Multichannel Intraluminal Impedance Research Articles

The Impact of Frenotomy on Gastroesophageal Reflux in Pediatric Ankyloglossia: A Systematic Review.

This systematic review was conducted to assess if there are changes in gastroesophageal reflux (GER) outcomes after frenotomy in infants with ankyloglossia. Systematic Review. CINAHL, Cochrane, EMBASE, Pubmed, and Scopus were searched from inception to May 20, 2023. Inclusion criteria consisted of all study designs, infants ≤12 months of age with ankyloglossia, and use of quantitative GER measures (esophageal pH manometry (pH) or multi-channel intraluminal impedance (MII), and/or patient-reported symptom scores) pre- and post-frenotomy. Quality assessment and data extraction were performed in duplicate. Of 37 articles screened, 7 met inclusion criteria (6 prospective cohort studies and 1 RCT). No studies utilized objective measures to quantify reflux, that is MII or pH. The number of infants with ankyloglossia ranged from 47 to 237 (mean age of 4.4-8.3 weeks). Qualitative analysis included all 7 studies which used the GIGER, I-GERQ-R, and GSQ-I scales to assess GER. Parent-reported GER scores decreased post-frenotomy. However, the lack of control groups in the prospective cohort studies precludes conclusive findings that changes are related to frenotomy. Meta-analysis was not possible due to the high risk of bias from limited sample sizes, poor methodology, and lack of adequate control groups. Limited work has been conducted on the relationship between frenotomy and GER in infants with ankyloglossia. The lack of high-quality studies precludes definitive conclusions, as GER symptoms are known to improve spontaneously with time. Future RCT studies are warranted to further elucidate the effect of frenotomy on symptoms of GER in infants with ankyloglossia. III.

Diagnosis and treatment of patients with gastroesophageal reflux disease - a systematic review of cost-effectiveness and economic burden.

This study aims to review the existing knowledge on the cost-effectiveness and item costs related to the diagnosis and treatment of gastroesophageal reflux disease (GERD) patients at different stages. The study adhered to the PRISMA guidelines. The systematic search involved several steps: finding and identifying relevant articles, filtering them according to the set criteria, and examining the final number of selected articles to obtain the primary information. The number of articles published between 2013 and September 2024 in the Web of Science and PubMed databases was considered. The CHEERS checklist was used for the risk of bias assessment. Ultimately, 36 studies were included. Regarding the cost-effectiveness of GERD treatment, Proton pump inhibitors (PPIs) appeared to be the dominant solution for non-refractory patients. However, this might change with the adoption of the novel drug vonoprazan, which is more effective and cheaper. With advancements in emerging technologies, new diagnostic and screening approaches such as Endosheath, Cytosponge, and combined multichannel intraluminal impedance and pH monitoring catheters should be considered, with potential implications for optimal GERD management strategies. The new diagnostic methods are reliable, safe, and more comfortable than standard procedures. PPIs are commonly used as the first line of treatment for GERD. Surgery, such as magnetic sphincter augmentation or laparoscopic fundoplication, is only recommended for patients with treatment-resistant GERD or severe symptoms. Advances in emerging technologies for diagnostics and screening may lead to a shift in the entire GERD treatment model, offering less invasive options and potentially improving patients' quality of life.

Association between laryngopharyngeal reflux clinical scores and esophageal multichannel intraluminal impedance pH monitoring interpretation according to Lyon Consensus 2.0.

Laryngopharyngeal reflux remains a diagnostic challenge due to the lack of a definitive diagnostic tool. Esophageal multichannel intraluminal impedance (MII) pH monitoring has been proven reliable for detecting gastric reflux. This study aims to evaluate the association between clinical scores and MII/pH monitoring according to the Lyon Consensus 2.0. Patients with laryngo-pharyngeal symptoms (LPS) who had a reflux symptom index (RSI) ≥13 or reflux finding score (RFS) ≥7 underwent MII/pH monitoring. The findings were analyzed in comparison with clinical scores. A total of 100 patients meeting the inclusion criteria were recruited for this study. MII/pH monitoring revealed a median acid exposure time (AET) of 1.9% (interquartile range [IQR] = 0.2, 4.9), with 22% of patients recording an AET above 6%. The median number of reflux episodes was 29.5 episodes per day (IQR = 19.0, 43.8), with 7% experiencing more than 80 episodes per day. Gas reflux was identified as the most prevalent type. Based on the Lyon Consensus 2.0, 25 patients exhibited conclusive pathological reflux, while 75 patients showed no conclusive evidence of pathological reflux. No significant differences were found in RSI and RFS between these groups. Only gas reflux episodes showed a significant correlation with RSI (r = 0.255, P = 0.011). RSI and RFS among patients with LPS showed no statistically significant differences in identifying pathological reflux or no conclusive evidence of pathological reflux. This finding suggests that the pathophysiology underlying LPS may not be solely attributable to reflux.

Exposures and coexisting conditions in pediatric nodular tracheobronchitis.

The aim of our study was to investigate the prevalence of coexisting conditions and exposures in children with nodular tracheobronchitis diagnosed by flexible bronchoscopy. We conducted a single-center retrospective review of 100 children diagnosed with nodular tracheobronchitis by flexible bronchoscopy between 2012 and 2023. Common coexisting diagnoses included gastroesophageal reflux disease (GERD, 50%), dysphagia/aspiration (40%), asthma (30%), recurrent croup (30%), tracheostomy dependence (19%) and eosinophilic esophagitis (EOE) (12%). Bronchoalveolar lavage (BAL) demonstrated cellular inflammation with elevated proportions of neutrophils in 63%, and lymphocytes in 24%. Among 88 patients in whom bacterial cultures were performed, 52% were positive, with Moraxella, Haemophilus, Streptococcal and Pseudomonas species predominating. Among 30 patients who underwent viral testing, 57% were positive, with rhinovirus (82%) and adenovirus (29%) predominating. Patients with neutrophilic inflammation were more likely to have a positive respiratory bacterial culture and/or viral polymerase chain reaction (p = 0.003, 0.005). Evaluation of the gastrointestinal tract included 79 patients with a history of esophagogastroduodenoscopy, 45 patients with a videofluoroscopic swallow study (VFSS), and 45 patients with multi-channel intraluminal impedance and pH testing. The majority of VFSS were abnormal (60%) demonstrating either laryngeal penetration (33%) or intratracheal aspiration (27%). Median pH reflux and impedance proximal reflux indices were 3.8% and 0.5% respectively. Potential contributing factors in the pathophysiology of nodular tracheobronchitis include bacterial and viral infections, GERD, dysphagia/aspiration, and EOE. When nodular tracheobronchitis is observed during bronchoscopy, further evaluation to assess for these conditions should be considered.

Transoral Incisionless Fundoplication Leads to Esophageal Mucosa Healing in Responder Patients Followed up to 2 Years, as Documented by Esophageal Mean Nocturnal Baseline Impedance.

Decrease of esophageal mean nocturnal baseline impedance reflects loss of mucosal integrity. It can predict response to anti-reflux therapy. Mean nocturnal baseline impedance after transoral incisionless fundoplication for gastroesophageal reflux disease has never been assessed. The aim of the study is to investigate mean nocturnal baseline impedance and conventional pathophysiological parameters following transoral incisionless fundoplication. Patients prospectively treated by transoral incisionless fundoplication in a single center were retrospectively reviewed regarding 1- and 2-year 24-hour pH-metry and multichannel intraluminal impedance with calculation of mean nocturnal baseline impedance, gastroesophageal reflux disease-health related quality of life and reflux symptom index scores. Thirty-eight and 17/38 patients with 1- and 2-year 24-hour pH-multichannel intraluminal impedance assessment and mean nocturnal baseline impedance's calculation after transoral incisionless fundoplication, respectively, were identified. Mean nocturnal baseline impedance significantly increased up to 2-year follow-up (P = 0.033), along with significant decrease in % of acid exposure time (P = 0.003), gastroesophageal reflux disease-health related quality of life score (P < 0.001), and reflux symptom index (P = 0.008), compared with baseline. The longest orthostatic reflux decreased too, approaching statistical significance (P = 0.054). These significant changes occurred in patients experiencing ≥ 50% reduction of symptom questionnaires' scores ("responders"). Conversely, mean nocturnal baseline impedance worsened and no significant changes of 24-hour pH-multichannel intraluminal impedance metrics were observed in "non-responder" patients (symptom questionnaires' scores decrease < 50%).ConclusionIn patients who responded a significant improvement of mean nocturnal baseline impedance and % acid exposure time was observed up to 2-year follow-up, suggesting that transoral incisionless fundoplication achieves an effective esophageal mucosa healing besides symptom improvement.

Evaluation of Gastroesophageal Reflux in Symptomatic Young Infants Using Multichannel Intraluminal pH-Impedance Testing: A large Cohort Study from a Single Center.

This study aimed to assess the use of combined multichannel intraluminal impedance and pH studies (MII-pH) in a large group of symptomatic young infants, to characterize the occurrence of gastroesophageal reflux disease (GERD), and to establish temporal association of the reflux behaviors with gastroesophageal reflux using symptom indices. This is a retrospective cohort study on 181 infants who underwent MII-pH studies for clinical behaviors that were suggestive of GERD. Symptom index (SI) and symptom association probability (SAP) were used to establish symptom association with reflux. More than 100 GER episodes in 24 hours or acid reflux index > 10% was considered pathological reflux. A total of 181 infants (median age: 60 days, interquartile range [IQR]: 34-108) underwent MII-pH studies with median study duration of 22.41 hours (IQR: 21.5-23.32). A total of 4,070 hours of data were analyzed, with 8,480 reflux events (2,996 [35%] acidic, 5,484 [65%] nonacidic). A total of 2,541 symptoms were noted, 894 (35%) were temporally related to reflux events. A total of 113 infants (62.4%) had positive symptom association with SI > 50% and/or SAP > 95% for at least one symptom. There was modest symptom association for choking and gagging, but apnea, bradycardia, and desaturations had poor symptom association. Only 29 infants (16%) had pathological reflux, and only 18 infants (10%) had both pathological reflux and positive symptom association. MII-pH can be used to characterize GERD in young infants, along with establishing temporal association with symptoms. Pathological reflux in symptomatic young infants is not common, but symptom association may occur without frequent or acidic reflux. · Gastroesophageal reflux (GER) disease can be studied in young infants using MII-pH, to characterize the frequency and nature of GER events.. · The probability of GER events being associated temporally with GER symptoms can also be determined using MII-pH in this population.. · Using frequency of GER events, reflux indices, and symptom association indices with MII-pH, infants having true GER disease can be identified, thereby reducing unnecessary therapy.. · Symptom association may occur even without frequent or severe acidic reflux..

363. REFLUX MICRO-ASPIRATION: WHAT HAVE WE LEARNED

Abstract Background The accurate diagnosis of gastro-oesophageal reflux pulmonary microaspiration has only become possible recently with the introduction of a novel technique of reflux micro-aspiration scintigraphy study combined with single photon emission computed tomography (SPECT) combined with x-ray tomography (CT) in a hybrid instrument. This has allowed the accurate diagnosis of pulmonary and airway contamination with refluxate. Previously only patients with large volume symptomatic reflux aspiration were diagnosed clinically (Mendelson syndrome) or by 2-dimentional barium meal or an older plantar (2 dimensional) technique of scintigraphic aspiration studies. The concept of reflux micro-aspiration has been implicated in multiple pulmonary diseases but without absolute proof from an adequate diagnostic test. Little was known about the natural history, physiology, and response to treatment amongst patients with silent reflux micro-aspiration. The aim of this presentation is to summarise a series of research projects studying the natural history of the disease, common presenting symptoms, pathophysiology and response to treatment. Methods A prospectively populated database of patients referred to a tertiary specialist reflux diagnostic service with atypical and/or treatment resistant reflux was evaluated. The database contained records of consecutive patients including demographic information, presenting symptoms, investigations including imaging, upper gastro-intestinal physiology studies and novel reflux micro-aspiration scintigraphy studies. Treatment details including medical and surgical treatment and post treatment clinical information and investigations. Multiple studies were conducted using the information from the database and findings are summarised in this presentation. Results The novel reflux micro-aspiration scintigraphy with SPECT/CT was compared with other studies (multichannel intraluminal impedance and 24-hour pH monitoring) and was found to be sensitive to reflux occurring outside the oesophagus. Patients with reflux micro-aspiration can present a wide variety of symptoms, commonly a combination of typical symptoms of gastro-oesophageal reflux disease (heartburn and regurgitation) and respiratory symptoms. Reflux micro-aspiration was associated with reduced lower oesophageal sphincter pressure, severe ineffective oesophageal motility (IOM), and pharyngeal contamination with refluxate on reflux scintigraphy. Delayed liquid gastric emptying was not associated with reflux micro-aspiration, however gastroparesis with solids is associated with micro-aspiration. Micro-aspiration was common in patients with giant hiatus hernias and mostly resolved with surgery. Anti-reflux surgery resulted in resolution of aspiration in the majority of patients, however severe IOM was associated with lesser rates of microaspiration resolution. Conclusion Reflux micro-aspiration appears to be a more common manifestation of GORD than previously thought. The work summarised in this presentation discusses the presentation, physiological associations, and treatment of patients with reflux micro-aspiration.

24 h combined esophageal multichannel intraluminal impedance and pH monitoring in children with chronic cough

BackgroundChronic cough in children is closely related to gastroesophageal reflux (GER). However, this association has not been adequately studied due to a lack of diagnostic tools. Combined esophageal multichannel intraluminal impedance and pH (MII-pH) monitoring is considered the most accurate method for evaluating the association between symptoms and reflux, but data on its use in children with chronic cough are still lacking. We aimed to assess the association between chronic cough and GER in children through MII-pH monitoring.MethodsChildren with chronic cough (> 4 weeks) who were suspected gastroesophageal reflux disease(GERD) were selected to undergo 24 h MII-pH monitoring at our hospital. Patients were divided into groups according to their age, body position, reflux index (RI) or total reflux events, and the differences between the groups were analyzed. Then the significance and value of 24 h pH and impedance monitoring in chronic cough and the relationship between chronic cough and reflux were discussed.ResultsOverall, 426 patients were included. The median age was 12 months (interquartile range: 6–39.5 months), 129 (30.3%) patients had RI > 7% detected by pH-metry, and 290 (68.1%) patients had positive diagnosis based on the impedance data. GER predominantly occurred in the upright position and mostly involved weakly acidic reflux and mixed gas–liquid reflux. There were 14.1% of children in non-acid GER group were SAP positive showing no difference in acid GER group 13.2% (P = 0.88), whereas patients with SAP > 95% in MII positive group (47[16.2%]) is higher than in MII negative group (P < 0.05).ConclusionTwenty four hour MII-pH monitoring is safe, well tolerated in children, but also has a higher detection rate of gastroesophageal reflux. It can find identify weakly acidic reflux, weakly alkaline reflux and reflux events with different physical properties, which can explain the relationship between GER and chronic cough more comprehensively. It provides new approach for exploring the etiology, diagnosis and treatment of children with chronic cough.

Comparing methods for detection of gastro-oesophageal reflux in anaesthetized dogs

ObjectiveTo compare the sensitivity and specificity of pH with multichannel intraluminal impedance (pH-MII), pH-metry (pH) alone and MII alone to direct observation of GOR by endoscopy in anaesthetized dogs. Study designA prospective comparative trial in a live canine model. AnimalsA group of 35 (22 females, 13 males) dogs of various breeds. The mean (range) body weight and age were 31.9 (14–40) kg and 5.6 (0.75–12) years, respectively. MethodsAll dogs were premedicated with medetomidine and morphine, anaesthesia was induced with propofol and maintained on isoflurane in oxygen. A monitoring assembly consisting of an endoscopy camera, endotracheal tube and a disposable flexible pH-MII catheter was used to measure oesophageal pH, MII and directly visualize reflux. Visual reflux score was (0–3) and pH was recorded on a data capture sheet. Reflux was considered to have occurred whenever oesophageal pH was < 4.0 or > 7.5, device software analysing MII data detected fluid or a visual reflux score of 2 or 3 were assigned. Receiver operator curves (ROC) analysis was used to determine sensitivity and specificity for each monitoring method to detect GOR. ResultsEndoscopy identified GOR in 20 dogs (57%), pH-MII in 19 dogs (54%), pH alone in 13 dogs (37%) and MII alone in 12 dogs (24%). ROC analysis showed fair accuracy for pH-MII and pH alone, whereas MII demonstrated low accuracy. Conclusions and clinical relevanceIn conclusion, pH-MII is a reliable method for detecting GOR and emerges as a promising tool for future research. Endoscopy is reliable and provides the ability to subjectively quantify the volume of reflux; however, it lacks the ability to discern the pH of refluxate. pH alone misses reflux events with intermediate pH (4.1–7.4). Incorporation of impedance addresses some of the limitations associated with pH alone and enhances diagnostic accuracy.

The impact of gastroesophageal reflux disease on upper esophageal sphincter function: Insights from PH impedance and high-resolution manometry.

Lower esophageal sphincter (LES) pathophysiology has been established in gastroesophageal reflux disease (GERD); however, less is understood regarding the role the upper esophageal sphincter (UES) plays in preventing laryngopharynphageal reflux. Sustained UES basal pressure prevents reflux into the pharynx while allowing relaxation during ingestion. We investigate whether GERD influences UES function via HRM and pH Impedance testing. A retrospective analysis of 318 patients who underwent high-resolution manometry with trans-nasally placed manometric catheter and 24-h multichannel intraluminal impedance pH monitoring. One hundred and forty-seven patients met Lyon consensus criteria for GERD based on acid exposure time >6%. The most common chief concern was heartburn or reflux, present in 59% of these patients. Upper esophageal sphincter basal and residual pressures were not significantly different between patients with GERD when compared to those without GERD, including a subanalysis of patients with extraesophageal symptoms. The LES basal and residual pressures, DCI and MNBI are statistically lower in patients with pathologic GERD. HRM and pH Impedance testing demonstrates no difference in UES basal and residual pressures based on pH diagnosis of GERD. We redemonstrate the association with hypotonic LES, diminished DCI and MNBI with GERD.

Editing combined multichannel intraluminal impedance and pHmonitoring tracings.

Editing combined multichannel intraluminal impedance and pHmonitoring tracings.

Non-Acid GERC: Pathogenesis, Diagnosis and Management

Total Recent investigations have highlighted the pivotal influence of non-acid reflux in the etiology of chronic cough associated with gastroesophageal reflux disease (GERC). Differentiation between acid and non- acid GERC is effectively achieved through esophageal pH monitoring, with non-acid reflux drawing attention for its linkage to non-standard symptoms and the intricacies involved in its management. The combination of multi-channel intraluminal impedance with pH monitoring (MII-PH) and its related metrics, including acid exposure time (AET), symptom association probability (SAP), and symptom index (SI), as well as the quantity, pH, nature of reflux, its spread, and acid clearance time, alongside innovative measures such as mean nocturnal baseline impedance (MNBI) and post- reflux induced peristaltic wave index (PSWPI), is pivotal in precisely delineating reflux patterns and identifying the temporal connection between non-acid reflux occurrences and episodes of coughing. The prevailing reliance on proton pump inhibitors (PPIs) for treatment has encountered constraints in effectively managing non-acid GERC, underscoring the necessity for personalized treatment modalities that confront the unique pathophysiology of non-acid GERC to ameliorate patient outcomes. As research continues to deepen our understanding and enhance treatment methods for this multifaceted condition, the pursuit of effective treatment strategies becomes crucial. Our review aims to delineate the spectrum of therapeutic options, advancements in diagnostics, and an improved grasp of the pathogenesis of non-acid GERD. The focus of this review is to further the advancement of patient care management and to inspire continued research in this intriguing domain of gastroenterology.

Differences Between Patients with Heartburn Refractory to Vonoprazan and Those Refractory to Proton Pump Inhibitors

BackgroundVonoprazan, a potassium-competitive acid blocker, demonstrates more potent acid inhibition than proton pump inhibitors (PPIs). This study aimed to evaluate the effect of vonoprazan in patients with unproven gastroesophageal reflux disease (GERD) by comparing patients with vonoprazan-refractory heartburn with those with PPI-refractory heartburn.MethodsThis study included 104 consecutive patients with vonoprazan- or PPI-refractory heartburn (52 patients each), no erosive esophagitis on endoscopy and who underwent combined multichannel intraluminal impedance–pH (MII–pH) testing with vonoprazan/PPI discontinuation. Patients’ backgrounds, symptom scores from four questionnaires, MII–pH results and high-resolution manometry results were compared between the two groups.ResultsThe vonoprazan group demonstrated significantly higher GERD symptoms and scores of abdominal pain and diarrhea on the Gastrointestinal Symptom Rating Scale questionnaire. MII–pH results revealed that the vonoprazan group demonstrated 40.4%, 17.3%, and 42.3% and the PPIs group exhibited 26.9%, 17.3%, and 55.8% of abnormal acid reflux [true non-erosive reflux disease (NERD)], reflux hypersensitivity and functional heartburn, respectively. The vonoprazan group demonstrated higher true NERD rates but with no significant difference (p = 0.307). Among the vonoprazan group, eight patients with true NERD underwent another MII–pH test on vonoprazan, and all cases demonstrated normal acid exposure times (0.0% [0.0–0.3]).ConclusionPatients with unproven GERD with vonoprazan-refractory heartburn demonstrated more symptoms, including not only GERD symptoms but also functional dyspepsia and irritable bowel syndrome symptoms, than those with PPI-refractory heartburn.

Investigation of the Relationship Between Laparoscopic Sleeve Gastrectomy and Gastroesophageal Reflux Disease Using 24-hour Multichannel Intraluminal Impedance With pH Testing According to Current Consensus.

Laparoscopic sleeve gastrectomy (LSG) is a popular weight loss procedure with potential effects on gastroesophageal reflux disease (GERD). However, research on the association between LSG and GERD using objective evaluation criteria, such as multichannel intraluminal impedance combined with pH testing (MII-pH), is limited. This study aimed to investigate the impact of LSG on GERD using MII-pH and current consensus guidelines. It was conducted as a prospective clinical study on 33 patients who underwent LSG between January 2022 and August 2022. MII-pH and high-resolution manometry were performed preoperatively and 3 to 6 months postoperatively. GERD diagnosis was based on MII-pH results using the Lyon and Update Porto consensus guidelines. Postoperative MII-pH analysis revealed a significant increase in acid reflux time, acid exposure time, reflux index, esophageal clearance, total reflux time, and longest reflux period. Weak acid reflux episodes decreased, while Demeester score and alkaline reflux showed nonsignificant increases. Pathologic reflux significantly increased postoperatively based on MII-pH diagnosis. High-resolution manometry showed a significant increase in unsuccessful motility. Although the Demeester score calculation consists of 6 metrics, including acid exposure time, the acid exposure time is more specific in detecting pathologic reflux. Pathologic GERD increases significantly with LSG in the early period. Therefore, preoperative and postoperative endoscopy and MII-pH can provide valuable information regarding the need for closer follow-up after LSG.

Executing and facilitating the successful combined multichannel intraluminal impedance and pH monitoring study.

Successful multichannel intraluminal impedance and pH monitoring (MII-pHM) studies rely on constant attendants (CAs) or family members (and sometimes the patients themselves) to assist in the execution and facilitation of the MII-pHM study. While "pushing buttons" [corresponding to specific symptoms, body position (upright versus recumbent), and meal start and stop times] on the MII-pHM system recording box is indeed a big part of MII-pHM study execution and facilitation, there are other concerns and duties that are equally as important. This paper outlines some of the important duties of the study facilitator (or patient) during a MII-pHM study. When provided with the proper training, study facilitators invigilating the MII-pHM study will be better able to contribute to the data collection process and ultimately to produce data that when analyzed will lead to better interpretations, clinical recommendations, and good clinical outcomes. When executed properly, MII-pHM studies have the potential to assess diurnal exposure of the esophageal mucosa to gastric/duodenal contents, provide insight regarding the proximal extent of gastroesophageal reflux (GER), provide a measurement of the mean esophageal pH, and assess mucosal integrity and temporal relationship between GER and the symptoms of interest. While several groups have offered recommendations for proper execution of the MII-pHM study, to our knowledge, there have not been publications wherein recommendations were compiled to form a single source document.

Mean nocturnal baseline impedance: Influencing factors and diagnostic value in gastroesophageal reflux disease.

At present, there are few studies related to mean nocturnal baseline impedance (MNBI), esophageal dynamic reflux monitoring, high-resolution esophageal manometry (HRM) parameter indexes, and its diagnostic value in gastroesophageal reflux disease (GERD). To analyze the factors influencing MNBI and examine the diagnostic value of MNBI in GERD. A retrospective analysis on 434 patients with typical reflux symptoms who underwent gastroscopy, 24-hour multichannel intraluminal impedance and pH monitoring (MII/pH) and HRM. They were divided into the conclusive evidence group (103 cases), borderline evidence group (229 cases), and exclusion evidence group (102 cases) according to the level of diagnostic evidence of GERD based on the Lyon Consensus. We analyzed the differences in MNBI, esophagitis grade, MII/pH and HRM index among the groups; the correlation between MNBI and the above indexes and its influence on MNBI; and to evaluate the diagnostic value of MNBI in GERD. There were significant differences in MNBI, Acid Exposure Time (AET) 4%, DeMeester score, and total reflux episodes among the three groups (P< 0.001). EGJ contractile integral (EGJ-CI) of the conclusive evidence group and the borderline evidence group was significantly lower than that in the exclusion evidence group (P< 0.001). MNBI was significantly and negatively correlated with age, BMI, AET 4%, DeMeester score, total reflux episodes, EGJ classification, esophageal motility abnormalities, and esophagitis grade (all P< 0.05), and significantly and positively correlated with EGJ-CI (P< 0.001). Age, BMI, AET 4%, EGJ classification, EGJ-CI, and esophagitis grade had significant effects on MNBI (P< 0.05); MNBI was used to diagnose GERD with a diagnostic cutoff of 2061 Ω, and AUC was 0.792 (sensitivity 74.9%, specificity 67.4%); MNBI was used to diagnose exclusion evidence group with a diagnostic cutoff of 2432 Ω, AUC was 0.774 (sensitivity 67.6%, specificity 72%). AET, EGJ-CI, and esophagitis grade are the most important influence factors of MNBI. MNBI has good diagnostic value in identifying conclusive GERD.

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.

Abnormal bolus reflux on impedance-pH testing independently predicts 3-year pulmonary outcome and mortality in pulmonary fibrosis.

Gastroesophageal reflux has been associated with idiopathic pulmonary fibrosis (IPF), although the directionality of the relationship has been debated. Data on the value of objective reflux measures in predicting IPF disease progression and mortality remain limited. We aimed to evaluate the association between multichannel intraluminal impedance and pH testing (MII-pH) and 3-year pulmonary outcomes in IPF patients. This was a retrospective cohort study of adults with IPF who underwent pre-lung transplant MII-pH off acid suppression at a tertiary center. Patients were followed for 3years after MII-pH for poor pulmonary outcomes (hospitalization for respiratory exacerbation or death). A secondary analysis was performed using mortality as outcome of interest. Time-to-event analyses using Kaplan-Meier and Cox regression were performed to evaluate associations between MII-pH and poor outcomes. One hundred twenty-four subjects (mean age=61.7±8years, 62% male) were included. Increased bolus exposure time (BET) on MII-pH was associated with decreased time to poor pulmonary outcomes and death (log-ranked P-value=0.017 and 0.031, respectively). On multivariable Cox regression analyses controlling for potential confounders including age, sex, smoking history, body mass index, proton pump inhibitor use, baseline pulmonary function, and anti-fibrotic therapy, increased BET was an independent predictor for poor pulmonary outcomes [hazard ratio 3.18 (95% confidence interval: 1.25-8.09), P=0.015] and mortality [hazard ratio 11.3 (95% confidence interval: 1.37-63.9), P=0.025] over 3years. Increased BET on MII-pH is an independent predictor of poor pulmonary outcomes and mortality over 3years in IPF patients. These findings also support a role for gastroesophageal reflux in IPF disease progression and the potential impact of routine reflux testing and treatment.

Multichannel Intraluminal Impedance with pH-metry in Children

Multichannel Intraluminal Impedance with pH-metry in Children

How Best to Estimate Insertion Length of Multichannel Intraluminal Impedance pH Probes in Children

To assess the reliability of the KidZ Health Castle formula (KHC-F) to determine the correct probe position of a multichannel intraluminal impedance pH. A retrospective cohort study was performed on 222 children between 1month and 18years of age undergoing multichannel intraluminal impedance pH. The primary outcome was the comparison of the pH sensor location determined by the KHC-F with the radiological target position. The margin of error was defined as 1 cm from the target position. Performance of the KHC-F and existing formulas was determined via the percentage with a correct position, mean error, 95% limits of agreement (Bland-Altman plots), and Spearman correlation. A post hoc analysis was performed with an updated KHC-F v2, subtracting -0.5cm from the KHC-F. Positioning with KHC-F was correct in two-thirds of the participants, with a very strong correlation (ρ = 0.91) with the target position. Bland-Altman plots showed good agreement between KHC-F and target position (mean error of -0.44cm, lower limit -3.2cm, upper limit 2.3cm). A post hoc analysis with the KHC-F v2 showed a correct positioning in 74% of patients. Comparison with other formulas showed a stronger performance of KHC-F and KHC-F v2 on correct positioning, mean error, and 95% limits of agreement. The KHC-F leads to reliable results. KHC-F v2 outperforms all other existing formulas in children, thereby reducing the need for repositioning and the amount of x-ray exposure. The age distribution of the sample may be a limitation, as well as the retrospective nature of the study.