Physiological Reflux Research Articles

Surgical treatment of Gastroesophageal Reflux disease: yesterday and today

Gastroesophageal reflux disease (GERD) is a set of signs and symptoms and changes resulting from pathological backward flow of gastric or intestinal contents to the esophagus. Reflux of gastric contents occurs periodically in all people during a 24-hour period. Therefore physiological reflux of gastric contents that does not cause any complaints or histopathological changes in the esophagus should be differentiated from gastroesophageal reflux disease that results in subjective complaints or its complications confirmed by diagnostic methods. Prevalence of gastroesophageal reflux disease is difficult to estimate, however it is believed to occur in 0.35 to 2% of the whole population (1). Before a decision is taken to proceed with surgical treatment, detailed diagnostic workup of causes of pathological gastroesophageal reflux is required and the strategy of surgical treatment should be based on three basic principles: alleviation of typical subjective complaints, healing and prevention of recurrences of reflux injury of the esophageal mucosa and prevention of possible complications of the long standing disease such as bleeding, ulceration and esophageal stricture, aspiration pneumonia and intestinal metaplasia. Approach of surgeons to pathogenesis of esophageal ulcerations changed since Quincke reported for the first time three cases of this condition in 1879. Quincke concluded that similar macroscopic nature of esophageal ulcers and gastric ulcers and close anatomical proximity indicated that reflux of gastric juice into the esophagus could be the cause of “ulcer ex digestion”. In 1906 Tileston presented a similar concept, on the basis of examination of 41 cases of esophageal ulcerations, supporting his concept with Albert’s publications from 1839. In 1946 Allison presented a new disease entity – “peptic oesophagitis”. He reported it on the basis of clinical signs and symptoms and radiographic picture. He concluded that abnormal reflux of gastric juice through abnormal cardia is a pathological factor of the new disease. However Barret in 1950 suggested a new term for the disease reported by Allison – reflux esophagitis that was to reflect relationship between esophagitis and the disease etiological factor. A paper published in 1988 allowed us to understand a role of individual anatomical factors of so called anti-reflux mechanism, protecting against pathological gastroesophageal reflux. Further progress in the understanding of gastroesophageal reflux was associated with development of diagnostic methods used to diagnose gastroesophageal reflux and its consequences. In 1926 Robin and Jankelson were the first to demonstrate gastroesophageal reflux using a radiological study (2-8). Detailed assessment of gastroesophageal reflux and development of knowledge about pathogenesis of reflux esophagitis facilitated progress in implementation of new methods of surgical treatment of this disease. In 1919 Soeresi was the first to perform an operation

Patients with physiological acid exposure and positive symptom association scores: a distinct group within the GORD spectrum

Studies comparing pH-metrically well-characterized gastro-oesophageal reflux disease (GORD) patients with physiological reflux to GORD patients with pathological reflux, with regard to clinical and epidemiological data, are lacking. We included 273 GORD patients with pathological 24-h pH-monitoring (pH+), defined as pH<4 > or = 6% of time. A symptom index (SI) > or = 50% was considered positive, as well as a symptom association probability (SAP) > or = 95%. We included 84 GORD patients with physiological acid exposure (pH-) and a positive SI and/or SAP. Manometry and endoscopy reports were reviewed. Subjects completed questionnaires about demographics and medical history, functional dyspepsia and irritable bowel syndrome, the Nepean Dyspepsia Index symptom score and the RAND-36 quality of life scale. pH- patients were younger (45 vs 50 years, P = 0.003), more often female (60%vs 39%, P = 0.001), smoked more (31%vs 19%, P = 0.021) and reported proton pump inhibition failure more often (47%vs 32%, P = 0.027). A hypotensive lower oesophageal sphincter was less common in pH- patients (18%vs 34%, P = 0.008) and distal oesophageal contraction amplitude was higher (11 vs 9.5 kPa, P = 0.045). pH- patients had hiatal hernia and oesophagitis less often (48%vs 73%, P < 0.0005; 36%vs 54%, P = 0.012 respectively). pH- patients less often reported no other symptoms besides GORD (20%vs 34%, P = 0.015). pH- patients scored worse at the Nepean (reflux 19 vs 12 out of 39, P < 0.0005; dyspepsia 54 vs 38 out of 156, P < 0.0005). In the subgroup of patients who have physiological oesophageal acid exposure the enhancement of the perceived symptom burden appears to be the most important mechanism in GORD pathogenesis.

S1900 EGJ pH Mapping: A Novel Model for Esophageal pH Monitoring Not Preceded By Lower Esophageal Sphincter Manometry

There are patients with reflux symptoms who have physiologic acid reflux and positive index symptom (PSI). By pH-multichannel intraluminal impedance (pH-MII) it is possible to detect abnormal non-acid gastro esophageal reflux, this reflux can explain the presence of symptoms and might allow us to classify the patients as carriers of gastroesophageal reflux disease, even if they have physiologic acid reflux. Our objective was to investigate characteristics of esophageal pH-MII in patients with physiologic acid reflux and PSI and to know how often non acid reflux is related to PIS. Cross-sectional study in adults whose results of pH-MII showed physiologic acid reflux and PSI.Divided into two groups: physiologic acid reflux and PSI and physiologic acid reflux and negative symptoms index (NSI).We analyzed DeMeester score, 24 hours acid exposure, total time of exposure to acid bolus, upright and recumbent exposure to acid bolus, total number of non-acid reflux events and, symptoms index for acid and non-acid reflux. For comparison between groups we used U Mann-Withney Test and for the analysis of proportions X2. Results:We included 50 patients. In group A there were 29 patients with a mean 24 hours acid exposure of 1.71% (0-5%), DeMeester score 5.2 (0.8-14.6). The total time of exposure to acid bolus, upright and recumbent exposures to acid bolus were 8 min (1%), 9.7min (1.7%) and 1.7 min (0.26%).In these patients total number of reflux events had a mean of 57.89 (16-182) of which, 24.04 (1-55) and 16 (1-160) were acid and nonacid respectively. In this group 62% (18) had PSI to acid reflux, 27.5% (8) PSI to non-acid reflux and, 10.3% (3) PSI to both. In group B there were 21 patients with a mean 24 hours acid exposure of 0.78% (0-3.6%), DeMeester Score 2.7 (0.8-11.8) and total number of reflux events of 32.2 (3-91) of which, 12.81 (150) and 12(0-77) were acid and nonacid respectively. The total time of exposure to acid bolus, upright and recumbent exposures to acid bolus were 3 min (0.41%), 3.5 min (0.67%), 0.6 (0.13%) respectively. In total there were 7 patients with more than 73 episodes of reflux in 24 hours, 4 in group A and 3 in group B respectively. When both groups were compared there were higher values of 24 hours acid exposure, DeMeester score, total and upright exposure to acid bolus in group A (p=0.002). Conclusions: We found that only in 27.5% of patients with physiologic acid reflux the presence of non acid reflux is related to symptoms.That means acid is still responsible for symptoms in the remaining patients.

Risks of proton‐pump inhibitors: what every doctor should know

Medical Journal of AustraliaVolume 190, Issue 3 p. 109-110 Editorial Risks of proton-pump inhibitors: what every doctor should know Nicholas J Talley MD, PhD, FRACP, Corresponding Author Nicholas J Talley MD, PhD, FRACP Professor of Medicine and Epidemiology, and Chair of Department of Medicine talley.nicholas@mayo.edu Mayo Clinic, Jacksonville, Fla, USA.Correspondence: talley.nicholas@mayo.eduSearch for more papers by this author Nicholas J Talley MD, PhD, FRACP, Corresponding Author Nicholas J Talley MD, PhD, FRACP Professor of Medicine and Epidemiology, and Chair of Department of Medicine talley.nicholas@mayo.edu Mayo Clinic, Jacksonville, Fla, USA.Correspondence: talley.nicholas@mayo.eduSearch for more papers by this author First published: 02 February 2009 https://doi.org/10.5694/j.1326-5377.2009.tb02305.xCitations: 10Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume190, Issue3February 2009Pages 109-110 RelatedInformation

Regurgitation in healthy and non healthy infants.

Uncomplicate regurgitation in otherwise healthy infants is not a disease. It consists of milk flow from mouth during or after feeding. Common causes include overfeeding, air swallowed during feeding, crying or coughing; physical exam is normal and weight gain is adequate. History and physical exam are diagnostic, and conservative therapy is recommended. Pathologic gastroesophageal reflux or gastroesophageal reflux disease refers to infants with regurgitation and vomiting associated with poor weight gain, respiratory symptoms, esophagitis. Reflux episodes occur most often during transient relaxations of the lower esophageal sphincter unaccompanied by swallowing, which permit gastric content to flow into the esophagus. A minor proportion of reflux episodes occurs when the lower esophageal sphincter fails to increase pressure during a sudden increase in intraabdominal pressure or when lower esophageal sphincter resting pressure is chronically reduced. Alterations in several protective mechanisms allow physiologic reflux to become gastroesophageal reflux disease; diagnostic approach is both clinical and instrumental: radiological series are useful to exclude anatomic abnormalities; pH-testing evaluates the quantity, frequency and duration of the acid reflux episodes; endoscopy and biopsy are performed in the case of esophagitis. Therapy with H2 receptor antagonists and proton pump inhibitors are suggested.

American Gastroenterological Association Institute Technical Review on the Management of Gastroesophageal Reflux Disease

American Gastroenterological Association Institute Technical Review on the Management of Gastroesophageal Reflux Disease

Gastroesophageal Reflux: Are There Differences of Characteristic in Infants and Children

Background: Gastroesophageal reflux (GER) is an involuntary passage of gastric contents into the esophagus. GER in infancy is usually a physiologic reflux whereas GER in children more than 12 months old is often considered as a pathologic reflux although without any clinical complications. This consideration may lead over-treatment of GER in children. The objective of this study was to find out the difference of GER characteristic in ‘healthy’ infants and children. Method: Cross sectional study in children age 0-36 months at Cipto Mangunkusumo Hospital Jakarta during 2005-2007 with inclusion criteria: clinically healthy, regurgitations/vomits ³ 4 times/day, well nourished and other etiologies of vomiting had been excluded. The characteristic of GER was evaluated by esophageal pH monitoring (pH-metri) included number of reflux episodes, reflux duration > 5 minutes, and reflux index. Results: Sixty children were enrolled in the study; consisting 30 infants (age 0-12 months) and 30 children (age 13-36 months). The median number of reflux in infants was 18 ( range1-19), whereas the median in children was 17 (range 3-27) ( p = 0.47). The median number of reflux > 5 minutes was 2 (range 0-2), whereas the median in children was 3 (0-30) (p = 0.85). The median reflux index in infants was 4.5% (range 0.6%-22.9%) whereas the median in children was 6.35% (0.1%-87.%) (p = 0.34). Conclusion: The characteristic of GER in ‘healthy’ infants and children were not significantly different; however reflux index > 5% (pathologic GER) was seen in children age 13-36 months. Clinical course monitoring are important in infants and children with GER. Keywords: gastroesophageal reflux, regurgitation, infant, children, pH monitoring

Physiological duodenogastric reflux in young healthy adults

Physiological duodenogastric reflux in young healthy adults

Normal Ambulatory 24-Hour Esophageal pH Values in Koreans -A Multicenter Study-

Ambulatory 24-hr esophageal pH monitoring is considered the gold standard for diagnosing gastroesophageal reflux disease. The aim of this study was to establish normal values for gastroesophageal acid exposure in healthy Koreans. Fifty healthy volunteers (24 males and 26 females; mean age, 45 yr) without reflux symptoms and without reflux esophagitis or hiatal hernia on upper endoscopy underwent ambulatory 24-hr esophageal pH monitoring after esophageal manometry. The 95th percentiles for the reflux parameters were: the percent total time pH <4, 3.7%; the percent upright time pH <4, 5.7%; the percent supine time pH <4, 1.0%; the number of reflux episodes with pH <4, 76.5; the number of reflux episodes with pH <4 for >5 min, 1.5; the duration of the longest episode, 12.5 min; and the composite score, 14.2. Age and gender were not associated with any of the pH parameters. In conclusion, physiological gastroesophageal reflux occurs in healthy Koreans. These normal esophageal pH values will provide reference data for clinical and research studies in Korea.

Authors' Response to Letter

To the Editor: We thank Dr Indrio and colleagues for their letter, which makes a number of salient points in reference to our manuscript on the effects of omeprazole in premature neonates with pathological esophageal acid exposure (1). We begin by reiterating that the principal aim of our study was to assess the safety and efficacy of omeprazole for the reduction of acid gastroesophageal reflux in premature infants with gastroesophageal reflux disease (GERD). Indrio et al correctly point out that the appropriateness or otherwise of the cutoff criteria of reflux index >5% to indicate pathological esophageal acid exposure is a matter of conjecture. Most pediatric centres would routinely use 5%; however, a fair reading of the limited literature that reports 24-hour pH studies in healthy infants indicates that higher cutoff criteria of 10% may be more appropriate. It is, however, not true that 8 of the infants enrolled in our study had a reflux index of between 5% and 7%. As our Figure 1 clearly shows, 7 of the 10 infants had a reflux index >10% on placebo, with 3 >20% (average 19% overall). Hence, measured acid exposure off-therapy was highly significant and not equivocal. When on proton pump inhibitor (PPI) therapy, the reflux index was reduced to ≤5% in 9 of the 10 infants (average, 4.9%). We, therefore, demonstrated that a once-daily dose of 0.7 mg/kg omperazole “normalised” the reflux index, the precise criteria applied had no impact on this major finding or the conclusions drawn from this study. The lack of symptomatic improvement, despite normalisation of esophageal acid exposure levels, was both disappointing and counterintuitive. We reiterate that this negative finding needs to be treated with caution due to limitations in the study design related to the accuracy of recording of symptomatic episodes and the 1-week treatment period which may have been too short. We do not believe the lack of symptomatic change relates to our specific diagnostic criteria because stratification of our patients, based on severity of esophageal acid exposure on placebo and/or magnitude of change in esophageal acid exposure with therapy, still failed to show significant symptomatic changes. We do not agree with the suggestion that the lack of a clinical response to omeprazole may have related to age at the time of study and whether our patients were technically preterm or term. The postmenstrual age of our patients ranged from 34 to 40 weeks, and the suggestion that specific reflux index criteria be developed across this age range seems futile given the high level of variability in this parameter. This is due to a number of factors that may influence the reflux index including feed type, feed frequency and volume, nasogastric tube placement, and xanthine therapy. Indeed, this highlights yet another limitation of reflux index as a diagnostic parameter. The most obvious explanation for the lack of symptomatic response relates to the fact that a “proven” association of symptoms with gastroesophageal reflux episodes was not a selection criterion. GERD in infants is a complex disorder due to the range of clinical presentations, and the causal relationship between significant acid exposure and clinical symptoms is often difficult to prove. Rather than relying on measurement of acid exposure based on arbitrary reflux index criteria, the ability to demonstrate a temporal association between individual reflux events and the onset of symptomatic episodes would, in our view, be more diagnostically useful. Intraluminal pH-impedance monitoring allows detection of all reflux independently of pH and, as already demonstrated in adults on and off PPI therapy, improves the accuracy of reflux-symptom associations (2,3). Similar studies in infants have yet to be published; however, given the increased prevalence of nonacid bolus reflux in infants due to frequent milk/formula feeding, it is our expectation that pH-impedance monitoring will improve the diagnostic yield over and above pH monitoring alone. The present lack of appropriate diagnostic tests for infants presenting with putative gastroesophageal reflux–related symptoms is contributing to the global expansion of empirical use of PPI in infants 0 to 6 months of age. This is despite the prevalence of so-called physiological reflux in this age group and the paucity of clear evidence-based guidance on appropriate dosing levels to achieve normalisation of acid exposure and clinical efficacy for reflux-related symptoms. Our study addresses the former with respect to the drug omeprazole; however, other PPIs need to be similarly tested. There is an urgent need to address the latter issue of clinical efficacy by way of randomised controlled trials. These trials must link PPI therapy with symptomatic improvement in patients specifically selected based on symptomatic, rather than pH-based, criteria. We would encourage all of those working in this field to take up this important challenge.

Endolaparoscopic Approach in the Management of Gastroesophageal Reflux Disease: An Experimental Study in Pigs

Chronic reflux of gastric content to the esophagus causes retrosternal burning, pain, and regurgitation, and results in histopathologic changes that may culminate in adenocarcinoma. Insufficiency of the lower esophageal sphincter and hiatal hernia are the two principal causative factors. In this paper, we present the early results of a new antireflux operation in pigs. The status of physiologic reflux was determined in 5 pigs (approximately 40-45 kg) with 24-hour pH monitorization. Under endoscopic guidance, a trocar was inserted into the stomach (similar to the percutaneous endoscopic gastrostomy technique). The endoscope was put into the retroflexed position; a mucomuscular pursestring suture was placed around the endoscope at the cardia and tied. Ten days later, pH monitorization was repeated to evaluate the effectiveness of the method. Late postoperative results have been reevaluated by 24-hour pH monitorization in the sixth month. The procedure achieved statistically significant improvements in total reflux time, number of reflux periods, number of long reflux periods, the longest reflux period, and the DeMeester score. The preoperative and postoperative DeMeester scores of the individual animals were 179.24-0.94, 11.48-0.98, 68.4-3.74, 132.2-46.49, and 38.72-5.86, respectively. Even though there appeared to be a slight increase in the pH monitorization levels after 6 months, these results did not reach significant degrees, and compared to the physiological reflux, the results were remarkable. The results obtained showed considerable decreases in physiologic reflux in all animals. We believe that this endoluminal, laparoendoscopic operation can be used in the treatment of gastroesophageal reflux disease as a minimally invasive method.

Otologic findings in children with gastroesophageal reflux

Nearly 90-95% of children with drool have physiologic gastroesophageal reflux (GER) that usually resolves by 12-15 months of age; however, 5-10% of children with drool have pathologic GER. Of these children, most recover clinically by 18 months of age without therapy, yet 10% develop chronic, recurrent gastroesophageal reflux disease (GERD) with sequelae. The respiratory symptoms associated with GER consist mainly of bronchial asthma and laryngospasm, but often include a persistent cough of unknown aetiology, obstructive apnoea, and an obstructive respiratory syndrome confined to the nasopharynx. Gastric acid reflux, enters the adenoids, causes oedema of the tubal orifices, and later leads to relapsing diseases of the middle ear in children. To evaluate the incidence of otologic manifestations in children with GER and the efficacy of treatment, comparing two different groups of children (i.e., treated versus untreated). From January 2005 to November 2006, audiologic screening of newborns and suckling children (0-24 months of age) at risk for auditory illnesses was held at the University Department of Otolaryngology in Catania. Seventy-three children (average age, 13 months) were selected after failing acoustic otoemissions for chronic bilateral catarrhal pathology involving the middle ear (tympanometry type B) and were positive for at least one of the different signs of GER at the time of history-taking. The children were randomised and subdivided into two groups: (1) a group of 40 children (27 females and 13 males; average age, 12 months) who received treatment; and (2) a group of 29 children (16 males and 13 females; average age, 14 months) who did not receive treatment. Four children were lost to follow-up after completing the study. All children enrolled in the study underwent a rhinopharynxlaryngeal fibroscopy with flexible optics, a gastric ultrasound scan after clinical observation, and a multi-channel pH-metry for 18-24h. Findings obtained by rhinopharynxlaryngeal fibroscopy showed that 82% of cases had diffuse hyperaemia involving the entire rhinopharyngeal mucosa and 13% of the cases had arytenoidal hyperaemia. Resolution and improvement of the reflux occurred in 52.5 and 40% of the cases in the treated group, respectively, versus complete resolution and an improvement in symptoms of 45 and 30% of cases, respectively, in the control group. The hypothesis of a correlation between reflux and chronic middle otitis of the serous-mucous type was confirmed in the present study. Adopting a preventive treatment strategy may be useful in reducing the possibility of ear involvement.

Review article: update on gastro-oesophageal reflux disease in children

It is critical for the clinician who cares for children to distinguish between normal physiological gastro-oesophageal reflux (GER), and signs and symptoms that occur due to the persistent reflux, defined as gastro-oesophageal reflux disease (GERD). The underlying natural history of physiological GER in the paediatric population up to about 12 years of age, is quite distinct from normal reflux in adults. Conversely, the underlying pathophysiology of GERD in both age groups is for the most part similar. Regurgitation symptoms, which peak by 4-6 months of age, appear to resolve commonly by 12-18 months of life. However, there is a growing body of evidence that demonstrates that GERD may not be outgrown in a subset of children. In practice, many clinicians include an empiric therapeutic trial of an H 2 receptor antagonist (H 2 RA) or proton pump inhibitor accompanied by symptom resolution for the diagnosis of GERD. GERD-associated symptoms in the paediatric population range from regurgitation, often accompanied by arching and irritability, to feeding refusal, and/or poor growth to respiratory symptoms such as nocturnal and/or chronic cough. Upper endoscopy with biopsy may be useful in documenting the presence and severity of macroscopic and microscopic mucosal abnormalities, as well as excluding other disorders such as eosinophilic oesophagitis. Conservative management, particularly useful in mild GERD, consists of positioning during and after feeds, a 2- to 4-week trial of hydrolysate formula, addition of cereal to formula, and smaller, more frequent feeds. Among the current pharmacotherapeutic options available in the United States (US), the prokinetic agent metaclopramide and the acid-inhibitory agents (H 2 RAS, proton pump inhibitors) are the most widely prescribed. Numerous clinical investigations in both adults and children demonstrated that the proton pump inhibitors are more effective than the H 2 RAS in the relief of GERD symptoms and healing of erosive oesophagitis. The safety profile of the proton pump inhibitors in children is excellent with no significant adverse events observed either in the short- or long-term (>5.5 years continuous use). Finally, surgical procedures for GERD may also be indicated in certain circumstances.

Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease is the most common and expensive digestive disease with complex and multi-factorial pathophysiologic mechanisms. Transient inappropriate relaxation of the lower esophageal sphincter is the predominant mechanism in the majority of patients with mild to moderate disease. Hiatal hernias and a reduced lower esophageal sphincter pressure have a significant role in patients with moderate to severe disease. Typical manifestations of gastroesophageal reflux disease include heartburn, regurgitation, and dysphagia. Atypical symptoms, such as noncardiac chest pain, pulmonary manifestations of asthma, cough, aspiration pneumonia, or ENT manifestations of globus and laryngitis, can be seen in patients with or without typical symptoms of gastroesophageal reflux disease. Endoscopy and ambulatory pH tests are best to evaluate the anatomic and physiologic impact ofgastroesophageal reflux disease. Complications of chronic gastroesophageal reflux disease include peptic strictures and Barrett metaplasia. Barrett esophagus is a major risk factor for esophageal adenocarcinoma, and upper endoscopy with surveillance biopsies is recommended for patients with Barrett esophagus. Medical therapy with anti-secretory agents (H2 blockers and proton pump inhibitors) is effective for most patients with gastroesophageal reflux disease. Surgical fundoplications and endoscopic treatment modalities are mechanical treatment options for patients with gastroesophageal reflux disease.

A Prospective Study of Gastric Acid Analysis and Esophageal Acid Exposure in Patients with Gastroesophageal Reflux Refractory to Medical Therapy

A number of factors have been proposed to account for the lack of response to medical therapy in patients with gastroesophageal reflux; however, no controlled studies are available in the literature. The goal of this study was to determine possible causes of medical refractoriness in patients with gastroesophageal reflux. Gastric acid output and esophageal acid exposure were measured in patients who continue to have reflux symptoms despite aggressive antisecretory therapy. In addition, an upper endoscopy was also performed in each patient. Patients with a drug-controlled acid output < 1 mEq/hr and a supine total esophageal pH < 4 for less than 1.7% of the time measured were considered responsive to therapy; on the other hand, those with a drug-controlled gastric acid output > 1 mEq/hr and a supine esophageal pH < 4 for more than 1.7% of the time measured were considered resistant to therapy. Twenty-four patients met the inclusion criteria (13 male and 11 female; mean age, 52). Drug-controlled gastric acid output was more than 1 mEq/hr in 25% of patients and less than 1 mEq/hr in the remainder. Of those patients with a gastric acid output of less than 1 mEq/hr (18 patients), 8(44%) had a supine esophageal pH < 4 for more than 1.7% of the time, suggesting that factors other than gastroesophageal reflux likely contributed to their reflux-like symptoms. Acid suppression appears adequate in the majority of patients with gastroesophageal reflux refractory to medical therapy. The exact cause of persistent reflux-like symptoms in patients who fail medical treatment is uncertain but may be related to non-acid-related factors such as esophageal hypersensitivity to physiologic reflux, increased intake of air resulting in aerophagia, or other factors such as bile reflux.

Gastroesophageal Reflux Disease in Infants: How Much is Predictable with Questionnaires, pH-metry, Endoscopy and Histology?

Symptoms of gastroesophageal reflux disease (GERD) are common in infants. It is often difficult to discriminate between physiological and pathologic gastroesophageal reflux, although this discrimination is essential to determine which infants to evaluate and treat. To identify the prevalence of reflux symptoms in infants and to evaluate the predictive value of a questionnaire and the correlation between pH study, histology and clinical score. Parents of 100 unselected infants visiting the well-baby clinic and 100 infants suspected of having gastroesophageal reflux disease were asked to fill in a 35-item questionnaire. A validated score, the Orenstein I-GERQ, was applied for selected questions. All infants suspected of having gastroesophageal reflux disease underwent prolonged esophageal pH monitoring and 44 or 100 underwent upper gastrointestinal tract endoscopy with esophageal biopsy. Parents of infants with suspected gastroesophageal reflux disease reported significantly more regurgitation (68% versus 45%, P < 0.05) and crying (51% versus 20%, P < 0.01) compared with the parents of healthy infants. A pathologic pH study (reflux index > 10%) was found in 21 of 100 (21%) infants and was significantly associated only with pneumonia, apnea with fussing (P = 0.013 for both), defecation less than once a day (P = 0.033) and constipation (P = 0.05). Esophagitis was present in 17 of 44 (39%) and no one question was found to be significantly predictive. 38% of infants with a pathologic pH study had a normal esophageal biopsy and 53% of infants with histologic esophagitis had a normal pH study. Discordance between pH study and biopsies occurred in 14 of 44 (32%) patients. The Orenstein I-GERQ cut-off score failed to identify eight of 31 (26%) infants with gastroesophageal reflux disease. Conversely, the score was positive in 17 of 22 (81%) infants with normal biopsy and pH study and in 14 of 47 (30%) infants with normal pH study. Clinical symptoms, histology and pH study show poor correlation in infants. Clinical symptoms such as regurgitation and crying are less frequent in unselected infants than in infants suspected of gastroesophageal reflux disease. However, questionnaires are poorly predictive for the severity of gastroesophageal reflux disease, as they do not correlate with esophageal acid exposure as measured by pH-metry and with esophagitis as evaluated by histology of esophageal biopsies.

Gastroesophageal Reflux Disease in Infants: How Much is Predictable with Questionnaires, pH‐metry, Endoscopy and Histology?

ABSTRACTSymptoms of gastroesophageal reflux disease (GERD) are common in infants. It is often difficult to discriminate between physiological and pathologic gastroesophageal reflux, although this discrimination is essential to determine which infants to evaluate and treat.Objectives:To identify the prevalence of reflux symptoms in infants and to evaluate the predictive value of a questionnaire and the correlation between pH study, histology and clinical score.Methods:Parents of 100 unselected infants visiting the well‐baby clinic and 100 infants suspected of having gastroesophageal reflux disease were asked to fill in a 35‐item questionnaire. A validated score, the Orenstein I‐GERQ, was applied for selected questions. All infants suspected of having gastroesophageal reflux disease underwent prolonged esophageal pH monitoring and 44 or 100 underwent upper gastrointestinal tract endoscopy with esophageal biopsy.Results:Parents of infants with suspected gastroesophageal reflux disease reported significantly more regurgitation (68% versus 45%, P &lt; 0.05) and crying (51% versus 20%, P &lt; 0.01) compared with the parents of healthy infants. A pathologic pH study (reflux index &gt; 10%) was found in 21 of 100 (21%) infants and was significantly associated only with pneumonia, apnea with fussing (P = 0.013 for both), defecation less than once a day (P = 0.033) and constipation (P = 0.05). Esophagitis was present in 17 of 44 (39%) and no one question was found to be significantly predictive. 38% of infants with a pathologic pH study had a normal esophageal biopsy and 53% of infants with histologic esophagitis had a normal pH study. Discordance between pH study and biopsies occurred in 14 of 44 (32%) patients. The Orenstein I‐GERQ cut‐off score failed to identify eight of 31 (26%) infants with gastroesophageal reflux disease. Conversely, the score was positive in 17 of 22 (81%) infants with normal biopsy and pH study and in 14 of 47 (30%) infants with normal pH study.Conclusions:Clinical symptoms, histology and pH study show poor correlation in infants. Clinical symptoms such as regurgitation and crying are less frequent in unselected infants than in infants suspected of gastroesophageal reflux disease. However, questionnaires are poorly predictive for the severity of gastroesophageal reflux disease, as they do not correlate with esophageal acid exposure as measured by pH‐metry and with esophagitis as evaluated by histology of esophageal biopsies.

Functional and Morphological Criteria of Internal Jugular Valve Insufficiency as Assessed by Ultrasound

Jugular venous valve insufficiency may play a role in different neurological diseases. This study describes the methodology to detect internal jugular valve insufficiency and establishes functional and morphological criteria to discriminate retrograde flow during valve closure from retro grade insufficiency flow. Valve closure was assessed in 100 valves (50 healthy volunteers). The valves were visualized in B-mode. During a pressure-controlled Valsalva maneuver, valve closure was monitored by color duplex. The duration and the peak velocity of retrograde flow were determined. Backward flow during valve closure in competent valves was visually clearly discernible from a retrograde flow jet through insufficient valves. Insufficiency was found in 29% of valves. The duration of backward flow in competent valves was between 0.22 and 0.78 seconds (mean = 0.46 +/- 0.14 seconds on Doppler measurements) and in insufficient valves between 1.23 and 6.15 seconds (mean = 2.66 +/- 1.28; P < .0001). Peak velocity of retrograde flow in competent valves was between 12 and 65 cm/s (mean = 26.2 +/- 11.1 cm/s) and between 25 and 160 cm/s (mean = 89.5 +/- 39.3 cm/s; P < .0001) in insufficient valves. On B-mode imaging, the "typical" aspect of an immobile, frozen valve was seen only in 5 cases of insufficient valves; 21 insufficient valves did not display this aspect. The duration of retrograde flow clearly discriminates competent and incompetent valves. On the basis of our results, we provide cut off values that help differentiate between physiological and insufficiency reflux. The differences in peak velocity and morphology criteria are helpful but not reliable to predict insufficiency of the valve.

Antireflux therapy--more than acid reduction?

Because gastroesophageal reflux disease (GERD) is a motility disorder, acid reduction with proton pump inhibitors (PPI) remains a symptomatic therapy with a recurrence rate of over 90% after discontinuation of acid suppression. This "therapeutic dilemma" becomes obvious in patients not responding sufficiently to the conventional medication (therapy resistance, necessity of high PPI doses, volume reflux). In this manuscript we analyze additional factors that may play a role in the pathogenesis and interpretation of GERD. These additional factors include gastroesophageal motility and esophageal barrier functions as well as duodenogastroesophageal reflux and Helicobacter pylori infection. In addition, basic problems in interpretation of therapeutic success such as placebo effect, spontaneous remission of GERD, the role of sensory function and subjective interpretation of symptoms and the overlap between physiological and pathological reflux as well as functional disorders will be discussed.

Laryngopharyngeal Reflux: Trends in Diagnostic Interpretation Criteria

Laryngopharyngeal reflux (LPR) is becoming recognized as a clinical entity with a variety of presentations distinct from those of gastroesophreflux disease (GERD). However, much uncertainty remains as to what is considered pathologic versus physiologic reflux. The aim of the study was to determine the normal range of pharyngeal reflux (PR) occurring in healthy adults based on pH-monitoring parameters utilized in the DeMeester scoring system for GERD. We have reviewed the current pool of prospective literature examining ambulatory dual-channel pH-monitoring study data derived from hypopharyngeal proximal probes in normal adults. From our review we have identified trends in several monitoring parameters based on the DeMeester scoring system for GERD. Our discussion recognizes and accepts the limitations imposed by small sample sizes and the number of healthy individuals that would be required to determine the general adult physiologic range of PR. We also explore the possible need for separate normal PR reference intervals based on age or gender disparities. Additional discussion and the summary address future directions for LPR research notably, (1) identification of the most appropriate research paradigm for LPR (i.e., pH 4 vs. 5), (2) establishing reproducibility for the appropriate LPR research paradigm, and (3) complementary modalities to ambulatory dual-channel pH monitoring for the study of acid and nonacid bolus movement within the esophagus