Multichannel Intraluminal Impedance Research Articles

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.

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.

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.

Bronchoalveolar lavage cytology in children with chronic unexplained cough and severely neurologically impaired children.

We aimed to compare the cellular composition of bronchoalveolar lavage (BAL) fluids in children with chronic unexplained cough (group 1) and severely neurologically impaired children with chronic or recurrent respiratory problems (group 2) with the BAL cytology of children without pulmonary or systemic diseases (group 3). Bronchoscopy with BAL fluid analysis was performed in all subjects. Children with respiratory symptoms underwent 24-hour multichannel intraluminal impedance monitoring. A significant difference was found between the groups in the total number of cells in BAL fluid cytology (191 [range, 24-12,747], 747 [range, 53-13,000], and 105 [range, 41-233] cells/μL, P = .015), in the percentage of neutrophils (21.2 [SD = 32.4], 49.4 [SD = 36.6], and 3.6 [SD = 2.4], P < .001), and in the percentage of lipid-laden macrophages (10.3 [SD = 11.4], 13.7 [SD = 15.8] and 0.44 [SD = 1.0], P < .001). The BAL fluid cytology provides useful data for determining the cause of chronic unexplained cough and chronic or recurrent respiratory problems in severely neurologically impaired children.

Non-acid reflux and esophageal dysmotility is associated with early esophageal squamous cell carcinoma.

Studies have demonstrated that non-acid reflux (NAR) is associated with esophageal squamous cell carcinoma (ESCC). Esophageal dysmotility is associated with NAR but few studies have focused on the esophageal motility of ESCC patients. We explored the relationship between ESCC, NAR and esophageal dysmotility with the aid of multichannel intraluminal impedance and pH (MII-pH) and high-resolution manometry (HRM). From Jan 2021 to Oct 2022, 20 patients with superficial ESCC were enrolled as the ESCC group, while 20 age and gender matched individuals without gastroesophageal reflux disease (GERD) symptoms and 20 age and gender matched patients with GERD symptoms were recruited as the control groups. Patients received 24h MII-pH and HRM procedure before endoscopic submucosal dissection (ESD), and the data were then collected to identify the type of reflux and esophageal dysmotility. Prevalence of esophageal dysmotility was significantly different among the three groups, 75.0% in the ESCC group, 35.0% in the non-GERD group and 70.0% in the GERD group (P = 0.029). NAR episodes at 15cm above the lower esophageal sphincter (LES) in the ESCC group were significantly higher than that in the non-GERD group (6.5 (3.5-9.3) vs 1.0 (0.8-4.0), P = 0.001) and were similar with that in the GERD group (6.5 (3.5-9.3) vs 5.5 (3.0-10.5), P > 0.05). NAR episodes at 5cm above LES was significantly higher in the ESCC group than that in the non-GERD group (38.0 (27.0-60.0) vs 18.0 (11.8-25.8), P = 0.001) and was significantly higher than that in the GERD group (38.0 (27.0-60.0) vs 20.0 (9.8-30.5)), P = 0.010). Prevalence of pathologic non-acid reflux was significantly different among the three groups, 30.0% in the ESCC group, 0.0% in the non-GERD group and 10.0% in the GERD group (P < 0.001). Our study found NAR and esophageal dysfunction frequently occur in ESCC patients. NAR and esophageal dysmotility may be associated with ESCC. ChiCTR2200061456.

Pediatric Laryngopharyngeal Reflux: An Evidence-Based Review

Pediatric laryngopharyngeal reflux (P-LPR) is associated with the development of common otolaryngological symptoms and findings. In the present study, the findings about epidemiology, clinical presentation, diagnostic and therapeutic outcomes of pediatric population were reviewed. A PubMed, Cochrane Library, and Scopus literature search was conducted about evidence-based findings in epidemiology, clinical presentation, diagnostic and therapeutic outcomes of P-LPR. The prevalence of LPR remains unknown in infant and child populations. The clinical presentation depends on age. Infants with LPR symptoms commonly have both gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux and related digestive, respiratory and ear, nose and throat symptoms. The GERD prevalence appears to decrease over the growth, and the clinical picture is increasingly associated with LPR symptoms and findings without GERD. The prevalence of LPR and proximal acid and nonacid esophageal reflux events may be high in some prevalent otolaryngological conditions (chronic otitis media, laryngolomalacia and apnea). However, the lack of use of hypopharyngeal-esophageal multichannel intraluminal impedance pH monitoring (HEMII-pH) limits the establishment of etiological associations. Proton pump inhibitors are less effective in P-LPR patients compared to GERD populations, which may be related to the high prevalence of weakly or nonacid reflux events. Many gray areas persist in P-LPR and should be not resolved without the establishment of diagnostic criteria (guidelines) based on HEMII-pH. The unavailability of HEMII-pH and the poor acid-suppressive therapeutic response are all issues requiring future investigations. Future controlled studies using HEMII-pH and enzyme measurements in ear, nose or throat fluids may clarify the epidemiology of P-LPR according to age and its association with many otolaryngological conditions.

Evaluation of Esophageal Motility in Obese Patients before and after Bariatric Surgery: Role of Multichannel Intraluminal Impedance and High-resolution Manometry

Abstract Background: A high prevalence of esophageal motor disorders has been reported in obese patients. Roux-en-Y gastric bypass (RYGB) can trigger symptoms of dysphagia by worsening preexisting esophageal motor disorders. Investigation of esophageal motility with multichannel intraluminal impedance (MII) and high-resolution manometry (HRM) is available. Objective: The aim is to compare the results of MII and HRM of nonobese patients with those of obese patients before and after RYGB to identify possible preoperative predictive factors of postoperative dysphagia. Materials and Methods: Twenty-eight obese patients were evaluated with a questionnaire of symptoms, endoscopy, HRM, and MII in different postures (supine and sitting) before and 6 months after laparoscopic RYGB. They were compared with eleven nonobese subjects. Chicago classification parameters were used to characterize esophageal motility disorders. Results: Obese patients evolved with more symptoms of dysphagia after surgery (7.10% preoperatively and 32.10% postoperatively). None had gastrojejunal anastomosis stenosis. After bariatric surgery, there was an increase in distal latency (HRM) and also a decrease in esophageal alimentary bolus progression (MII). Twenty-one percent of obese patients already had some dysmotility before the surgery and 92% of them evolved to dysphagia after the operation. Conclusions: Previous esophageal motility disorder is a good predictive factor of postoperative dysphagia. HRM and MII should be performed in some situations, such as bariatric surgery for older adults and before narrowing the gastrojejunal anastomosis as a treatment for weight recidivism.

Reflux definitions in esophageal multi-channel intraluminal impedance.

In this study, we aim to propose consensus-based interpretations to enhance both automatic, and manual analysis and then present our recommendations about reflux-related variables to enhance Multichannel Intraluminal (MII) measurements. Multichannel Intraluminal Impedance-pH (MII-pH) monitoring is the most sensible option to evaluate Gastroesophageal Reflux Disease (GERD), specifically for the patients with normal endoscopy findings, and persistent symptoms without response to Proton Pomp Inhibitor therapy. There were only a few studies on the interpretation of reflux events in MII tracings. Several 200 episodes of reflux events were reviewed during several meetings in five steps, to discuss and categorize unresolved issues within existing interpretations, and propose technical principles for accurate characterization of reflux events. In this study, we show that baseline impedance is determined using a moving average procedure to the impedance data of each channel with a time window of 60 seconds based on this finding; a liquid reflux event is defined as a retrograde 50% drop in baseline impedance, gas reflux event is defined as a rapid increase in impedance greater than 5 kΩ, Mixed liquid-gas reflux is defined as gas reflux occurring immediately before or during liquid reflux. The reliability of final diagnosis is significantly dependent on the accurate detection of reflux events, which is currently confronting technical limitations. A pathological reflux event propagates to at least three of the impedance sites, according to the literature. We think that taking three impedance locations into account might be too strict.