Pathologic Gastroesophageal Reflux Research Articles

The index of failure of the antireflux function of the cardia (IFAFC), as a criterion for the effectiveness of its videolaparoscopic correction for gastroesophageal reflux disease (gerd) in pthe index of failure of the antireflux function of the cardia after video-laparoscopic correction in gerd patients with hiatal hernia

The purpose of the study was to create an index based on the total results of special research methods that characterizes the antireflux function of the cardia in the long term after its video-laparoscopic correction in GERD patients with hiatal hernia (HH). Long-term results of video-laparoscopic antireflux intervention in 213 patients with GERD and HH were analyzed. Based on the results of a remote survey and instrumental examination, the patients were divided into three groups. The first group consisted of the patients who had symptoms of GERD, but the presence of pathological gastroesophageal reflux was not confirmed by instrumental methods (122 patients, 57.3 %); the second group included the patients with recurrent GERD (19 patients, 8.9 %); the third group (72 patients, 33.8 %) consisted of the patients without GERD symptoms or its recurrence. To assess the antireflux function of the cardia in the long term after its video-laparoscopic correction, the index of failure of the antireflux function of the cardia (IFAFC) was developed based on the generalized results of instrumental research methods. Before surgery in all groups of the patients, the IFAFC did not have a statistically significant difference and indicated a very significant severity of signs of failure of the antireflux function of the cardia (0.70±0.06, 0.74±0.05, and 0.70±0.06, respectively; р>0.05). In the long term after surgery, the patients with false-positive GERD symptoms showed an improvement in the IFAFC by 87.14 % (p<0.001), the patients without symptoms of GERD and its recurrence — by 92.86 % (p<0.001), and the patients with recurrent GERD — by 16.22 % (p<0.05). The IFAFC allows assessing the results of the antireflux surgery. In the absence of recurrent GERD, the IFAFC is 0.05±0.01; in patients with recurrent GERD, it is 0.62±0.07. The IFAFC equal to 0.09±0.07 is typical for patients at risk with false-positive symptoms of GERD without confirmation of its relapse by special studies. These patients require follow-up.

Roles of Cytokines in Pathological and Physiological Gastroesophageal Reflux Exposure.

Gastroesophageal reflux disease is frequently observed and has no definitive treatment. There are 2 main views on the pathogenesis of gastroesophageal reflux disease. The first is that epithelial damage starts from the mucosa by acidic-peptic damage and the inflammatory response of granulocytes. The other view is that T-lymphocytes attract chemoattractants from the basal layer to the mucosa, and granulocytes do not migrate until damage occurs. We aim to investigate the inflammatory processes occurring in the esophageal epithelium of the phenotypes at the molecular level. We also examined the effects of these changes on tissue integrity. Patients with mild and severe erosive reflux, nonerosive reflux, reflux hypersensitivity, and functional heartburn were included. Inflammatory gene expressions (JAK/STAT Signaling and NFKappaB Primer Libraries), chemokine protein levels, and tissue integrity were examined in the esophageal biopsies. There was chronic inflammation in the severe erosion group, the acute response was also triggered. In the mild erosion group, these 2 processes worked together, but homeostatic cytokines were also secreted. In nonerosive groups, T-lymphocytes were more dominant. In addition, the inflammatory response was highly triggered in the reflux hypersensitivity and functional heartburn groups, and it was associated with physiological reflux exposure and sensitivity. "Microinflammation" in physiological acid exposure groups indicate that even a mild trigger is sufficient for the initiation and progression of inflammatory activity. Additionally, the anti-inflammatory cytokines were highly increased. The results may have a potential role in the treatment of heartburn symptoms and healing of the mucosa.

Clinical and functional characteristics, possible causes, and impact of chronic cough in patients with cerebellar ataxia, neuropathy, and bilateral vestibular areflexia syndrome (CANVAS)

Cerebellar ataxia with neuropathy and bilateral vestibular areflexia syndrome (CANVAS) is an hereditary autosomal recessive disease. Recent studies propose including chronic cough (CC) as a symptom of CANVAS. For 10 patients with CANVAS as genetically confirmed by biallelic expansion of the AAGG repeat motif (AAGGGexp) in intron 2 of replication factor C subunit 1 (RFC1), our aim was, as a multidisciplinary team, to describe clinical and functional characteristics and possible causes of CC following European Respiratory Society (ERS) recommendations, and to evaluate CC impact on quality of life (QoL) using self-administered questionnaires (Cough Severity Diary, Leicester Cough Questionnaire, Discrete Emotions Questionnaire, and EQ-5D-5L). In all 10 patients, the CC was a dry cough that developed several years prior to the neurological symptoms (mean 14.2 years); 7 patients had symptoms compatible with gastroesophageal reflux (GER), 5 with pathological GER diagnosed by 24-h esophageal pH testing, and 6 patients had impaired esophageal motility diagnosed by high-resolution esophageal manometry, most frequently ineffective peristalsis. Although further studies are required for confirmation, we conclude that CC may be a characteristic prodrome of CANVAS and may be related to GER and esophageal disorders. Furthermore, CC affects patients’ QoL, especially in the psychosocial sphere.

Predictors of Pathological Gastroesophageal Reflux among Emirati Patients with Reflux Symptoms Who Undergo Wireless pH Monitoring.

Background: Diagnosis of gastroesophageal reflux disease (GERD) relies on recognizing symptoms of reflux and mucosal changes during esophagogastroduodenoscopy. The desired response to acid suppression therapy is reliable resolution of GERD symptoms; however, these are not always reliable, hence the need for pH testing in unclear cases. Our objective was to identify potential predictors of a high DeMeester score among patients with potential GERD symptoms to identify patients most likely to have pathological GERD. Methods: We conducted a retrospective case-control study on patients who underwent wireless pH monitoring from January 2020 to April 2022. Cases were patients with a high DeMeester score (more than 14.7), indicating pathological reflux, and controls were those without. We collected clinical and demographic data, including age, sex, body mass index (BMI), smoking status, non-steroidal anti-inflammatory drugs (NSAIDs) use, and presence of atypical symptoms. Results: 86 patients were enrolled in the study. 46 patients with high DeMeester scores were considered cases, and 40 patients with DeMeester scores less than 14.7 were considered controls. Esophagitis (grade A) was found in 41.1% of the cases and in 22.5% of the control group. In our study, age of more than 50 years compared with age of 20-29 years and being overweight appeared to be predictors of true pathological reflux among patients with reflux symptoms who underwent wireless pH monitoring. Conclusion: Age above 50 years compared with age between 20-29 years and being overweight appeared to be predictors of true pathological reflux among patients with reflux symptoms who underwent wireless oesophageal pH monitoring. The presence of oesophagitis was approximately four times more likely to be associated with true pathological reflux.

Diagnostic Yield of Ambulatory Reflux Monitoring Systems for Evaluation of Chronic Laryngeal Symptoms.

Among patients with chronic laryngeal symptoms, ambulatory reflux monitoring off acid suppression is recommended to evaluate for laryngopharyngeal reflux (LPR). However, reflux monitoring systems are diverse in configuration and monitoring capabilities, which present a challenge in creating a diagnostic reference standard in these patients. This study aimed to compare diagnostic yield and performance between reflux monitoring systems in patients with chronic laryngeal symptoms. This multicenter, international study of adult patients referred for evaluation of LPR over a 5-year period (March 2018-May 2023) assessed and compared diagnostic yield of pathologic gastroesophageal reflux (GER+) on ambulatory reflux monitoring off acid suppression. Of 813 patients, 296 (36%) underwent prolonged wireless pH, 532 (65%) underwent 24-hour pH-impedance monitoring, and 15 (2%) underwent both tests. Overall diagnostic yield for GER+ was 36% and greater for prolonged wireless pH compared with that for 24-hour pH-impedance monitoring (50% vs 27%; P < 0.01). Among 15 patients who underwent both prolonged wireless pH and 24-h pH-impedance monitoring, concordance between systems for GER+ was 40%. The most common source of discordance was strong evidence of GER+ across multiple days on prolonged wireless pH compared with no evidence of GER+ on pH-impedance. In this multicenter international study of patients with chronic laryngeal symptoms referred for LPR evaluation, diagnostic yield of ambulatory reflux monitoring off acid suppression was 36% and rose to 50% when using wireless pH monitoring. In patients referred for chronic laryngeal symptoms, 24-hour pH-impedance monitoring may risk a low negative predictive value in patients with unproven GER+ disease.

Gastroesophageal reflux after Roux-en-Y gastric bypass: Is it just related to technical details?

Although it is uncommon, gastroesophageal reflux disease can present after Roux-en-Y gastric bypass, and it is usually related to technical errors. Hiatal hernia, a narrow calibrated gastrojejunostomy and a long gastric pouch are all factors associated with the development of pathologic gastroesophageal reflux. Techniques are available to treat this condition, such as fundoplications with the gastric remnant, gastropexy to the arcuate ligament, teres ligament repair, or sphincter augmentation with the LINX device.Despite the growing number of reports of gastroesophageal reflux after Roux-en-Y gastric bypass, it should be still considered the best surgical option for patients with obesity and a large hiatal hernia or complications secondary to gastroesophageal reflux disease.

Reflujo tras bypass gástrico. ¿Solo depende de aspectos técnicos?

Although it is uncommon, gastroesophageal reflux disease can present after Roux-en-Y gastric bypass, and it is usually related to technical errors. Hiatal hernia, a narrow calibrated gastrojejunostomy and a long gastric pouch are all factors associated with the development of pathologic gastroesophageal reflux. Techniques are available to treat this condition, such as fundoplications with the gastric remnant, gastropexy to the arcuate ligament, teres ligament repair, or sphincter augmentation with the LINX device.Despite the growing number of reports of gastroesophageal reflux after Roux-en-Y gastric bypass, it should be still considered the best surgical option for patients with obesity and a large hiatal hernia or complications secondary to gastroesophageal reflux disease.

Reliability of self-assessment of quality of life in patients with hiatal hernia associated with gastroesophageal reflux disease after videolaparoscopic anti-reflux surgery

This article aims to investigate the reliability of self-assessment of the quality of life in patients with hiatal hernia after undergoing videolaparoscopic anti-reflux intervention. To achieve this, the responses to a questionnaire were compared with the results of a study on the failure of the cardia anti-reflux mechanism.Materials and methods. A total of 213 patients who underwent videolaparoscopic oesophagus fundoplication were included in this study. The participants completed three questionnaires: GORD-HRQL, GIQLI, and SF-36. The responses obtained from the questionnaires were then compared with the results of a cardia anti-reflux mechanism study, which involved X-ray endoscopy of the oesophagus and stomach, daily oesophageal pH-metry, and oesophagogastric junction manometry. Based on the responses to the three questionnaires, the quality of life index was calculated for all patients. Additionally, a composite index of cardia anti-reflux mechanism failure was computed to assess the severity of pathological gastro-oesophageal reflux and describe the effectiveness of the cardia anti-reflux mechanism in preventing it.Results. The comparison of the components forming the integral quality of life index with the composite index of cardia anti-reflux mechanism failure before and after the operation revealed an inverse relationship: as the values of the integral quality of life index decreased, the values of the composite index of cardia anti-reflux mechanism failure increased.Conclusion. The self-assessment of the quality of life by patients with GORD-associated hiatal hernia after anti-reflux intervention, as assessed through GORD-HRQL, GIQLI, and SF-36 questionnaires, is accurate and can be effectively utilized for screening and diagnosing disease recurrence.

Severe Intermittent Dysphagia is not a Contraindication for Total Nissen Fundoplication

Aim: To study the effect of total Nissen fundoplication on severe intermittent esophageal dysphagia according to a hiatal hernia. Methods: Twenty-three consecutive patients (12 men, 11 women, median age 43 yrs) with severe intermittent dysphagia and with hiatal hernia verified by endoscopy were included in the study. They were investigated with esophageal high-resolution manometry (HRM)-, and 24-hr pH- monitoring prior to hiatal hernia repair and at follow-up 6 months after surgery. On both test occasions, the patients were asked to fill in a questionnaire comprising 17 questions on esophageal and chest symptoms (severity grades 0-3). Results: A hiatal hernia was recorded via HRM in all 23 patients prior to surgery and in no one at follow-up. Prior to surgery, all patients had either severe no stenotic dysphagia or frequent retention symptoms in the chest while eating. These two mechanical problems were relieved by surgery (p&lt; 0.0001). Motility disturbances in the distal esophagus were recorded in 35 % of patients prior to surgery, but in no one at follow-up. The median total reflux time prior to surgery was 2.2 % (range 0.2 – 36.5 %) and at follow-up 0 % (0 – 0.3 %). Five patients had no pathological gastro-esophageal reflux prior to surgery. Conclusion: Severe intermittent esophageal dysphagia in hiatal hernia patients can be successfully treated with total Nissen fundoplication, and this should be a strong indication for hiatal hernia surgery even in the absence of pathological gastro-esophageal reflux.

Efficacy of laparoscopic fundoplication in patients with chronic cough and gastro-oesophageal reflux

BackgroundThe outcome of anti-reflux surgery in patients with suspected gastro-oesophageal reflux-induced cough is frequently uncertain. The aims of this study were to assess the efficacy of laparoscopic fundoplication for controlling cough in patients with chronic cough without asthma, who have pathologic gastro-oesophageal reflux, and to identify predictors of response.MethodsFrom a prospective database of 1598 patients who have undergone laparoscopic fundoplication, 66 (4%) with proven gastro-oesophageal reflux disease (GORD) and chronic cough without asthma were studied. All patients underwent gastroscopy and 24-h pH monitoring before operation. Heartburn and regurgitation were assessed using a modified DeMeester score. Severity of cough before and after surgery was self-assessed by the patient using a visual analog scale at a minimum of 12 months post-operatively (median 43 mo; range: 14–104 mo). Patients were considered to have responded to fundoplication if they had no cough or the cough had improved by 50% or more after operation.ResultsCough and heartburn/regurgitation were relieved in 61% (40/66) and 90% (44/49) of the patients, respectively. The presence of typical GORD symptoms or oesophagitis, and pH study variables did not predict the response of the cough to fundoplication.ConclusionRefinement in the aetiological diagnosis of chronic cough due to GORD is necessary for improved outcome. Patients diagnosed with GORD-related chronic cough need to be counseled regarding their expectations from anti-reflux surgery.

320. EFFICACY OF LAPAROSCOPIC FUNDOPLICATION IN PATIENTS WITH CHRONIC COUGH AND GASTRO-OESOPHAGEAL REFLUX

Abstract The outcome of anti-reflux surgery in patients with cough suspected to be induced by gastro-oesophageal reflux disease is frequently uncertain. The aims of this study were to assess the efficacy of laparoscopic fundoplication (LF) for controlling cough in a patient population suffering chronic cough when alternative aetiologies (e.g. asthma) had been excluded and pathologic gastro-oesophageal reflux had been confirmed on ambulatory pH monitoring, and to identify predictors of response. From a prospective database of 1,598 patients who had undergone laparoscopic fundoplication, 66 (4%) had a principal presenting symptom of chronic cough as well as objective evidence of gastro-oesophageal reflux disease (GORD). Patients completed questionnaires for GORD symptoms (modified DeMeester score) and severity of cough (visual analog scale) both before and after LF, and had pre-operative gastroscopy and 24-hour pH monitoring before operation. Patients were considered to have responded to LF if they had no cough or the cough had improved by 50% or more after operation. Follow-up data was available for 66/66 patients (100%), with a median follow-up time of 43 months (range 14–104 months) after operation. Cough was relieved in 40/66 (61%), while typical GORD symptoms (heartburn, regurgitation) was relieved in 44/49 (90%). The presence of typical GORD symptoms, oesophagitis, or pH study variables did not predict the response of the cough to LF. At 1 year, 67% of patients were satisfied with the results of their surgery, 20% were not and 13% were unsure. For comparison, the 1430/1598 patients in the database with no laryngopharyngeal symptoms had a satisfaction rate of 94%. Based on our study and available literature, it appears there are no reliable pre-operative clinical predictors of a satisfactory response of cough to LF. This probably reflects a current inability to obtain an accurate aetiological diagnosis of chronic cough, even in the presence of known abnormal gastro-oesophageal reflux disease. Regardless, in a well-chosen cohort of patients with chronic cough, LF can yield good patient satisfaction rates, albeit less than for patients with typical GORD symptoms.

Robotic surgery for the treatment of achalasia

ObjectiveTo describe the experience of the robotic approach for achalasia surgery in a tertiary center. Material and methodsPatients with achalasia who underwent robotic surgery between May 2010 and April 2019 were analyzed. The study variables were collected in a prospective database and a descriptive analysis was performed. Results45 patients (55.6% male) with a mean age of 44 years were included. The main symptom at diagnosis was dysphagia. 19 patients (42.2%) received endoscopic treatment prior to surgery, mostly pneumatic dilation (84.2%). Heller's myotomy associated with Toupet fundoplication was the surgical technique of choice, with a mean operative time of 211 min. The average stay was 5 days. There were 2 postoperative perforations (4.4%). Perioperative mortality was 0%. The mean follow-up was 64 months. At 3 and 5 years, a significant decrease in the Eckardt score was observed and the manometric study showed a decrease in the lower esophageal sphincter pressure at rest of 58% and 70%, respectively, with persistence of hypomotility of the esophageal body. Pathological gastroesophageal reflux was diagnosed in two patients (5.4%) and 4 (10.8%) presented recurrence of symptoms, requiring endoscopic pneumatic dilations. In 2 cases, the dilations were not effective, so an endoscopic myotomy was considered. ConclusionsIn our experience, robotic surgery is a safe and effective procedure for the treatment of achalasia.

Laparoscopic Heller Myotomy with Dor Fundoplication: An Operation that has Withstood the Test of Time.

Achalasia is a primary esophageal motility disorder characterized by aperistalsis and defective relaxation of the lower esophageal sphincter in response to swallowing. Patients' symptoms include dysphagia, regurgitation, weight loss, chest pain and aspiration. The disease is idiopathic, and the goal of treatment is to eliminate the resistance determined by the abnormal lower esophageal sphincter, therefore allowing passage of the ingested food from the esophagus into the stomach. Three effective treatment modalities are available today-pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller myotomy with a partial fundoplication. We described the technique to perform a laparoscopic Heller myotomy and a Dor fundoplication. Five steps to perform a laparoscopic Heller myotomy and a Dor fundoplication were described. The surgical approach is favored in many centers as it is very effective in relieving symptoms, while avoiding pathologic gastroesophageal reflux in most patients.

Results of laparoscopic Heller esophagocardiomyotomy with Dor fundoplication in patients with stages 3 and 4 of the esophageal achalasia

INTRODUCTION. The choice of a treatment method in patients with stages 3–4 of the esophageal achalasia remains an actual topic.The OBJECTIVE was to evaluate the long-term results of Heller esophagocardiomyotomy with Dor hemiesophagofundoplication at stages 3–4 of the esophageal achalasia by comparing the results of patient survey with data of instrumental methods of diagnosis of esophageal function.METHODS AND MATERIALS. The results of the operation were analyzed in 67 patients, including 35 patients with stage 3 and 32 patients with stage 4 of the disease. The period of postoperative follow-up was 1–5 years. The results of X-ray examination of the esophagus and stomach, esophageal manometry, 24-hour pH-metry and the data of the Eckardt and GIGLI scale questionnaires were evaluated.RESULTS. The data of X-ray examination of the esophagus and stomach, in the long-term period, showed a complete restoration of the esophagus evacuation function in all patients (p=0.001), according to manometric data, a significant decrease in the tone of the lower esophageal sphincter in all patients to normal values (p=0,001) was revealed, esophageal atony was noted in three patients with stage 4 of the disease. Pathological gastroesophageal reflux before and after surgery was not registered by pH-metry, the De Meester index was within the normal range in all groups (less than 14.72). Dysphagia in the long-term period decreased in all patients. Long-term results on the Eckardt scale in patients with stage 3 improved by 83.5 %, with stage 4 by 78.3 % (p=0.001), according to the GIGLI questionnaire, patients with stage 3 scored 83.5 %, with stage 4 by 78.3 % more than before surgery.CONCLUSION. Laparoscopic Heller esophagocardiomyotomy with Dor fundoplication reduces symptoms of the disease in patients with stages 3–4 of the esophageal achalasia, increases the gastrointestinal index of quality of life, which makes it advisable to perform organ-preserving surgery at stage 4 of the disease.

To Wrap or Not? Utility of Anti-reflux Procedure in Infants Needing Gastrostomy Tubes.

PurposeGastrostomy tube (GT) insertion is commonly performed in children with failure to thrive. Pediatric patients' frequently have gastroesophageal reflux (GER) and discerning pathological GER can be challenging. Moreover, there is some evidence that GT insertion may lead to worsening GER and to avoid a subsequent anti-reflux procedure (ARP), though controversial some surgeons advocate considering an ARP concomitantly. The purpose of this report is to assess outcomes in infants who underwent a GT vs. GT with ARP.MethodsRetrospective review of all infants who had a GT placed at a single institution from 2009–2014. The patients were then divided into two cohorts based on the index operation i.e., GT vs GT with ARP and outcomes compared.Results226 operations (104 GT, 122 GT with ARP) were performed. The cohorts were similar in gender, gestational age, race, weight, median age, LOS, and proportion of neurologically impaired patients. Preoperative GER was significantly higher in the GT with ARP cohort (91 vs. 18%). No difference in the rate of immediate complications was noted between the two groups. Postoperative increase in anti-reflux medications was significantly higher in the GT cohort (p = 0.01). Post-op GER needing a secondary procedure (ARP or GJ tube) was noted in 21/104 (20%) patients. Those needing an additional procedure vs. those with GT alone were similar in the proportion of patients with pre-op GER, neurologic impairment, type of feeds, and age.ConclusionIdentifying patients who would benefit from a concomitant ARP remains challenging. A fifth of GT patients needed a subsequent procedure despite most high-risk patients having already undergone an ARP. Since the overall rate of complications remained similar, initial GT approach can be considered reasonable.

Gastroesophageal reflux disease in patients with morbid obesity

Aim. To study the prevalence and manifestations of gastroesophageal reflux disease (GERD) in patients with morbid obesity based on endoscopic, X-ray findings and the function of the lower esophageal sphincter. Materials and methods. The study involved 98 obese patients with a mean body mass index (BMI) of 55.6 ± 10.3 kg/m2. Of these, 30 were men (34.48 %) and 68 were women (65.52 %) aged 18–64 years, mean age – 42.3 ± 8.5. All the patients subsequently underwent fibroesophagogastroduodenoscopy, esophagomanometry, 24-hour esophageal pH monitoring, X-ray examination and bariatric surgery. The presence and severity of pathological gastroesophageal reflux were assessed using esophageal pH monitoring data based on the DeMeester score. In addition, the lower esophageal sphincter function was assessed, the number of refluxes and the duration of the longest reflux episode were calculated according to the data of esophagomanometry and 24-hour esophageal pH monitoring. Statistical data processing was carried out using the StatPlus 2007 software package. Results. In this paper, we studied the prevalence and manifestations of gastroesophageal reflux in 98 obese patients. The mean BMI was 55.6 ± 10.3 kg/m2, the maximum was 72 kg/m2. GERD was diagnosed in 37 (37.76 %) patients, including 8 (8.16 %) patients with a hiatal hernia. The erosive form prevailed in the GERD pattern – in 24 (24.48 %) patients. In 32 (32.65 %) examined patients, pathological reflux was diagnosed during the daytime, especially after eating. Conclusions. The study results indicate that 37.76 % of obese patients are diagnosed with GERD arising from anatomical features and function of the gastroesophageal junction with the predominance of erosive forms of GERD. The state of the gastroesophageal junction in obese patients should be considered when choosing the optimal bariatric or metabolic surgery.

Этапная диагностика патологического гастроэзофагеального рефлюкса у детей

Цель работы: разработать и обосновать алгоритм этапной диагностики патологического гастроэзофагеального рефлюкса (ГЭР) в зависимости от тяжести течения и возраста ребенка.Материалы и методы. Под наблюдением были 172 ребенка в возрасте от 3 месяцев до 3 лет, находившихся на амбулаторном и стационарном лечении в детской городской больнице № 3 и городской клинической больнице № 9 им. проф. А.И. Минакова г. Одессы в период с июня 2012 г. по февраль 2014 г. Для скринингового обследования детей использовался рефлюкс-опросник. Также проводилось эндоскопическое исследование пищевода, позволяющее подтвердить наличие рефлюкс-эзофагита и оценить степень его тяжести. На следующем этапе проводился молекулярно-генетический анализ мутаций гена коллагена А3 на основе исследования ДНК клеток слизистой оболочки ротовой полости. Для подтверждения диагноза выполнялось рН-мониторирование пищевода. Статистический анализ полученных данных осуществлялся с использованием пакетов Statistica 7.0 и Microsoft Excel 2010 с интеграцией AtteStat 12.5, интернет-калькулятора SISA (Simple Interactive Statistical Analysis).Результаты и выводы. Этапная диагностика патологического ГЭР позволяет установить и подтвердить диагноз с минимальным использованием инвазивных методов. Использование рефлюкс-опросника способствует ранней диагностике патологического ГЭР и гастроэзофагеальной рефлюксной болезни у детей, дифференцированному подходу к использованию инвазивных методов исследования.

Современные аспекты диагностики и лечения рефрактерной гастроэзофагеальной рефлюксной болезни

Objective of the Review: To analyze current data on the diagnosis and treatment of refractory gastroesophageal reflux disease (GERD). Key points. Refractory GERD is diagnosed when there is insufficient response to proton pump inhibitors (PPIs) twice daily for 8 weeks with the presence of pathological gastroesophageal reflux. Possible mechanisms underlying PPI-refractory symptoms characteristic of GERD include persistence of pathological reflux, esophageal hypersensitivity to reflux, association of symptoms with other diseases, and functional nature of symptoms. To diagnose refractory GERD, a thorough analysis of symptoms, esophagogastroscopy with morphological examination, pH-impedancemetry and esophageal manometry are performed. Treatment includes dietary and lifestyle modifications to reduce body weight in obese patients, optimization of PPI prescribing, use of other drugs, and, if indicated, surgery. Conclusion. Diagnosing the reasons for the decrease in the effectiveness of PPIs in patients with GERD is a complex process that requires the use of modern endoscopic methods with the performance of a morphological study of the esophagus, pH-impedance testing and highresolution manometry to determine the nature of reflux, the relationship of reflux with symptoms of GERD and the differential diagnosis of various GERD syndromes. The choice of therapy for patients with refractory GERD is determined by the results of the examination and the final diagnosis. Keywords: refractory gastroesophageal reflux disease, proton pump inhibitors, diagnosis, treatment.

Результати добового моніторингу рівня пепсину в секреті ротової порожнини дітей раннього віку із синдромом регургітації

Regurgitation syndrome in infants is one of the manifestations of gastroesophageal reflux disease (GER), which can be both an age-related physiological condition and pathological one with the risk of gastroesophageal reflux disease (GERD) developing. Differential diagnosis of GERD in infants and young children is difficult due to invasiveness and low availability of the recommended diagnostic methods, in particular esophageal pH3metry. Today, the search for new non-invasive and simple, but sensitive and specific, methods for diagnosing GERD in pediatric practice is relevant and promising. Purpose — to determine the dynamic patterns of the salivary pepsin level in young children within the framework of daily monitoring and depending on the clinical manifestations of regurgitation. Materials and methods. 55 children from 3 to 18 months were examined, among them was 38 children with visible regurgitation syndrome and 17 healthy children without clinical manifestations of the regurgitation syndrome. The intensity of regurgitation was assessed using a five-point scale «ESPGHAN». A reflux questionnaire was used for screening diagnostics of pathological GER in children. Salivary pepsin level was determined three times a day by enzyme-linked immunosorbent assay (ELISA pepsin). Statistical processing was performed using «Statistica v.6.1» software package. Results. Regurgitation syndrome was registered in all children of the main group according to their current complaints. The results of reflux questionnaire showed the following data: half of the children (52.6%) had no signs of GER, possible reflux was revealed in 31.6% of children, and probable reflux was revealed in 15.8% of children. The results of daily monitoring of salivary pepsin level in infants showed that it was significantly higher in children with regurgitation than in control group, both in terms of average daily values and intermediate values. It was found that the maximum pepsin activity in children was immediately after regurgitation. There were no significant differences between the three saliva samples and the average daily pepsin index in the children of the main group, which may indicate the presence of latent episodes of reflux during the day. Сhildren with a high risk of GERD according to the reflux questionnaire had significantly higher values of salivary pepsin on an empty stomach and its average daily level, which has sufficient specificity and predictive value according to the ROC analysis results. Conclusions. Determination of salivary pepsin levels in infants can be included in screening noninvasive tests for the GER diagnosis. The use of these tests to predict the risk of extraesophageal damage requires further study. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: regurgitation, GER, GERD, pepsin, children.

Phenotyping patients with borderline elevated esophageal acid exposure.

Acid exposure time (AET) <4% on ambulatory reflux monitoring definitively rules out pathologic gastroesophageal acid reflux, while AET >6% indicates pathologic reflux per the Lyon Consensus, leaving AET of 4-6% as borderline. We aimed to elucidate the borderline AET population and identify metrics that could help differentiate this group. A total of 50 subjects in each group, AET <4, 4-6, and >6% on pH-impedance monitoring between 2015 and 2019, were retrospectively reviewed. In addition to demographic and clinical information, the extracted data included mean nocturnal baseline impedance (MNBI) on reflux study and high-resolution manometry (HRM) parameters and diagnosis. After excluding patients with prior foregut surgery, major esophageal motility disorder, or unreliable impedance testing, a total of 89 subjects were included in the analysis (25 with normal AET < 4%, 38 with borderline 4-6%, 26 with abnormal >6%). MNBI in borderline AET patients was significantly lower compared to normal AET (1607.7 vs. 2524.0 ohms, P < 0.01), and higher than abnormal AET (951.5 ohms, P < 0.01). Borderline subjects had a greater frequency of ineffective esophageal motility (IEM) diagnosis per Chicago classification v3.0 (42.1 vs. 8.0%, P = 0.01), but did not demonstrate any differences compared to abnormal subjects (34.6%, P = 0.56). Patients with borderline AET had an average MNBI that was in between normal AET and abnormal AET. Borderline AET patients also commonly demonstrate IEM on HRM, similar to those with abnormal AET. Our findings can be potentially useful in assigning higher clinical significance for patients found to have borderline AET with concomitant low MNBI and IEM on manometry.