MII-pH Monitoring Research Articles

Effect of different tube feeding methods on gastroesophageal reflux features in preterm infants: a pH-impedance monitoring study.

Continuous feeding and boluses may have a different impact on pH-MII GER features in symptomatic tube-fed preterm infants, whereas the permanence of the feeding tube across LES did not seem to worsen GER indexes. • Due to the functional and anatomical immaturity of the gastrointestinal tract, gastroesophageal reflux (GER) is common in preterm infants. • A stepwise therapeutical approach which firstly undertakes conservative strategies is the most advisable choice to avoid potentially harmful pharmacological overtreatments in the preterm population. • Continuous feeding and boluses may have a different impact on GER features assessed by pH-MII monitoring in tube-fed preterm infants. • The permanence of the feeding tube during or after the feeding period did not seem to worsen GER occurrence. • By reducing GER features, especially acid GER, continuous feeding may potentially contribute to limit the need for antiacid medications in this population.

Comparison of Esophageal Dysmotility and Reflux Burden in Patients with Different Metabolic Obesity Phenotypes Based on High-Resolution Impedance Manometry and 24-h Impedance-pH

Introduction: The relationship between the metabolically healthy obesity (MHO) phenotype and the occurrence of gastroesophageal reflux disease (GERD) and inefficient esophageal motility (IEM) is still unclear. Thus, we assessed the association between different metabolic obesity phenotypes and GERD and IEM using empirical data. Methods: We collected clinical and test data of 712 patients, including 24-h multichannel intraluminal impedance-pH (24-h MII-pH) monitoring, high-resolution manometry (HRM), and endoscopy. We divided 567 individuals into four categories according to their metabolic obesity phenotype: metabolically unhealthy non-obesity (MUNO), metabolically unhealthy obesity (MUO), metabolically healthy non-obesity (MHNO), and MHO. We compared differences in the 24-h MII-pH monitoring, HRM, and endoscopy findings among the four metabolic obesity phenotypes. Results: Patients with the MUNO, MHO, or MUO phenotype showed a greater risk of IEM and GERD (pathologic acid exposure time [AET] >6%) compared with patients with the MHNO phenotype. Regarding the HRM results, patients with the MHNO or MUNO phenotype had a lower integrated relaxation pressure, esophageal sphincter pressure, and esophagogastric junction contractile integral, and more ineffective swallows than patients with the MHO or MUO phenotype (p < 0.05). In terms of 24-h MII-pH, patients with the MHO or MUO phenotype had a higher total, upright, and supine AET; a higher total number of reflux episodes (TRs); and a lower mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index compared with those with the MHNO or MUNO phenotype (all p < 0.05). Considering the odds ratio of 19.086 (95% confidence interval 6.170–59.044) for pathologic AET and 3.659 (95% confidence interval 1.647–8.130) for IEM, patients with the MUO phenotype had the greatest risk after adjusting for all confounding variables. Conclusion: Obesity and metabolic disorders increase the risk of GERD and IEM. Obesity has a greater impact on esophageal dysmotility and pathologic acid exposure than metabolic diseases.

Utility of the Post-Reflux Swallow-Induced Peristaltic Wave Index and Mean Nocturnal Baseline Impedance for the Diagnosis of Gastroesophageal Reflux Disease Phenotypes in Children.

(1) Objectives: Assessment of novel impedance parameters such as the post-reflux swallow-induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) have been proposed to enhance the accuracy of gastroesophageal reflux disease (GERD) diagnosis. We aimed to evaluate the clinical value of MNBI and the PSPW index in discerning different phenotypes of GERD in children. (2) Methods: We conducted a prospective, observational study that included 49 children aged 5-18 years, referred for MII-pH monitoring due to negative endoscopy and persisting gastroesophageal reflux symptoms despite acid-suppressant treatment. The PSPW index and MNBI were assessed along with conventional metrics. (3) Results: Using a receiver operating characteristic (ROC) curve analysis, MNBI (AUC 0.864) and the PSPW index (AUC 0.83) had very good performance in differentiating between non-erosive reflux disease (NERD) and functional phenotypes. The PSPW index (AUC 0.87) discriminated better between functional heartburn (FH) and reflux hypersensitivity (RH) compared to the MNBI (AUC 0.712). A PSPW cut-off value of 65% provided a sensitivity of 76.9% and a specificity of 90% in distinguishing FH and RH. The PSPW index (AUC 0.87) proved to have better performance than the MNBI (AUC 0.802) in differentiating between FH and non-FH patients. MNBI diagnosed FH with a sensitivity of 84% and a specificity of 80.6% at a cut-off value of 2563 Ω. (4) Conclusions: The PSPW index and MNBI are useful to distinguish between GERD phenotypes in pediatric patients.

Assessing the role of dryness and burning sensation in diagnosing laryngopharyngeal reflux

Laryngopharyngeal reflux disease (LPRD) is a condition characterized by the regurgitation of stomach and duodenal contents into the laryngopharynx, with variable and non-specific symptoms. Therefore, developing an accurate symptom scale for different regions is essential. Notably, the symptoms of “dryness and burning sensation in the laryngopharynx or mouth” are prevalent among the Chinese population but are often omitted from conventional symptom assessment scales, such as the Reflux Symptom Index (RSI) and Reflux Symptom Score-12 (RSS-12) scales. To address this gap, our study incorporated the symptoms into the RSI and RSS-12 scales, developing the RSI-10/RSS-13 scales. Afterward, we assessed the role of the new scale’s reliability (Cronbach’s α and test–retest reliability), construct validity (confirmatory factor analysis and confirmatory factor analysis), and diagnostic efficiency. Our study encompassed 479 participants (average = 39.5 ± 13.4 years, 242 female) and 91 (average = 34.01 ± 13.50 years, 44 female) completed 24 h MII-pH monitoring. The Cronbach’s α values of 0.80 and 0.82 for the RSI-10 and RSS-13 scales, respectively. RSI-10 and RSS-13 exhibited strong test–retest reliability (ICCs = 0.82–0.96) and diagnostic efficacy (AUC = 0.84–0.85). Furthermore, the factor analysis identified the RSS-13 and its three sub-scales (ear-nose-throat, digestive tract, respiratory tract) exhibited good to excellent structural validity (χ2/df = 1.95, P < 0.01; CFI = 0.95, RMSEA = 0.06, SRMR = 0.05). The AUC optimal thresholds for the RSI-10 and RSS-13 in the Chinese population were 13 and 36, respectively. Besides, the inclusion of the new item significantly improved the diagnostic efficiency of the RSI scale (P = 0.04), suggesting that RSI-10 holds promise as a more effective screening tool for LPRD, and global validation is needed to demonstrate the impact of this new symptom on the diagnosis of LPRD.

Post-reflux swallow-induced peristaltic wave index: a new parameter for the identification of non-acid gastroesophageal reflux-related chronic cough.

The current available diagnostic criteria for gastroesophageal reflux-related chronic cough (GERC) dominated by non-acid reflux is imperfect. The post-reflux swallow-induced peristaltic wave index (PSPWI) is a parameter reflecting esophageal clearance function. This study aims to investigate its diagnostic value for non-acid GERC. This study sought to compare the diagnostic value of PSPWI in different types of GERC, particularly non-acid GERC, and explore the clinical significance of PSPWI in the diagnosis of non-acid GERC through diagnostic experiments. A retrospective analysis was performed based on 223 patients with suspected GERC who underwent multichannel intraluminal impedance-pH monitoring (MII-pH) in the outpatient clinic of our department from August 2016 to June 2021. Their clinical information, laboratory test results, and treatment responses were assessed and the underlying etiologies of chronic cough were categorized. The predictive value of the PSPWI in diagnosing different types of GERC, especially non-acid GERC, was analyzed and compared. A total of 195 patients with chronic cough who met the inclusion criteria underwent MII-pH monitoring. 143 patients had a definitive diagnosis of GERC, including 98 with acid GERC and 45 with non-acid GERC. The diagnostic value of PSPWI alone was moderate for GERC with an area under the working curve (AUC) 0.760, but poor for non-acid GERC with an AUC of 0.569. However, PSPWI < 39.8% combining with acid exposure time (AET) ⩽ 6.2% demonstrated a moderate diagnostic value for non-acid GERC, with an AUC of 0.722. When PSPWI < 39.8% combined with a non-acid reflux ratio >68.75%, the diagnostic value for non-acid GERC was improved (AUCROC = 0.80 versus AUCROC = 0.722, p < 0.05), which was significantly superior to non-acid symptom index (AUCROC = 0.804 versus AUCROC = 0.550, p < 0.05) and non-acid symptom association probability (AUCROC = 0.804 versus AUCROC = 0.571, p < 0.05). PSPWI < 39.8% and AET ⩽ 6.2% have demonstrated good diagnostic value for non-acid GERC. The diagnostic value was further improved when combined with non-acid reflux ratio >68.75%.

Diagnostic Utility of pH-MII Monitoring in Preschool Children with Recurrent Wheeze and Suspected Gastroesophageal Reflux Disease: A Prospective Study

Background: Recurrent wheezing and gastroesophageal reflux disease (GERD) are common in young children, with a suggested but challenging link between them. This study aimed to investigate the diagnostic value of pH-MII monitoring in preschool children with recurrent wheezing and evaluate GERD-related therapy effects. Methods: Children under 6 years with recurrent wheeze were eligible. The pH-MII monitoring was conducted in those clinically suspected of GERD’s involvement. Flexible bronchoscopy with bronchoalveolar lavage (BAL) was performed in severe cases. The primary outcome was the difference in wheezing episodes between proven GERD and non-GERD groups. Secondary outcomes included GERD therapy impact and predictive factors for wheezing reduction. Results: Of 66 children (mean age 3.9 years), 71% had proven GERD on pH-MII. Compared to the non-GERD group, the GERD group had higher total, liquid, mixed, and gas reflux episodes, as well as more acidic and weakly acidic episodes. GERD treatment significantly reduced wheezing episodes. PPI (proton pump inhibitor) introduction was associated with ≥50% wheezing reduction. Children with GERD showed ≥50% wheezing reduction more frequently than those without GERD. PPI usage, higher total GER episodes, acidic episodes, and liquid and proximal episodes on MII predicted ≥50% wheezing reduction. No significant BAL differences were observed between GERD and non-GERD groups. Conclusions: The pH-MII monitoring is valuable in diagnosing GERD-related wheezing in preschool children. GERD therapy, particularly PPI usage, was associated with reduced wheezing episodes. The pH-MII parameters correlated with wheezing reduction, suggesting their potential predictive role. BAL did not differentiate between GERD and non-GERD cases.

Diagnostic value and application of 24 h multichannel intraluminal impedance-pH monitoring in children with gastroesophageal reflux disease

Objective: To evaluate the diagnostic value and application of 24 h multichannel intraluminal impedance-pH (24 h MII-pH) monitoring in children with gastroesophageal reflux disease (GERD). Methods: This is a cross-sectional study. From January 2013 to December, 2020, 417 patients who received 24 h MII-pH monitoring in Department of Gastroenterology of Children's Hospital Capital Institute of Pediatrics were included. According to results, these children were divided into the GERD and non-GERD groups. Furthermore, the 132 children with GERD who had gastroscopy were divided into the reflux esophagitis (RE) and non-erosive reflux disease (NE) groups to investigate the differences in their refluxes. Non-parametric Mann-Whitney U test or indepentent sample t test was used for comparisons between the groups. Results: Among the 417 children, 232 were males and 185 females, aged (7.3±3.9) years. The course of disease was 0.5 (0.1, 2.0) years. The main clinical symptoms included acid reflux (128 cases), vomiting (173 cases), abdominal pain (101 cases), and cough (76 cases). The 24 h MII-pH monitoring were positive in 243 children (58.3%, 243/417), which was higher than that by 24 h esophageal pH monitoring (43.6%, 182/417). The 24 h MII-pH monitoring results demonstrated significant differences in the episodes of acid reflux, weakly acidic reflux, non-acidic reflux, liquid reflux and mixed reflux between GERD and non-GERD groups (10 (4, 19) vs. 4 (1, 9) times/24 h, 14 (6, 32) vs. 7 (3, 13) times/24 h, 0 (0, 0) vs. 0 (0, 0) times/24 h, 19 (10, 34) vs. 8 (3, 14) times/24 h, and 6 (2, 12) vs. 3 (1, 5) times/24 h, Z=-6.96, -7.25, -5.62, -8.75, and -6.48, all P<0.05, respectively). Besides, the results also showed significant differences in Boix-Ochoa score, episodes of long reflux, course of long reflux, and episodes of weakly acidic reflux between the RE and NE groups (51.2 (21.4, 153.2) vs. 20.7 (12.1, 34.7), 5 (2, 10) vs. 1 (0, 4) times/24 h, 19 (7, 87) vs. 8 (3, 22) min, and 5 (2, 15) vs. 15 (6, 33) times/24 h, Z=-3.44, -3.41, -2.65, and -2.27, all P<0.05, respectively). Conclusion: 24 h MII-pH monitoring not only improves the detection rate of GERD in children, but also provides a possibility to early etiological diagnosis.

Normative Ambulatory Reflux Monitoring Metrics for Laryngopharyngeal Reflux: A Systematic Review of 720 Healthy Individuals.

To review the normative data for acid, weakly acid, and nonacid proximal esophageal (PRE) and hypopharyngeal reflux (HRE) events in diagnosing laryngopharyngeal reflux (LPR) using ambulatory reflux monitoring. PubMed, Cochrane Library, and Scopus. A literature search was conducted about the normative data for PRE and HRE on multichannel intraluminal impedance-pH monitoring (MII-pH), hypopharyngeal-esophageal MII-pH (HEMII-pH), or oropharyngeal pH monitoring using PICOTS (population, intervention, comparison, outcome, timing, and setting) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statements. Outcomes reviewed included device characteristics, impedance/pH sensor placements, study duration, number/average and percentiles of PRE or HRE occurrence, and the event characteristics (pH, composition, and position). Of 154 identified studies, 18 met criteria for analysis, including 720 healthy individuals. HEMII-pH, MII-pH, and oropharyngeal pH monitoring were used in 7, 6, and 5 studies, respectively. The definition and inclusion/exclusion criteria of healthy individuals varied substantially across studies, with 6 studies considering only digestive symptoms to exclude potential LPR patients. Substantial heterogeneity across studies was noted, including impedance/pH sensor placements/configurations and definitions of composition (liquid, gas, mixed) and type (acid, weakly acid, nonacid) of PRE/HRE. The 95th percentile thresholds were 10 to 73 events for PRE, 0 to 10 events for HRE on HEMII-pH, and 40 to 128 for events with pH <6.0 on oropharyngeal pH monitoring. Most HREs were nonacid and occurred upright. The mean HRE among healthy individuals was 1. The low number of studies and the heterogeneity in inclusion criteria, definitions, and characterization of PRE and HRE limit the establishment of consensual normative criteria for LPR on ambulatory reflux monitoring. Future large multicenter studies are needed.

Diagnosis and Management of Gastroesophageal Reflux Disease in Children: Recommendations of Pediatric Gastroenterology Chapter of Indian Academy of Pediatrics, Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition (ISPGHAN)

Gastroesophageal reflux (GER) related symptoms are a major cause of parental concern and referrals at all ages. These guidelines have been framed to inform pediatricians regarding current diagnosis and management of gastro-esophageal reflux disease (GERD). A group of experts from the pediatric gastroenterology sub-specialty chapter of Indian Academy of Pediatrics (ISPGHAN) discussed various issues relating to the subject online on 25 October, 2020. A consensus was reached on most aspects and a writing committee was constituted. This committee had three meetings for a detailed discussion. The statement was sent to the entire group and their approval obtained. To formulate a consensus statement to enable proper diagnosis and management of GERD in children. GER is physiological in most infants and it improves as age advances. The pathological form, called GERD causes distressing symptoms that affect daily activities and may result in complications. The presentation would vary from regurgitation to severe symptoms due to esophageal or respiratory tract disease. In older children, esophagitis is the commonest manifestation of GERD. A careful history and clinical examination are adequate to make a diagnosis in most patients, but judicious investigations are necessary in a few. Upper gastro intestinal tract endoscopy may be required in those with esophageal manifestations, dysphagia and hematemesis. In children with extra-esophageal symptoms, MII-pH monitoring and scintigraphy are necessary. Empirical treatment with a Proton pump inhibitor (PPI) has not been proven useful in infants, but a four-week trial is recommended in older children without complications. While positioning and feed thickening have limited benefit in infants, life-style modifications are important in older children.

Pharyngeal reflux episodes in patients with suspected laryngopharyngeal reflux versus healthy subjects: a prospective cohort study.

This study aimed to analyze pharyngeal reflux episodes in patients with suspected LPR versus healthy subjects using 24-h MII-pH monitoring. One hundred twenty-one patients who visited our clinic with a chief complaint of LPR-related symptoms and underwent 24-h MII-pH monitoring were enrolled prospectively. Also, 27 healthy subjects were enrolled and underwent 24-h MII-pH monitoring during the same period. We analyzed sensitivity, specificity, and accuracy comprehensively to determine appropriate cut-off values of pharyngeal reflux episodes in 24-h MII-pH monitoring to diagnose patients with LPR. Twenty-nine of 121 patients with suspected LPR showed no pharyngeal reflux episodes, while 92 showed more than one pharyngeal reflux event. In contrast, the 22 healthy subjects showed no pharyngeal reflux episodes, three showed one reflux event, and two showed two reflux events. A cut-off value of ≥ 1 showed best accuracy reflected by combined sensitivity and specificity values, while ≥ 2 demonstrated better specificity with slight loss of sensitivity and slightly lower overall accuracy, suggesting cut-off value of ≥ 1 pharyngeal reflux episodes is a good clinical indicator. A cut-off value of ≥ 1 in pharyngeal reflux episodes on 24-h MII-pH monitoring in patients with suspected LPR might be an acceptable diagnostic tool for LPR.

Comparison of clinical characteristics of patients with different types of laryngopharyngeal reflux disease

Objective: To compare the clinical characteristics of patients with different type of laryngopharyngeal reflux disease in order to study the effect of non-acid reflux on laryngopharyngeal reflux disease. Methods: From January 2015 to January 2020, 349 inpatients or outpatients suspected of having laryngopharyngeal reflux underwent 24-hour multichannel intraluminal impedance pH monitoring (MII-pH). There were 303 male and 46 female patients, with an average age of 56.03 years old ranged from 25 to 81 years old. The reflux symptom index (RSI)and reflux findings score(RFS)were recorded before MII-pH monitoring. The number of acid reflux events and non-acid reflux events in hypopharynx were counted. It was defined mainly acid reflux type when the ratio of acid reflux to all reflux events was greater than 50%, mainly non-acid reflux type when the ratio of non-acid reflux to all reflux events was greater than 50%. The clinical characteristics of patients with different type of reflux were compared. SPSS 19.0 software was used for statistical analysis, and multiple independent samples were compared between groups. The quantitative data were analyzed by multivariate analysis of variance, and the counting data were analyzed by chi-square test, the difference was statistically significant when P<0.05. Results: The 24-hour MII-pH showed that there were 90 patients with no reflux events, 51 patients with mainly acid reflux type, 198 patients with mainly non-acid reflux type and 10 patients with equal acid reflux events and non-acid reflux events. Statistics showed that the RSI(10.72±4.40), RFS(7.70±2.73) and the average number of reflux events(0) in the group without reflux events were significantly lower than those in patients with mainly acid reflux type (RSI 13.16±6.62,RFS 10.08±3.03,average number of reflux events 5.33±3.15,P<0.05) and mainly non-acid reflux type(RSI 13.25±5.54,RFS 8.81±2.54,average number of reflux events 7.93±5.26, P<0.05). There was no significant difference in RSI between the mainly non-acid reflux type group and the mainly acid reflux type group, but the RFS of the mainly non-acid reflux type group was significantly lower than that of the mainly acid reflux type group. The average number of reflux events in the mainly non-acid reflux group was significantly higher than that in the mainly acid reflux type group (P<0.05). Conclusion: The results show that non-acid reflux plays a certain role in laryngopharyngeal reflux disease, but the effect of acid reflux is greater.

Changes in Pharyngeal Baseline Impedance in Patients With Laryngopharyngeal Reflux.

Few studies have investigated pharyngeal intraluminal baseline impedance (BI) levels in patients with laryngopharyngeal reflux (LPR). The aim of this study was to compare intraluminal BI levels between patients with LPR and healthy controls. Retrospective case series. Tertiary care medical center. We conducted a retrospective analysis of 24-hour multichannel intraluminal impedance (MII)-pH monitoring results from patients with suspected LPR complaining of reflux symptoms. Patients with suspected LPR were divided into 2 groups according to the 24-hour MII-pH monitoring (LPR group: patients with symptoms with reflux events ≥1, symptom but no reflux [SNR] group: patients with symptoms but no reflux event). Healthy controls were recruited and also underwent 24-hour MII-pH monitoring. We compared the esophageal and pharyngeal BI levels and ratios between 3 groups. Pharyngeal BI levels in the LPR group were significantly higher than in the healthy controls. In addition, the pharyngeal BI levels in the SNR group were significantly higher than in the healthy controls. All ratios of pharyngeal to distal esophageal BI levels in the LPR and SNR group were significantly higher than in the healthy controls. However, there were no significant differences in esophageal BI levels and ratios between the 3 groups. We found that the pharyngeal BI levels were higher in patients with LPR than in healthy controls. In addition, the pharyngeal BI levels measured by 24-hour MII-pH monitoring in patients with LPR symptoms, but without a reflux episode, were higher than in the healthy controls.

Preliminary efficacy analysis of Cheng's Giraffe reconstruction after proximal gastrectomy in adenocarcinoma of esophagogastric junction

Objective: To investigate the safety and feasibility of proximal partial gastrectomy with Cheng's Giraffe esophagogastric reconstruction for the treatment of early Siewert II adenocarcinoma of esophagogastric junction (AEG). Methods: Indication of Cheng's Giraffe esophagogastric reconstruction: (1) Siewert II AEG or Siewert III AEG with diameter < 4 cm; (2) preoperative staging as cT1-2N0M0. A descriptive case series study was carried out. Clinical data of 34 patients with Siewert II AEG undergoing proximal partial gastrectomy and Cheng's Giraffe esophagogastric reconstruction at Department of Abdominal Surgery of Zhejiang Cancer Hospital and Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine from February to July 2018 were retrospectively collected and analyzed, including 14 cases in IA stage, 11 cases in IIA stage and 8 cases in IIB stage. Brief procedure of Cheng's Giraffe esophagogastric reconstruction was as follows: Firstly, 12 cm long tubular stomach was formed by longitudinal incision 4 cm away from the great curvature of the stomach. Secondly, the gastric fundus and His angle were formed. Finally, the distance from His angle to esophagal-tubular gastric anastomosis should be more than 5 cm. The reflux disease questionare (RDQ) scores, radionuclide gastric emptying scintigraphy, and 24-hour multichannel intraluminal (MII)-pH monitoring technology were used to evaluate postoperative gastric emptying and gastroesophageal reflux. Result: All 34 patients successfully completed proximal partial gastrectomy with Cheng's Giraffe esophagogastric reconstruction, including 13 cases by open surgery and 21 cases by laparoscopic surgery. The operation time was (144.6±39.8) minutes, the blood loss during operation was (35.4±17.2) ml. No laparoscopic case was converted to open surgery and no postoperative complication was observed. The postoperative hospital stay was (8.4±2.5) days. The postoperative RDQ score was 4.4±3.1 one month after operation, and 3.3±2.5 six months after operation. Gastric-half emptying time was (67.0±21.5) minutes, and the residual ratio was (52.2±7.7)% in 1 hour, (36.4±3.1)% in 2 hours and (28.8±3.6)% in 3 hours at postoperative 1-month. The 24-hour MII-pH monitoring at postoperative 2-month revealed the frequency of acid reflux was (12.6±7.9) times, frequency of non-acid reflux was (19.6±9.7) times, DeMeester score was 5.8±2.9. Conclusion: Cheng's Giraffe esophagogastric reconstruction is safe and feasible in the treatment of Siewert type II AEG, and has good dynamic and anti-reflux effects.

Feasibility analysis of pepsin strip test in diagnosis of laryngopharyngeal reflux disease

Objective: To evaluate the feasibility of pepsin strip test in the diagnosis of laryngopharyngeal reflux. Methods: From August 2017 to September 2018,80 patients in Department of Otorhniolaryngology Head and Neck Surgery,Chinese People's Liberation Army General Hospital-Six Medical Centre, underwent pepsin strip test and 24-hour multichannel intraluminal impedance(MII)-pH monitoring. The results of the two methods were analyzed for consistency,and 24-hour MII-pH monitoring was used as a statistical reference for the sensitivity and specificity of pepsin strip test in the diagnosis of laryngopharyngeal reflux. Data were analyzed by SPSS 19.0 software. Results: There were 57 patients with positive pepsin test strip and 23 patients with negative pepsin test strip. The score of reflux symptoms and signs, and the positive rate of laryngopharyngeal reflux events in patients with positive pepsin strip test were significantly higher than those in patients with negative pepsin test strip. If there was one or more throat reflux events (including acid reflux,weak acid reflux and alkali reflux) as the positive results of 24-hour MII-pH monitoring,the consistency between the results of pepsin strip and 24-hour MII-pH was moderate (Kappa=0.614). The sensitivity and specificity of pepsin strip were 86.9% (53/61) and 78.9% (15/19) respectively. Conclusions: Pepsin strip detection has the advantages of non-invasive,cheap and easy to operate.As an objective method for early diagnosis of laryngopharyngeal reflux, pepsin strip detectionis feasible,but can not be the final diagnosis for laryngopharyngeal reflux disease.

DOZ047.60: Evaluation of gastroesophageal reflux in children born with esophageal atresia using pH and impedance monitoring

Abstract Aim of the Study The ESPHGAN-NASPGHAN guideline (Krishnan, 2016) recommends routine prescription of proton pump inhibitors in the first year of life after esophageal atresia (EA) repair, and to monitor gastroesophageal reflux (GER) using pH-impedance (pH-MII) monitoring and/or endoscopy at time of discontinuation and during long term follow up of these patients. This study aimed to evaluate acid and non-acid GER in infants and school-aged children with EA using pH-MII monitoring. Methods Children born with EA between 2011–2017, who underwent a 24-hour pH-MII study during infancy (≤18 months) or at 8 years old as part of a standardized longitudinal follow-up program, were included. Exclusion criteria were: isolated tracheoesophageal fistula, esophageal replacement therapy, tube feeding and monitoring &lt; 18 hours. Anti-acid therapy was discontinued before pH-MII measurement. Data was collected on reflux index (RI; exposure to pH &lt; 4 in %, &gt;7% considered abnormal), retrograde bolus movements (RBM) and bolus clearance time (BCT). Automatically detected RBM were manually reviewed and modified/deleted if necessary. Results We included 57 children (51% male, 2% isolated EA, 44% thoracoscopic repair): 24 infants (median age 0.6 years) and 33 school-aged children (median age 8.2 years). In infants, median RI was 2.6% (abnormal in n = 2), median RBM was 61 (62% non-acid, 58% mixed) and median of the mean BCT was 11 seconds. In school-aged children, median RI was 0.3% (abnormal in n = 4), median RBM was 21 (64% non-acid, 75% mixed) and median of the mean BCT was 13 seconds. Of the automatically detected 3,313 RBM, 1,292 were manually deleted from the tracings: 52% of non-acid RBM and 8% of acid RBM (mainly misinterpreted swallows or one event recognized as several events). Conclusions Most children with EA off medication have a normal RI, yet experience a significant number of non-acid RBM. After manual revision of the tracings a high percentage of RBM was deleted. Our data show that automated impedance analysis software needs refinement for use in infants and children with EA, and question the need for standard anti-acid therapy in these patients.

DOZ047.109: Impact of positive expiratory pressure breathing on gastroesophageal reflux: preliminary report in children with esophageal atresia and tracheoesophageal fistula and residual tracheomalacia

Abstract Introduction The usefulness of positive expiratory pressure (PEP) through a PEP valve to enhance expiratory flow and improve cough efficiency is well known in children with tracheoesophageal fistula (TEF) and residual tracheomalacia. Gastroesophageal reflux (GER) is one of the most frequent complications encountered in patients with repaired esophageal atresia (EA) ± TEF. The impact of airway clearance techniques with a PEP valve on GER is not well defined in this group of patients. The aim of this prospective study was to determine the effects of PEP chest physiotherapy on GER burden measured by multichannel intraluminal impedance and pH monitoring (MII-pH) in EA/TEF children. Since the study is still ongoing, preliminary results are hereby presented. Methods EA/TEF patients with tracheomalacia received three 20-min sessions of PEP chest therapy during the 24-hour MII-pH monitoring performed as a routine care. All children were off acid suppression therapy. The PEP session, performed after a 3-hour fasting period, consisted of 10 cycles lasting 1 minute of breathing with a PEP valve, followed by the forced expiratory technique and coughing. Esophageal acid exposure time (AET) and number of reflux episodes (RE) during each PEP session were measured as primary outcomes. Baseline impedance (BI) was also evaluated. MII-pH was defined abnormal if AET was &gt;7% and/or the total RE was &gt;70. Results From January and December 2018, 5 consecutive male EA/TEF children (mean age 8.5 years; range 3–14 years) were enrolled. All of them showed low distal BI (1040 ± 143.2) and normal MII-pH findings (AET: 1.8 ± 2.9%; number of RE: 20.2 ± 9.0). Over the period of the PEP sessions, no significant changes in AET (0.0 ± 0.0), RE (0.6 ± 0.5), and BI were detected compared with the background monitoring. Conclusions Although the limited number of participants prevents any definitive conclusions, our preliminary results indicate that PEP chest physiotherapy does not exacerbate GER in EA/TEF children. Continuation of the study across a larger sample of EA/TEF patients is needed to better define the effects of this simple chest physiotherapy technique on GER burden.

Association between 24-hour combined multichannel intraluminal impedance-pH monitoring and symptoms or quality of life in patients with laryngopharyngeal reflux.

To evaluate the association between the parameters of 24-hour multichannel intraluminal impedance (MII)-pH monitoring and the symptoms or quality of life (QoL) in laryngopharyngeal reflux (LPR) patients. Prospective cohort study without controls. University teaching hospital. Forty-five LPR patients were selected from subjects who underwent 24-hour MII-pH monitoring and were diagnosed with LPR from September 2014 to May 2015. Reflux Symptom Index (RSI), Health-related Quality of Life (HRQoL), Short Form 12 (SF-12) Survey questionnaires were surveyed. Spearman's correlation was used to analyse the association between the symptoms or QoL and 24-hour MII-pH monitoring. Most parameters in 24-hour MII-pH monitoring showed weak or no correlation with RSI, HRQoL and SF-12. Only number of non-acid reflux events that reached the larynx and pharynx (LPR-non-acid) and number of total reflux events that reached the larynx and pharynx (LPR-total) parameters showed strong correlation with heartburn in RSI (R = 0.520, P < 0.001, R = 0.478, P = 0.001, respectively). Multiple regression analysis showed that there was only one significant regression coefficient between LPR-non-acid and voice/hoarseness portion of HRQoL (b = 1.719, P = 0.022). Most parameters of 24-hour MII-pH monitoring did not reflect subjective symptoms or QoL in patients with LPR.

Esophageal mucosal integrity improves after laparoscopic antireflux surgery in children with gastroesophageal reflux disease

BackgroundEsophageal intraluminal baseline impedance reflects the conductivity of the esophageal mucosa and may be an instrument for in vivo evaluation of mucosal integrity in children with gastroesophageal reflux disease (GERD). Laparoscopic antireflux surgery (LARS) is a well-established treatment option for children with proton pump inhibitory (PPI) therapy resistant GERD. The effect of LARS in children on baseline impedance has not been studied in detail. The aim of this study was to evaluate the effect of LARS on baseline impedance in children with GERD.MethodsThis is a prospective, multicenter, nationwide cohort study (Dutch national trial registry: NTR2934) including 25 patients [12 males, median age 6 (range 2–18) years] with PPI-resistant GERD scheduled to undergo LARS. Twenty-four hour multichannel intraluminal impedance pH monitoring (MII-pH monitoring) was performed before and 3 months after LARS. Baseline impedance was evaluated during consecutive 2-h intervals in the 24-h tracings.ResultsLARS reduced acid exposure time from 8.5 % (6.0–16.2 %) to 0.8 % (0.2–2.8 %), p < 0.001. Distal baseline impedance increased after LARS from 2445 Ω (1147–3277 Ω) to 3792 Ω (3087–4700 Ω), p < 0.001. Preoperative baseline impedance strongly correlated with acid exposure time (r −0.76, p < 0.001); however, no association between symptomatic outcome and baseline impedance was identified.ConclusionsLARS significantly increased baseline impedance likely reflecting recovery of mucosal integrity. As the change in baseline impedance was not associated with the clinical outcome of LARS, other factors besides mucosal integrity may contribute to symptom perception in children with GERD.

Reflux monitoring in children.

Recently, multichannel intraluminal impedance (MII) monitoring was added to the repertoire of tests to evaluate the (patho)physiology of gastroesophageal reflux (GER) in children. Its advantage above the sole monitoring of the esophageal pH lies in the ability of the detection of both acid and nonacid GER and to discern between liquid and gas GER. Currently, combined 24h pH-MII monitoring is recommended for evaluation of gastro-esophageal reflux disease (GERD) and its relation to symptoms in infants and children, despite the lack of reference values in these age groups. There is new evidence in the current issue of this Journal supporting the role of pH-MII monitoring for the evaluation of children presenting with gastrointestinal symptoms suggestive of GERD and the prediction of the presence of reflux esophagitis. However, several issues should be taken into account when performing pH-MII clinically.

Functional Heartburn Overlaps With Irritable Bowel Syndrome More Often than GERD.

We aimed to evaluate the prevalence of irritable bowel syndrome (IBS) in patients with typical reflux symptoms as distinguished into gastroesophageal reflux disease (GERD), hypersensitive esophagus (HE), and functional heartburn (FH) by means of endoscopy and multichannel intraluminal impedance (MII)-pH monitoring. The secondary aim was to detect pathophysiological and clinical differences between different sub-groups of patients with heartburn. Patients underwent a structured interview based on questionnaires for GERD, IBS, anxiety, and depression. Off-therapy upper-gastrointestinal (GI) endoscopy and 24 h MII-pH monitoring were performed in all cases. In patients with IBS, fecal calprotectin was measured and colonoscopy was scheduled for values >100 mg/kg to exclude organic disease. Multivariate logistic regression analysis was performed to identify independent risk factors for FH. Of the 697 consecutive heartburn patients who entered the study, 454 (65%) had reflux-related heartburn (GERD+HE), whereas 243 (35%) had FH. IBS was found in 147/454 (33%) GERD/HE but in 187/243 (77%) FH patients (P<0.001). At multivariate analysis, IBS and anxiety were independent risk factors for FH in comparison with reflux-related heartburn (GERD+HE). IBS overlaps more frequently with FH than with GERD and HE, suggesting common pathways and treatment. HE showed intermediate characteristic between GERD and FH.