Mixed Reflux Research Articles

In vitro and in vivo evaluation of a novel wired transmission pH-combined photographic catheter for ambulatory gastroesophageal reflux monitoring (with videos).

Twenty-four-hour pH-impedance monitoring is an important diagnostic approach for gastroesophageal reflux disease (GERD). Reflux monitoring results cannot be synchronized with ambulatory motility imaging of the esophageal sphincter. We have designed a novel wired transmission pH-combined photographic catheter (WT-CPC) for the synchronous acquisition of reflux image and pH. Different patterns of reflux events were simulated to perform in a porcine gastroesophageal reflux model in vitro. The live porcine model of gastroesophageal reflux was established in three Bama pigs. Monitoring was conducted with the WT-CPC and pH-impedance catheter simultaneously. Measurements included the number and proportion of reflux events, as well as acid exposure time (AET). The detection rates of WT-CPC for distal and horizontal acid reflux events were significantly higher compared to those of pH-impedance catheters (100% vs. 14.29%, 100% vs. 57.14%, P < 0.05). There was no significant difference between the two methods in proximal acid reflux events (P = 0.217). Regarding mixed reflux events, WT-CPC exhibited higher detection rates for distal events than pH-impedance catheter (100% vs. 42.86%, P < 0.05). However, there was no significant difference between the two methods for proximal reflux events (P > 0.05). Both methods showed similar results for horizontal reflux events. A porcine gastroesophageal reflux model was successfully established and utilized for reflux monitoring. A total of 28 episodes of reflux were detected within 6.5min. The detection rate achieved by WT-CPC for reflux events was significantly higher than that obtained by pH-impedance (100% vs. 78.57%, P = 0.023). The WT-CPC has demonstrated reflux monitoring capabilities in an isolated reflux organ model. It also showed good operability and performance in the porcine model. The WT-CPC holds promising potential to provide valuable diagnostic evidence for GERD.

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.

Analysis of clinical characteristics in proximal and distal reflux monitoring among patients with gastroesophageal reflux disease.

The purpose of this study was to examine the characteristics of proximal and distal gastroesophageal reflux in patients with gastroesophageal reflux disorder and analyze their clinical symptoms. A total of 67 patients with typical esophageal symptoms were selected for this study. All participants completed the reflux disease questionnaire and a questionnaire survey of extraesophageal symptoms. Diagnosis was made using a 24-h impedance-pH detection and proton pump inhibitor. The results showed that the proximal reflux group had a higher number of acid reflux episodes compared to the distal reflux group (P < 0.05). Similarly, the proximal reflux group also had a higher number of gas reflux episodes compared to the distal reflux group (P < 0.05). On the other hand, the distal reflux group had a higher number of mixed reflux episodes compared to the proximal reflux group (P < 0.05). These differences were statistically significant. This study revealed that acid reflux and gas reflux were more predominant in the proximal reflux group, while mixed reflux was more predominant in the distal reflux group.

Evaluation of Smectite Effect as a Food Thickener in Gastroesophageal Reflux Disease in Neonates Using Combined Esophageal Multichannel Intraluminal Impedance

Introduction Gastroesophageal reflux disease (GERD) occurs when reflux of the gastric contents causes symptoms, MII-pH offer several advantages over the traditional diagnostic measures as it detects reflux regardless of its pH and distinguishes swallows from GER. Thickening of infant formulas has been recommended for the treatment of GERD. Agents that have been used include cereal, rice, bean gum, sodium carboxymethyl cellulose, pectin, cellulose and carobel. We aimed to assess the efficacy of (Smectite) as a food thickener in treating GERD in neonates using MII-pH before and after Smectite. Patients and Methods Twenty preterm neonates ≤ 36 weeks of age from maternity hospital, Ain Shams University, enrolled during the period 2018 to 2020, all had signs suggestive of GERD, Feeding intolerance, and repeated chest infections due to frequent apneas, aspiration or associated with bronchopulmonary dysplasia as well as nonspecific behavioral signs including arching, irritability, and apparent discomfort associated with feedings, GERD was confirmed by MII-pH for 24hrs. Diagnosis of reflux was done by total number of liquid and mixed Reflux &amp;gt; 100 as per (1) López-Alonso et al., 2006. patients then were prescribed Smectite (3 g/day for 7 days). On the 8th day, a second 24-hour MII-pH was performed to assess the response. Results Preterm infants with more than 100 impedance events were diagnosed with GERD most of these attacks were non acidic and weakly acidic attacks. Using Smectite as a food thickener was followed by a significant decrease in total reflux time and total frequency of reflux episodes (P. value &amp;lt;0.001), there was also a significant decrease in the frequency of impedance events per 24hrs. Total frequency of reflux episodes before and after Smectite decreased in terms of number of signs related to reflux before and after treatment such as vomiting, acute life threatening events like bradycardia, apnea, wheezy chest, desaturations all of which improved significantly after treatment. Conclusion MII-pH is one of the most sensitive tools for the diagnosis of reflux and Smectite could be used as a feed thickener to decrease reflux signs and symptoms for more studies on a larger scale to confirm.

Relevance of Excessive Air Swallowing in GERD Patients With Concomitant Functional Dyspepsia and Poor Response to PPI Therapy.

The present study was aimed at evaluating the possible role of air swallowing in the association between gastroesophageal reflux disease (GERD) symptoms and concomitant functional dyspepsia (FD) and their role in GERD symptom persistence despite proton pump inhibitor (PPI) therapy. It has been shown that individuals with excessive air swallowing experience FD. It has been also demonstrated that a consistent group of GERD patients not responding to PPI therapy swallow more air during mealtime and also have more mixed refluxes. Multichannel intraluminal impedance-pH tracings from consecutive patients were retrospectively evaluated. A validated structured questionnaire was used to evaluate GERD and concomitant FD symptoms. All patients were treated, within the previous year, with at least 8 weeks of standard-dose PPI therapy. A total of 35 patients with conclusive GERD, 35 patients with reflux hypersensitivity, and 35 with functional heartburn were studied. A direct relationship was observed between the number of air swallows and of mixed refluxes ( R =0.64). At receiver operating characteristic curve analysis, air swallows and mixed refluxes were significantly associated to the presence of FD and PPI refractoriness. An air swallow cutoff of 107 episodes/24 hours was identified to discriminate patients with and without FD (sensitivity: 87%, specificity: 82.8%). A mixed reflux cutoff of 34 episodes/24 hours was identified to discriminate PPI responders from nonresponders (sensitivity: 84.8%, specificity: 69%). At multivariate analysis, an abnormal number of air swallows and of mixed refluxes were significantly associated to FD and PPI refractoriness. Our study highlights the relevant role of excessive air swallowing in eliciting both dyspepsia and refractoriness of typical GERD symptoms to PPI therapy.

The effect of reflux schemes in hydrogen peroxide electric pump on anti-cavitation of inducer

Hydrogen peroxide electric pump supply system can provide an improvement to hybrid rocket motor performance. Due to the physical and chemical properties of hydrogen peroxide, a canned pump scheme is more suitable to be used in hybrid rocket motor. The high-temperature liquid between the rotor and stator of the electric pump, returning to the inlet of the inducer, has a considerable influence on the anti-cavitation performance. The numerical simulation results show that the optimal reflux scheme is different when the inlet pressure range of the inducer is different. When the inlet pressure of the inducer is 0.4 MPa, the performance of the inducer is less affected by the reflux schemes, and the optimal scheme is the axial scheme in the simulation. When the inlet pressure is 0.12 MPa and there is a large cavitation area in the inducer, the radial reflux scheme is better than the axial and mixed reflux. When the inlet pressure is 0.1 MPa and the cavitation areas almost extend to the whole blade passage, the radial reflux scheme is much better than the axial and mixed reflux.

Anxiety correlates with excessive air swallowing and PPI refractoriness in patients with concomitant symptoms of GERD and functional dyspepsia.

Anxiety may exacerbate GERD and FD symptoms perception and reduce quality of life. As many as 50% of patients with GERD symptoms have incomplete relief with PPI therapy, and psychological factors may influence PPI responsiveness. The potential relationship between anxiety, excessive air swallowing, and PPI responsiveness was evaluated. GERD patients with concomitant FD were prospectively evaluated. Validated structured questionnaires were used to evaluate anxiety, GERD, and FD symptoms. All patients were treated, within the previous year, with at least 8 weeks of standard dose PPI therapy. One hundred sixty-one patients were included. Frequency of non-responders in patients with moderate/severe anxiety was significantly higher compared to patients with mild anxiety (62.7% vs. 37.3%, p < 0.01). Patients with moderate/severe anxiety displayed a significantly higher mean FD symptoms score value compared to patients with mild anxiety. A significantly higher mean number of air swallows were observed in patients with moderate/severe anxiety. At ROC analysis, air swallows and mixed reflux episodes were significantly associated with the presence of PPI refractoriness (AUC: 0.725, 95% CI: 0.645-0.805 and 0.768, 0.692-0.843). According to univariate analysis, an abnormal number of air swallows, mixed reflux episodes and presence of moderate/severe anxiety was significantly associated with PPI refractoriness. Our results, if confirmed in in a larger, prospective clinical and therapeutic study, demonstrate the usefulness of an up-front evaluation with anxiety questionnaire and esophageal testing in patients with a broad spectrum of upper gastrointestinal symptoms who fail to respond to PPI treatment, supporting the option of alternative treatment modalities.

Long-term (18 Years) Results of Patients With Long-segment Barrett Esophagus Submitted to Acid Suppression-duodenal Diversion Operation: Better Than Nissen Fundoplication?

To determine late results of AS-DD procedure in long-segment (LSBE) and extralong-segment BE (ELSBE) using subjective and objective measurements to ascertain the histological impact over intestinal metaplasia (IM) and progression to EAC. Barrett esophagus (BE) is a known precursor of esophageal adenocarcinoma (EAC), and Nissen fundoplication has proven to be unable to stop mixed reflux among them. Our group proposed a surgical procedure that handles pathophysiological changes responsible for BE. This prospective study included 127 LSBE and ELSBE subjects submitted to clinical and functional analyses. They were presented to selective vagotomy, fundoplication, partial gastrectomy with Roux-en-Y reconstruction. The changes in IM were determined in both groups. Follow-up was completed at a mean of 18 years in 81% of the cases. Visick I-II scores were seen in 88% of LSBE and 65% in ELSBE ( P < 0.01). There was significant healing of erosive esophagitis and esophageal peptic ulcers, and strictures were resolved in 71%. There was 38% of IM regression in LSBE. Two cases in each group progressed to EAC at a mean of 15 years. Pathologic acid reflux was abolished in 91% and duodenal in 100%. There was a regression of low-grade dysplasia to IM in 80%. AS-DD permanently eliminates pathologic refluxate to the esophagus. The progression to HGD/EAC is lower compared to medical treatment, with an 8-fold reduction in LSBE and 2.2-fold in ELSBE. AS-DD seems to influence IM behaviors, and it is a tool that could reduce and delay progression to EAC.

Enhanced treatment effect and universality of novel ARAO coupling process on municipal sewage: A pilot study

Under the impending demand of wastewater treatment plants (WWTPs) upgrading and reconstruction, it is feasible to propose a new process with low cost and high efficiency based on traditional process. Novel anaerobic-RBC-anoxic-oxic (ARAO) process was obtained after coupling traditional anaerobic-anoxic-oxic (A2/O) process with rotating biological contactor (RBC). Compared to traditional A2/O process, ARAO process has more efficient municipal wastewater treatment effect. Within 40 days of continuous operation, the average removal rates of COD, NH4+-N, TN and TP of sewage by ARAO process are 87%, 87%, 75% and 87%, respectively. The optimal operating conditions of ARAO process are the mixed liquor reflux ratio (MLRR) of 200%, the mixed liquor suspended solids (MLSS) of 3500–4500 mg/L, the dissolved oxygen (DO) concentration of 2–3 mg/L and the hydraulic retention time (HRT) of 6 h. The enhanced enzyme activity of ARAO process compared with A2O was determined through extracellular enzyme activity (EEA) and extracellular polymeric substances (EPS), and the microbial abundance and dominant species were further analyzed through high-throughput sequencing. The three-dimensional fluorescence measurement results showed a significant improvement in wastewater treatment efficiency. In addition, ARAO process has good adaptability to low temperature wastewater, low concentration wastewater and high concentration wastewater, which provides a good reference for the upgrading and reconstruction of WWTPs in the future.

IL-33 Participates in the Development of Esophageal Adenocarcinoma.

Background: The progression from chronic gastroesophageal reflux disease (GERD) to Barrett esophagus (BE) and esophageal adenocarcinoma (EAC) is an inflammatory-driven neoplastic change. Interleukin-33 (IL-33) has identified as a crucial factor in several inflammatory disorders and malignancies. Methods: The high-density tissue microarray of the human EAC was analyzed with IL-33 immunohistochemistry staining (IHC). By anastomosing the jejunum with the esophagus, the rat model of EAC with mixed gastroduodenal reflux was established. The expression of IL-33 was determined using quantitative real-time polymerase chain reaction (RT-qPCR), western blot (WB), IHC and enzyme-linked immunosorbent assay (ELISA). Esophageal adenocarcinoma cells (OE19 and OE33) and human esophageal epithelial cells (HEECs) were used. Results: In the cytoplasm of human EAC tissue, IL-33 expression was substantially greater than in adjacent normal tissue. In rat model, the expression of IL-33 in the EAC group was considerably greater than in the control group, and this expression increased with the upgrade of pathological stage. In in vitro experiment, the mRNA and protein levels of IL-33 were considerably greater in OE19 and OE33 than in HEECs. The stimulation of IL-33 enhanced the proliferation, migration, invasion, and epithelial-mesenchymal transition (EMT) of OE19 and OE33, but soluble ST2 (sST2) inhibited these effects. IL-33 stimulated the release of IL-6 by OE19 and OE33 cells. Conclusion: This study demonstrated the overexpression of IL-33 in the transition from GERD to EAC and that IL-33 promoted carcinogenesis in EAC cells through ST2. IL-33 might be a possible preventive target for EAC.

The role of laryngopharyngeal reflux in the development of nasopharyngeal manifestations of GERD in preschoolers

Purpose. To study the level of vitamin D and the levels of antimicrobial peptides in the blood of children suffering from gastroesophageal reflux disease with nasopharyngeal symptoms, to find out how they depend on the composition of refluxate in LFR and how they affect microbial colonization in the nasopharynx.&#x0D; Materials and methods. The clinical study was conducted on the basis of the ENT and the Gastroenterology Departments of the Municipal Non-Commercial Enterprise “City Children's Hospital no. 5" of Zaporizhia City Council. By clinical examination and pH monitoring in the esophagus, the following groups of children 3 to 6 years were established: the 1st group of 22 children with gastroesophageal reflux disease with nasopharyngeal signs, the 2nd group of 22 children with gastroesophageal reflux disease without nasopharyngeal signs. Children were assigned to 1st group on the basis of the presence of clinical manifestations that indicated like a high GER. For children with nasopharyngeal manifestations of GERD, there are not only complaints specific to GERD, as well as symptoms that may indicate LFR: cough after eating and morning hoarseness, redness of the larynx and swelling of the vocal cords.The control group (the 3rd group) consisted of 22 children without pathology from the gastrointestinal tract and ENT systems. The children were tested for the levels of 25(ОН)D3, 1,25(ОН)2D, vitamin D binding protein (DBP), α­defensins 1–3 and cathelicidins. Microbial contamination of the mucous membrane of the nasopharyngeal zone was carried out. As far as the distribution differed from normal one (p&lt;0.05), the data are presented as median and inter-quartile ranges Me (Q25; Q75). The results were processed in Microsoft Excelfor Windows 4.0 and Statistica 6.0.&#x0D; Results. Vitamin D deficiency was revealed in all children of the 1st group (with GERD with LFR). Also, the level of 25(OH)D3 was statistically significantly lower than in children with GERD without LFR and in children of the control group. So, in children of the 1st group, the level 25(ОН)D3 was equel to 13.3 (11.6; 14.9) ng / ml, while in the children of 2nd group it was equal to 21.6 (20.3; 22.9) ng / ml at p &lt; 0.0001 and in children of the control group it was equal to 24.6 (22.8; 28.2) ng / ml at p &lt; 0.0001. The study of the level of antimicrobial peptides showed their significant decrease in children with LFR: the level of α­defensins 1–3 was equel to 2535.0 (1950.0; 3120.0) pg / ml and cathelicidins was equel to 17.9 (5.8; 33.3) ng / ml, which showed a significant statistical difference at p &lt;0.01 compared to other groups. It was noted that in children with acidic and mixed LFR, the level of cathelicidins is lower than in children with alkaline reflux. Thus, in most children with LFR, Haemophilus influenza was detected in nasopharyngeal cultures. Haemophilus influenza in the nose was sown only in children with mixed and acid reflux (30.0% and 80.0%, respectively). This is not typical of children with alkaline reflux. Also, more than two microorganisms were found in half of children with mixed and acid reflux, which was also not registered in children with alkaline reflux (p = 0.05). It was determined that in children with nasopharyngeal manifestations of GERD with Haemophilus influenza in the throat and nose at the same time higher parameters of the total number of acid reflux (180.0 (91.0; 310.0)), the number of prolonged acid reflux (8.0 (4.0; 12.0)) and the percentage of acid reflux per day (20.0 (11.0; 37.6)), which is significant at р˂0,05 than in children when the pathogen was detected only in the throat and in children who do not detected this microorganism Thus, the data obtained confirm that pathological manifestations from the ENT organs are a consequence of the LFR due to GERD.&#x0D; Conclusions. Our study indicates the aggressive effect of acid reflux on the nasopharyngeal mucosa in children suffering from gastroesophageal reflux disease with LFR. Thus, the lack of anti-inflammatory action of cathelicidins due to their increased utilization and reduced formation in conditions of vitamin D deficiency, leads to significant colonization by gram-negative flora, which can contribute to severe disease.

Simvastatin Inhibits Histologic Changes Associated with Gastroduodenal Reflux in a Murine Model.

Observational studies demonstrate a protective effect of statins on the development and progression of esophageal adenocarcinoma. The role of statins in the prevention of reflux-induced esophageal changes remains unknown. Using a mixed gastroduodenal reflux mouse model, we hypothesized that oral administration of simvastatin would attenuate reflux-induced mucosal changes of the distal esophagus. Human Barrett's (CPB) and esophageal adenocarcinoma (FLO1 and OE19) cells were treated with simvastatin. Cell proliferation and apoptosis were evaluated using the MTS proliferation and annexin V apoptosis assays, respectively. A reflux mouse model was generated by performing a side-to-side anastomosis between the gastroesophageal junction and first portion of the duodenum (duodeno-gastroesophageal anastomosis, DGEA). DGEA mice were fed a standard or simvastatin-containing diet following surgery. Mice were euthanized 6weeks post-operatively. Simvastatin significantly decreased proliferation and increased apoptosis in all cell lines. Compared to control animals, mice undergoing DGEA who were fed a standard diet demonstrated a fourfold increase in mucosal thickness and significant increase in proliferating cells (p < 0.0001). DGEA mice fed a simvastatin-containing diet had an attenuated response to reflux, with a significant reduction in mucosal hyperplasia and proliferation (p < 0.0001). DGEA mice fed a simvastatin-containing diet demonstrated significant upregulation of procaspase-3 (p = 0.009) and cleaved caspase-3 (p = 0.034) in the distal esophagus. We demonstrate for the first time a reduction in reflux-induced histologic changes of the distal esophagus following oral administration of simvastatin in vivo. These findings identify simvastatin as a potential preventative agent to inhibit the development and progression of reflux-induced esophageal injury.

Determinants of reflux perception in patients with non-erosive reflux disease who have reflux-related symptoms on potassium-competitive acid blocker therapy.

This study investigated potential determinants of reflux perception in patients with non-erosive reflux disease (NERD) who had reflux-related symptoms on potassium-competitive acid blocker (P-CAB) therapy. This study included 23 patients with reflux-related symptoms despite P-CAB therapy. Esophageal impedance-pH monitoring was performed on P-CAB and the following potential determinants of reflux perception were investigated: reflux nadir pH value; change in pH (baseline-nadir); bolus clearance time; reflux extent; proportions of acid, weakly acidic, and weakly alkaline reflux episodes; and proportions of liquid and mixed reflux episodes. Overall, ≥ 90% of all and symptomatic reflux episodes were weakly acidic reflux and 63% of symptomatic reflux episodes were reflux episodes with pH ≥ 5. There were no significant differences regarding potential determinants between symptomatic and asymptomatic reflux episodes. However, the proportion of symptomatic reflux episodes was significantly greater with pH < 5 (13.8%) than with pH ≥ 5 (9.5%) (P = 0.0431). In reflux episodes with pH < 5, the proportion of symptomatic reflux episodes was significantly greater in proximal sites (20.6%) than in distal sites (10.6%) (P = 0.0178). Conversely, in reflux episodes with pH ≥ 5, there was no significant difference regarding reflux perception according to reflux extent (proximal: 9.6% vs. distal: 9.0%, P = 0.9337). In patients with P-CAB-resistant NERD, reflux symptoms were mainly caused by reflux episodes with pH ≥ 5 on P-CAB therapy. The proportions of symptomatic reflux episodes among reflux sites differed according to reflux pH value; thus, the mechanisms of reflux perception may differ according to reflux pH value.

Acid Reflux Is Common in Patients With Gastroesophageal Reflux Disease After One-Anastomosis Gastric Bypass.

Patients with one-anastomosis gastric bypass (OAGB) can develop gastroesophageal reflux disease (GERD). The nature of this GERD (acid or biliary) remains unclear. To assess the nature of GERD via impedance pH testing in patients presenting with reflux post OAGB. Retrospective analysis of a prospectively collected database of 43 patients with OAGB backgrounds who developed postoperative GERD and were investigated with impedance pH monitoring between 2006 and 2019. Mean age was 52.48 ± 9 years. Mean body mass index (BMI) prior to OAGB was 46.82 kg/m2. None of these patients had clinical GERD before surgery. The median time interval between surgery and investigation with 24-h impedance pH monitoring was 64 (56) months. The mean BMI at the time of investigations was 32.67 ± 6.9 kg/m2. The type of reflux was acid in 13 (30.2%), non-acid (biliary) in 12 (27.9%), and mixed (acid and biliary) in 5 (11.6%) patients. However, it remained not confirmed in 13 (30.2%). Median DeMeester score was 48.95 (27.67) in patients with acid, 2.8 (7.4) in patients with biliary, and 28.7 (5.6) in patients with mixed reflux. Median percent of time spent with pH < 4 was 9.65 (8) in patients with acid, 0.6 (1.75) in patients with biliary, and 7.7 (3.9) in patients with mixed reflux. Acid reflux seems to be as common as bile reflux in patients presenting with GERD after OAGB. In case of revisional surgery for severe GERD post OAGB, 24-h impedance pH monitoring could be essential to determine the surgical procedure of choice.

Reflux characteristics triggering post-reflux swallow-induced peristaltic wave (PSPW) in patients with GERD symptoms.

BackgroundEsophageal chemical clearance has been evaluated with the post‐reflux swallow‐induced peristaltic wave (PSPW) index. The factors triggering PSPW in Gastro‐esophageal reflux disease (GERD) have not yet been investigated. This multicenter study was aimed at evaluating the characteristics of reflux episodes associated with PSPW occurrence in patients with typical GERD symptoms.MethodsImpedance‐pH tracings from patients with typical reflux symptoms were analyzed. Sixteen healthy subjects were included for comparison. Multivariate analysis was performed to determine predictors of PSPW events.Key resultsImpedance‐pH tracings from 60 patients and 16 healthy subjects were evaluated. A total of 3454 refluxes were recorded. In patients, comparing reflux episodes followed with those not followed by a PSPW, significantly higher proportions of acid (79% vs. 74%, p: 0.02), mixed (47% vs. 32%, p: 0.0001) and proximal refluxes (34% vs. 20%, p: 0.0001) were observed. A multivariate analysis, acid (OR: 1.3, 95% CI: 1.05–1.6), mixed (OR: 2, 95% CI: 1.6–2.3), and proximal (OR: 2.1, 95% CI: 1.7–2.5) refluxes were independently associated with PSPWs. Reflux episodes followed by a PSPW were characterized by a significantly higher bolus clearing time [(mean ± SD) 41 s ± 6 s vs. 30 s ± 5 s, p < 0.05] whereas nadir pH value of reflux events preceding PSPWs was tangentially but not significantly lower [(mean ± SD) 2.61 ± 1.22 vs. 2.74 ± 1.26, p: 0.057].Conclusions and inferencesAcid, mixed and proximal refluxes, and their duration are key factors in eliciting PSPWs. PSPW represents a response to reflux directly related to the potential harmfulness of reflux contents.

Резистентность слизистой оболочки пищевода у больных ГЭРБ: диалог клинициста и морфолога

Gastroesophageal reflux disease (GERD) is the most common of all acid-related diseases, it is recognized as the leading cause of esophageal adenocarcinoma. The natural factor of protection against aggressive refluxate components is the integrity of the esophageal mucosa, which performs a barrier function with the participation of a number of mechanical, chemical and immunological mechanisms. Their damage under the regular influence of acidic or mixed reflux causes the development of the pathological process. The review was prepared to systematize knowledge of the main components of mucosal barrier of the esophagus providing resistance of mucosa under conditions of GERD. The literature was searched in Embase, PubMed, and Google Scholar using the keywords: gastroesophageal reflux disease, mucosal protection, esophageal mucosa epithelium, dense contact proteins, epithelial protection, esophagoprotection. The main structural and functional components of esophageal mucosal protection were emphasized

The efficacy of a personalised treatment depending on the characteristics of reflux at multichannel intraluminal impedance-pH monitoring in patients with acid, non-acid and mixed laryngopharyngeal reflux.

To assess the evolution of symptoms and findings of laryngopharyngeal reflux (LPR) patients according to the type of reflux (acid, non-acid, mixed and gastro-oesophageal (GERD)). Prospective uncontrolled multicentre study. One hundred and six patients with LPR have been recruited from 3 European Hospitals. According to the reflux characteristics at the impedance-pH monitoring (acid, non-acid, mixed, GERD), patients received a personalised treatment based on the association of diet, pantoprazole, alginate or magaldrate for 3months. Reflux Symptom Score (RSS) was assessed at baseline, 6 and 12weeks post-treatment. Reflux Sign Assessment (RSA) has been used to rate laryngeal and extra-laryngeal findings at baseline and 12weeks post-treatment. Overall success rate and the evolution of symptoms and findings were evaluated according to the LPR types. One hundred and two LPR patients (42 acid, 33 non-acid, 27 mixed, including 49 with LPR and GERD) completed the study. RSS and RSA total scores significantly improved from baseline to post-treatment time in acid, mixed and non-acid groups. The presence of GERD in addition to LPR did not impact the clinical improvement. The 3-month success rates of treatment ranged from 62% to 64%, and there were no significant differences between groups. The success rate of patients with non-acid LPR was similar to those of patients with mixed and acid LPR. MII-pH is useful to specify the type of LPR and the related most adequate therapeutic regimen. Non-acid or mixed LPR similarly respond to treatment than acid LPR but require a treatment based on alginate or magaldrate covering the non-acid proximal reflux events.

Refractory Gastro-oesophageal Reflux Disease and Laryngopharyngeal Reflux - Use the Bottom up Approach

Most gastro-oesophageal reflux events are triggered by transient lower oesophageal sphincter relaxations (TLOSRs). Acid-related reflux disease with typical heartburn and reflux oesophagitis generally responds well to acid suppression with proton pump inhibitors (PPI), but treating non-acid and mixed gaseous reflux has proven more challenging.

Management of laryngopharyngeal reflux in Brazil: a national survey

IntroductionStudies assessing the management of laryngopharyngeal reflux by otolaryngologists have reported an important heterogeneity regarding the definition, diagnosis, and treatment, which leads to discrepancies in the management of the patient. Information about the current knowledge and practices of Brazilian otolaryngologists in laryngopharyngeal reflux is lacking. ObjectiveTo investigate the trends in management of laryngopharyngeal reflux disease among Brazilian otolaryngologists. MethodsA survey was sent by email to the members of the Brazilian Association of Otolaryngology-Head Neck Surgery. This survey has initially been conducted by the laryngopharyngeal reflux study group of young otolaryngologists of the International Federation of Otolaryngological Societies. ResultsAccording to the survey responders, the prevalence of laryngopharyngeal reflux was estimated to be 26.8% of patients consulting in otolaryngology and the most common symptoms were globus sensation, throat clearing, cough and stomach acid reflux. Nasal obstruction, Eustachian tube dysfunction, acute and chronic otitis media, vocal fold nodules and hemorrhage were considered not associated with laryngopharyngeal reflux by the majority of responders. About 2/3 of Brazilian otolaryngologists based the diagnosis of laryngopharyngeal reflux on the assessment of both symptoms and findings and a positive response to empiric therapeutic trials. Proton pump inhibitor utilized once or twice daily, was the most commonly used therapeutic scheme. Only 21.4% of Brazilian otolaryngologists have heard about nonacid and mixed laryngopharyngeal reflux and the awareness about the usefulness of multichannel intraluminal impedance pH monitoring (MII-pH) was minimal; 30.5% of responders did not consider themselves as well-informed about laryngopharyngeal reflux. ConclusionAlthough the laryngopharyngeal reflux-related symptoms, main diagnostic and treatment approaches referred by Brazilian otolaryngologists are consistent with the literature, the survey identified some limitations, such as the insufficient awareness of the role of laryngopharyngeal reflux in many otolaryngological conditions and of the possibility of non-acid or mixed reflux in refractory cases. Future studies are needed to establish international recommendations for the management of laryngopharyngeal reflux disease.

Esophageal pH-impedance monitoring of reflux patterns in non-erosive reflux disease, reflux hypersensitivity and functional heartburn

To analyze the differences in reflux patterns in 24-hour esophageal pH-impedance monitoring in patients with non-erosive reflux disease (NERD), reflux hypersensitivity (RH) and functional heartburn (FH) and explore the possible mechanism of symptoms in patients with heartburn and negative endoscopic findings. Seventy-nine patients with heartburn as the main symptoms but negative endoscopic findings, including 35 with NERD, 16 with RH and 28 with FH, were enrolled in this study.All the patients underwent 24-h esophageal pH-impedance monitoring and esophagogastroscopy, and the results were compared among the 3 groups. Acid reflux episode was significantly increased and weakly alkaline reflux episode was significantly decreased in NERD group in comparison with RH group and FH group (P < 0.05).The patients in NERD group showed significantly increased total reflux episode, mixed reflux episode, proximal acid reflux episode, proximal weak acid reflux episode, total proximal reflux episode, percentage of proximal acid reflux, percentage of proximal weak acid reflux, and percentage of total proximal reflux as compared with the other two groups (all P < 0.05).Bolus clear time was significantly prolonged in NERD group compared with that in the other two groups (P < 0.05).Analysis of the reflux acidity showed that the percentages of different reflux episodes differed significantly among the 3 groups (P < 0.05);acid reflux was the main reflux in NERD, while weak acid reflux was the main reflux in RH and FH groups, which had also significantly increased weakly alkaline reflux episodes compared with NERD group. Patients with NERD, RH and FH had different reflux patterns.Acid reflux is predominant in the NERD, while weakly alkaline reflux is significantly increased RH and FH.In patients with normal esophageal acid exposure but without symptoms or without recorded symptoms during esophageal pH-impedance monitoring, analysis of the total reflux episode, mixed reflux episode, proximal acid reflux episode and percentage can help in the differential diagnosis between RH and FH.