (SI) and symptom association probability (SAP) were 19.47% (22/113) and 14.16% (16/113), respectively. (2) The frequencies of DeMeester scores, the %time at pH<4, and the numbers of reflux episodes and of long reflux episodes >5 min were significantly higher in male patients than in female patients. (3) The %time at pH<4 was much higher during upright periods than during supine periods. During supine periods, 31.86% (36/113) of GERD patients had delayed bolus clearance time, compared with 19.47% (22/113) during upright periods. (4) The number of abnormal DeMeester scores, %time at pH<4, and the number of acid refluxes during upright periods were significantly higher in obese GERD patients than in GERD patients with a normal BMI. Overweight GERD patients also had many more acid refluxes during upright periods than GERD patients with a normal BMI. Weakly acidic refluxes were prevalent in Chinese GERD patients. The factors male, gender, upright position, obesity (BMI≥25), but not age, may increase the frequency and severity of GER.

Barium Esophagram In Idiopathic Pulmonary Fibrosis Patients Being Evaluated for Lung Transplant Demonstrates Limited Utility

Introduction: Gastroesophageal Reflux (GER) has been implicated in the development of Idiopathic Pulmonary Fibrosis (IPF), and its prevalence has been documented in the IPF population undergoing lung transplant evaluation. The gold standard for detection of increased GER is quantitation by 48-hour pH capsule placement (BRAVO®) or 24-hour pH-impedance testing. Esophageal dysmotility, which predisposes to GER, is best detected using high resolution esophageal manometry (HREM). Barium esophagram is a radiographic test that can detect both GER and dysmotility. It is less invasive and often better tolerated than HREM or quantitative reflux testing in dyspneic IPF patients. Our aim was to determine the utility of barium esophagram in identifying GER and esophageal dysmotility in the pre-transplant IPF population. Methods: All IPF patients evaluated for lung transplant at our institution between January 2009 and July 2013 were included. Testing options included barium esophagram, HREM, upper endoscopy and quantitative reflux testing. These results were used in our analysis. Results: Of the 100 IPF patients evaluated, 63 were male with an average age of 61 years. Testing included barium esophagram (53 patients), HREM (40) and quantitative reflux testing (39). A total of 38 patients had both esophagram and reflux testing. Of these patients, 11 had abnormal reflux on both studies, 5 patients had abnormal reflux on esophagram alone, and 11 patients had abnormal reflux on quantitative testing but not esophagram. Based on these data, barium esophagram had a sensitivity of 50% and a specificity of 69% for detection of GER. Severity of GER did not correlate with quantitative testing, as abnormal reflux testing was seen in 75% of patients with mild GER on esophagram and only 50% of patients with moderate or severe GER. Esophageal dysmotility on HREM was defined as a low mean distal amplitude of contraction (<43 mmHg) or less than 80% peristaltic swallows. A total of 39 patients had both esophagram and HREM. Of these patients, 13 had dysmotility on both studies, 9 had dysmotility only on esophagram, and 6 had dysmotility on HREM but not esophagram. Overall, esophagram had a sensitivity of 68% and a specificity of 55% for detection of dysmotility. Only 50% of patients with mild dysmotility on esophagram had an abnormal HREM, while 80% of patients with moderate radiographic dysmotility also had abnormal HREM. Conclusion: Esophagram has a low sensitivity and specificity for detection of both GER and esophageal dysmotility in pre-transplant IPF patients. Larger studies are needed to confirm these findings. If these results are validated, use of esophagram likely can be bypassed in favor of quantitative reflux testing and HREM.

Su1805 Survival Following Neoadjuvant Chemotherapy in Esophagogastric Cancer: Evolving Improvements and Survival

BACKGROUND: Gastric decompression(GD) with nasogastric(NG) tube is considered to be necessary after esophagectomy and esophagogastrostomy because it can prevent the dilation of intra-thoracic stomach(ITS) and the postoperational Gastroesophageal reflux(GER). Thus it might be useful to prevent the anastomostic leakage. But the use of NG tube will bring about numerous complications and worsen the gross experience of patients. If we can limite the dilation of intra-thoracic stomach and alleviate GER with tubular gastroplasty and ITS emdedding with a medical sealant glue, is gastric decompression with NG tubes still Necessary?. METHODS: 150 patients with esophageal cancer were randomly divided into groups with gastric decompression (GD group) and without gastric decompression (NGD group) after surgery. According to the incision chosen, patients in each group were subdivided into Sweet group and Ivor Lewis group. In the operation, all patients received tubular gastroplasty, and a medical sealant glue was used to fix the stomach into mediastinum. The variables recorded for each patient included the gross feeling(with a 1-10 score system), the minimun diameter of ITS on the level of inferior pulmonary vein(with CT), the severity of GER(with Reflux Symptom Questionnaire), the need for placing/replacing the NG tube, the need for gastrointestinal prokinetic drugs, as well as the duration of postoperative hospitalization, pulmonary complications, anastomosis leak. RESULTS: After stratified analysis of operation mode, we found the gross feeling of patients is significantly worse in GD group(p<0.05). No difference was found in severity of GER, dilation of ITS, occurrence of complications, as well as the need for gastrointestinal prokinetic drugs and placing/replacing the NG tube between two groups. CONCLUSIONS: With the use of tubular gastroplasty and ITS emdedding, Gastric decompression with nasogastric(NG) tube is not necessary to be considered as a routine treatment after esophagectomy and esophagogastrostomy.

Su1803 Is Gastric Decompression Necessary After Esophagectomy and Esophagogastrostomy

BACKGROUND: Gastric decompression(GD) with nasogastric(NG) tube is considered to be necessary after esophagectomy and esophagogastrostomy because it can prevent the dilation of intra-thoracic stomach(ITS) and the postoperational Gastroesophageal reflux(GER). Thus it might be useful to prevent the anastomostic leakage. But the use of NG tube will bring about numerous complications and worsen the gross experience of patients. If we can limite the dilation of intra-thoracic stomach and alleviate GER with tubular gastroplasty and ITS emdedding with a medical sealant glue, is gastric decompression with NG tubes still Necessary?. METHODS: 150 patients with esophageal cancer were randomly divided into groups with gastric decompression (GD group) and without gastric decompression (NGD group) after surgery. According to the incision chosen, patients in each group were subdivided into Sweet group and Ivor Lewis group. In the operation, all patients received tubular gastroplasty, and a medical sealant glue was used to fix the stomach into mediastinum. The variables recorded for each patient included the gross feeling(with a 1-10 score system), the minimun diameter of ITS on the level of inferior pulmonary vein(with CT), the severity of GER(with Reflux Symptom Questionnaire), the need for placing/replacing the NG tube, the need for gastrointestinal prokinetic drugs, as well as the duration of postoperative hospitalization, pulmonary complications, anastomosis leak. RESULTS: After stratified analysis of operation mode, we found the gross feeling of patients is significantly worse in GD group(p<0.05). No difference was found in severity of GER, dilation of ITS, occurrence of complications, as well as the need for gastrointestinal prokinetic drugs and placing/replacing the NG tube between two groups. CONCLUSIONS: With the use of tubular gastroplasty and ITS emdedding, Gastric decompression with nasogastric(NG) tube is not necessary to be considered as a routine treatment after esophagectomy and esophagogastrostomy.

Role of reflux‐induced epithelial–mesenchymal transition in periprosthetic leakage after prosthetic voice rehabilitation

Gastroesophageal reflux (GER) contributes to periprosthetic leakage after prosthetic voice rehabilitation. However, underlying mechanisms are unclear, and markers predicting anti-reflux therapy response are missing. We assessed epithelial-mesenchymal transition in 148 consecutive biopsies from 44 patients with/without fistula enlargement under dual-probe pH monitoring before and after proton-pump inhibitor (PPI) therapy applying immunohistochemistry. Results were correlated with reflux intensity and clinical and histologic findings. Epithelial-mesenchymal transition correlated with GER in all samples, and patients with fistula enlargement showed higher epithelial-mesenchymal transition scores. Contrary to patients without enlargement, epithelial-mesenchymal transition scores did not regress during therapy in this group. Furthermore, pretherapeutic epithelial-mesenchymal transition scores were lower in therapy responders than in nonresponders without reaching significance (p = .07). We demonstrate that epithelial-mesenchymal transition correlates with severity of GER and presence of periprosthetic fistula enlargement in patients who underwent prosthetic voice rehabilitation, but epithelial-mesenchymal transition seems to be reversible upon PPI treatment in early stages only.

Cricopharyngeal Muscle Electromyography Findings in Patients with Gastroesophageal Reflux Disease

To analyze the grade of reflux and the behavior of the cricopharyngeal muscle (CPM) in patients with gastroesophageal reflux (GER) by means of electromyographic (EMG) analysis of CPM. Prospective clinical study. Istanbul Training and Research Hospital. Motor unit potential (MUP) recordings and kinesiological recordings of CPM were performed using a concentric needle electrode during dry material swallowing and 3-, 5-, and 10-mL water swallowing. Twenty-four patients with GER were compared with 21 healthy volunteers. GER was mild in 15 patients and moderate-to-severe in 9 patients. MUP recordings were normal in both groups during the preswallowing/postswallowing periods. Kinesiological investigations revealed that the number of patients who did not show a preswallow EMG burst had a positive correlation with the severity of reflux and the amount of liquid swallowed. Rebound bursts were observed in the patient and the control groups. Duration of preswallow and rebound bursts was similar in all groups. Duration of swallowing was shorter in mild GER patients compared with healthy volunteers and moderate-to-severe GER patients. Piecemeal deglutition during 10-mL liquid swallowing was higher in moderate-to-severe GER patients. We also found a positive correlation between the number of swallows and the severity of reflux. Needle EMG of the upper esophageal sphincter was normal in GER patients. Kinesiological evaluations showed increased piecemeal deglutition and number of swallows that correlated positively with the severity of GER.

The outcome of conservative treatment for anastomotic leakage after surgical repair of esophageal atresia

Objective The aim of this study was to evaluate the clinical outcome of conservative management of anastomotic leakage (AL) after surgical repair for esophageal atresia. Methods Data from 85 neonates with esophageal atresia who underwent surgical correction were retrospectively analyzed. Conservative treatment had been adopted for AL. The incidence and severity of postoperative AL as well as its effects were analyzed. Results Among the 85 neonates, postoperative AL occurred in 21 (25%) cases, with major leaks in 15 cases and minor leaks in 6. The stricture index of the 21 neonates with AL (0.615 ± 0.032) was significantly different ( P = .008) from that of the 64 neonates without leakage (0.509 ± 0.018). The overall incidence of gastroesophageal reflux (GER) was 36%. Esophageal dysmotility and clinically significant tracheomalacia were observed in 69 and 7 infants, respectively, of the 80 surviving patients. The incidence of GER, dysmotility, and tracheomalacia in patients with or without AL was similar. The severity of GER in patients with different numbers of sessions of dilation was significantly different ( P = .0015). Conclusions Postoperative esophageal AL is effectively treatable by conservative methods in most neonates. The occurrence of AL may aggravate the severity of esophageal stricture but does not affect the incidence of GER, esophageal dysmotility, and tracheomalacia.

Changes in Gastroesophageal Reflux in Patients With Nasogastric Tube Followed by Percutaneous Endoscopic Gastrostomy

Despite frequent use of percutaneous endoscopic gastrostomy (PEG) for enteral feeding, the relationship between it and gastroesophageal reflux (GER) remains an incompletely answered question. We conducted this study to compare the GER between the same patients fed with a nasogastric (NG) tube and later with a PEG tube. We enrolled 15 patients who had received NG tube feeding for > 6 months and were about to receive PEG tube insertion. We used Ponsky's pull method with 24 Fr feeding tubes. They received two GER scans, one just before PEG tube insertion and another 1 week after insertion. We drew regions of interest of radioactivity in the esophagus and stomach manually. The ratios of radioactivity of the region of interest in the esophagus over the stomach (GER ratio) were calculated to evaluate the severity of GER and compared. The GER ratios of these patients were all small and <3% except one that was 4.7% in one patient before PEG tube insertion. There was a small but substantial decrease (65% risk reduction) in GER ratio after PEG tube insertion. After arcsine transformation, the difference in the transformed data between patients fed with an NG tube and after PEG tube insertion was significant (t= 2.46, p = 0.028), and was lower after PEG tube insertion. Our study demonstrates by scintigraphy a small but significant reduction of GER after shifting from NG to PEG tube feeding.

Induced Sputum Substance P in Children with Difficult-to-Treat Bronchial Asthma and Gastroesophageal Reflux: Effect of Esomeprazole Therapy

Objectives. To assess the induced sputum substance P (ISSP) levels in children having difficult-to-treat asthma (DA) with and without gastroesophageal reflux (GER). We aimed also to evaluate the association of GER with childhood DA, relationship of GER severity with childhood asthma control test (C-ACT), FEV1, peak expiratory flow (PEF) variability, and ISSP. Finally, we tried to evaluate esomeprazole treatment effect on C-ACT and FEV1 in children with DA. Methods. Spirometry, C-ACT, upper gastrointestinal endoscopy, and ISSP measurement were done for children with DA compared to healthy controls. Results. ISSP was high in DA with higher levels in the group having associated GER. In the latter group, ISSP and C-ACT improved significantly after esomeprazole treatment while FEV1 and PEF variability did not improve. Reflux severity was positively correlated with ISSP and negatively correlated with FEV1. Conclusions. GER was found in 49% of our patients with childhood DA. Very high ISSP levels in children with DA may be used as a marker for presence of GERD. Esomeprazole therapy improved asthma symptoms but did not improve lung function.

Serum lipid levels are positively associated with non‐erosive reflux disease, but not with functional heartburn

Metabolic syndrome and obesity are known risk factors for gastro-esophageal reflux disease (GERD), especially for erosive esophagitis. Although non-erosive reflux disease (NERD) is probably associated with obesity or other metabolic syndrome, there is little direct evidence to support this assertion. Workers in Keio University who underwent a general health examination between September 2006 and August 2007 were enrolled. Reflux symptom questionnaires were administered and metabolic parameters were obtained. The severity of gastro-esophageal reflux (GER) was scored using a validated scale of videoesophagography. Two hundred and eighty-three subjects (243 men and 40 women; mean age 49.8 +/- 6.9 years) with no radiographic evidence of erosive esophagitis were enrolled. The severity of GER was worse among men than among women, whereas the severity of reflux symptoms was worse among women. The severity of GER was associated with age and serum triglyceride levels in men, and with the serum low-density lipoprotein cholesterol levels in women. The severity of reflux symptoms, however, was not associated with metabolic parameters. There were more women than men with reflux symptoms but without GER ('presumed' functional heartburn group), compared with subjects with neither GER nor reflux symptoms. In men, the presence of both reflux symptoms and GER ('presumed' NERD group) was associated with the serum triglyceride levels. While NERD is associated with serum lipid levels, functional heartburn is not. The prevalence of GER was greater among men; conversely, the prevalence of functional heartburn was greater among women.

Characteristics of gastroesophageal reflux in adults with cystic fibrosis

Background Gastroesophageal reflux (GER) in adults with cystic fibrosis (CF) is poorly characterized. This study examines the frequency and predictors of GER symptoms and their relationship to lung function in adults with CF. Methods Cross-sectional study of adults at the University of Minnesota CF Clinic using two validated self report surveys: The Mayo GER questionnaire and the GERD Symptom Assessment Scale (GSAS). Results Of 274 invited patients, 201 (73%) completed the surveys and 173 performed spirometry at the same visit. Frequent symptoms (at least weekly) were reported by 24% of the patients and an additional 39% experienced occasional symptoms. Heartburn, acid regurgitation and dysphagia were the most common symptoms and 18% reported that GER symptoms worsened their respiratory condition. Females and patients reporting weight loss had more symptoms (mean GSAS symptom score 4.9 vs. 4.0, p = 0.025 and 5.3 vs. 4.2, p = 0.04) and more severe symptoms (mean GSAS distress score 5.6 vs. 3.8, p = 0.005 and 6.8 vs. 4.0, p = 0.01) compared to males and those who did not report weight loss. Patients on acid suppression (n = 122, 61%) continued to report heartburn (n = 80, 66%) and acid regurgitation (n = 47, 23%). GER symptoms and severity of symptoms were not predictive of FEV 1 or FVC. Conclusions GER symptoms were present in a majority of patients. Females and patients with weight loss require special attention to their GER symptoms. Many patients on acid suppression continued to be report symptoms.

Gastroesophageal reflux and obstructive sleep apnea in childhood

To examine the relationship between gastroesophageal reflux (GER) and obstructive sleep apnea syndrome (OSAS) with polysomnographic alterations and symptom severity. Eighteen children aged from 6 to 12 years (8.14+/-1.75) with adenotonsillar hypertrophy and OSAS were evaluated with the OSA-18 questionnaire nasofibrolaringoscopy and full overnight polysomnography performed simultaneously with esophageal pH monitoring. OSAS (Apnea-index (AI)>or=1/hour) was present in all cases. Reflux parameters did not correlate to OSAS severity and a temporal relationship between GER and apnea-hypopnea events was not observed. Body mass index was lower than 18 in 9 cases (52.9%) and 7 children (41.1%) presented a history of abnormal behavior during sleep. In most cases oxygen desaturation and reduction of sleep efficiency were mild. Sleep architecture was similar to the young adult pattern. Seven children (41.1%) presented pH monitoring values below 4 during more than 10% of total sleep time. pH monitoring values were correlated to emotional distress (p=0.008) and to daytime problems (p=0.03) as evaluated by the OSA-18. GER is frequent and should be assessed in children from 6 to 12 years with OSAS. Emotional distress and daytime problems are correlated to increased GER severity.

Sleep Related Gastroesophageal Reflux

With many medical disorders, it takes decades for investigators to examine their effects on sleep. This is truly the case for gastroesophageal reflux (GER). Gastroesophageal reflux is very common in our population, with 7% of adults experiencing symptoms daily and 20% experiencing symptoms at least weekly.1,2 Since obesity is a predisposing factor for GER, the prevalence of GER prevalence will increase as obesity prevalence reaches epidemic proportions. Currently, sleep related GER is underappreciated from a clinical standpoint.3 Although gastroenterologists were slow to recognize the impact of sleep related GER on daytime functioning, they were insightful enough to recognize the need for 24-hour monitoring when esophageal pH testing was developed in the 1970s.4 Since then, Orr and colleagues have performed multiple experiments examining esophageal acid clearance during sleep using esophageal acid infusions.5,6 Over the past 3 years, research has focused on the impact of GER on sleep itself and on daytime consequences of sleep related GER. The tip of the iceberg was discovered' A national population-based telephone survey of 1000 people with heartburn conducted by the Gallup Organization noted that nighttime heartburn was reported by 79% of respondents; 75% of these reported that heartburn affected their sleep, and 40% believed that nighttime heartburn impaired their daytime functioning.3 Despite having prescription GER medications, only 49% of respondents had adequate control of their GER symptoms. Fass and colleagues examined predictors of heartburn during sleep in the 15,314 subjects of the Sleep Heart Health Study, noting that 25% reported heart-burn during sleep.7 Predictors of heartburn during sleep, using multivariate models include increased body mass index, snoring, sleepiness (as noted on the Epworth Sleepiness Scale), hypertension, asthma, and use of benzodiazepines.7 In this issue of the Journal of Clinical Sleep Medicine, Dickman and colleagues examined 48 subjects with GER symptoms, with 16 subjects undergoing esophageal pH monitoring during polysomnography.8 Disorders of initiating and maintaining sleep were associated positively with GER severity on validated questionnaires. Furthermore, subjects who reported more nighttime awakenings had higher GER symptom scores. This study also gives insight as to when acid GER events occur. Approximately 54% of the GER events occurred during sleep and of those, 62% of GER events were followed by an awakening. Ninety percent of GER events that occurred during sleep were associated with sleep disruption. So, individual GER events do disrupt sleep architecture. Although this study was not specifically designed to answer the question as to whether sleep time events can affect wake time GER, it gives preliminary evidence that it may. Poor sleep did worsen GER the following day. Poorer sleep quality obtained from the Sleep Quality Questionnaire was associated with longer acid GER events.8 This cycle can be stopped because aggressive GER therapy can improve sleep outcomes and daytime functioning as noted by Johnson and colleagues.9 They performed a placebo-controlled trial utilizing esomeprazole 40 mg, 20 mg, or placebo for 6 weeks in 750 adults with GER-associated sleep disturbance. Fifty percent of the esomeprazole-treated subjects had resolution of nighttime heartburn, and by 4 weeks, 73% of the esomeprazole-treated subjects had resolution of their GER-associated sleep disturbance. Both doses of esomeprazole resulted in improved sleep quality, reduced lost work hours, and increased work productivity.9 So now that the tip of the iceberg is exposed and treatment is available, sleep professionals need to inquire about GER symptoms in patients who present with awakenings and/or excessive daytime sleepiness. Many unanswered questions still remain concerning sleep related GER that will require interdisciplinary studies with our gastroenterology colleagues.

Cough and reflux esophagitis in children: their co-existence and airway cellularity

BackgroundThere are no prospective studies that have examined for chronic cough in children without lung disease but with gastroesophageal reflux (GER). In otherwise healthy children undergoing flexible upper gastrointestinal endoscopy (esophago-gastroscopy), the aims of the study were to (1) define the frequency of cough in relation to symptoms of GER, (2) examine if children with cough and reflux esophagitis (RE) have different airway cellularity and microbiology in bronchoalveolar lavage (BAL) when compared to those without.MethodsData specific for chronic cough (>4-weeks), symptoms of GER and cough severity were collected. Children aged <16-years (n = 150) were defined as 'coughers' (C+) if a history of cough in association with their GER symptoms was elicited before BAL were obtained during elective esophago-gastroscopy. Presence of esophagitis on esophageal biopsies was considered reflux esophagitis positive (E+).ResultsC+ (n = 69) were just as likely as C- (n = 81) to have esophagitis, odds ratio 0.87 (95%CI 0.46, 1.7). Median neutrophil percentage in BAL was significantly different between groups; highest in C+E- (7, IQR 28) and lowest in C-E+ (5, IQR 6). BAL positive bacterial culture occurred in 20.7% and were more likely present in current coughers (OR 3.37, 95%CI 1.39, 8.08). Airway neutrophilia (median 20%, IQR 34) was significantly higher in those with BAL positive bacterial cultures than those without (5%, 4; p = 0.0001).ConclusionIn children without lung disease, the common co-existence of cough with symptoms of GER is independent of the occurrence of esophagitis. Airway neutrophilia when present in these children is more likely to be related to airway bacterial infection and not to esophagitis.