Association Of Reflux Research Articles

Distribution patterns of pathological venous reflux and risk factors in patients with skin changes due to primary venous disease in North India.

To determine the distribution patterns of pathological venous reflux and risk factors in patients with skin changes due to primary venous disease. Two hundred limbs belonging to C4, C5 & C6 classes were examined with duplex ultrasound to determine the sites of reflux. We also analyzed the correlation of risk factors with patterns and severity of disease. Among 200 limbs, superficial system reflux was found in 163 limbs (81.5%), deep system reflux in 10 limbs (5%) and perforator system reflux in 180 limbs (90%). The most common pattern of abnormality was combined superficial and perforator system reflux. Of all the risk factors, prolonged standing, obesity and in the female history of pregnancy preceding varicose occurrence had the highest prevalence. In patients with primary chronic venous disease, lifestyle modification is required to avoid risk associated with obesity and prolonged standing. The higher prevalence of pathological perforator reflux in association with advanced venous disease necessitates careful treatment of this least reported pathology to achieve better treatment results.

Prevalence of Urinary Tract Infection and Vesicoureteral Reflux in Children with Lower Urinary Tract Dysfunction

Lower urinary tract dysfunction is a common pediatric urological problem that is often associated with urinary tract infection. We determined the prevalence of a urinary tract infection history in children with lower urinary tract dysfunction and its association, if any, with gender, bowel dysfunction, vesicoureteral reflux and specific lower urinary tract conditions. We retrospectively reviewed the charts of children diagnosed with and treated for lower urinary tract dysfunction, noting a history of urinary tract infection with or without fever, gender, bowel dysfunction and vesicoureteral reflux in association with specific lower urinary tract conditions. Of the 257 boys and 366 girls with a mean age of 9.1 years 207 (33%) had a urinary tract infection history, including 88 with at least 1 febrile infection. A total of 64 patients underwent voiding cystourethrogram/videourodynamics, which revealed reflux in 44 (69%). In 119 of the 207 patients all infections were afebrile and 18 underwent voiding cystourethrogram/videourodynamics, which revealed reflux in 5 (28%). A urinary tract infection history was noted in 53% of girls but only 5% of boys (p <0.001). Patients with detrusor underutilization disorder were statistically more likely to present with an infection history than patients with idiopathic detrusor overactivity disorder or primary bladder neck dysfunction (each p <0.01). Females with lower urinary tract dysfunction have a much higher urinary tract infection incidence than males. This association was most often noted for lower urinary tract conditions in which urinary stasis occurs, including detrusor underutilization disorder and dysfunctional voiding. Reflux was found in most girls with a history of febrile infections. Since reflux was identified in more than a quarter of girls with only afebrile infections who were evaluated for reflux, it may be reasonable to perform voiding cystourethrogram or videourodynamics in some of them to identify reflux.

Editorial Comment

Lower urinary tract dysfunction with primary vesicoureteral reflux is recognized as a major risk factor for recurrent urinary tract infection, 1 Dias C.S. Silvia J.M. Diniz J.S. et al. Risk factors for recurrent urinary tract infections in a cohort of patients with primary vesicoureteral reflux. Pediatr Infect Dis J. 2010; 29: 2139-2144 Crossref Scopus (39) Google Scholar as well as for failure of open or endoscopic surgery. The authors outline their experience with endoscopic treatment of vesicoureteral reflux in a select group of children with symptoms of overactive bladder (OAB)—urgency or urge incontinence. All patients were toilet trained at diagnosis and had initially received a course of behavior modification, with anticholinergic medication in some cases, and 10% had failed previous dextranomer (Dx)/hyaluronic acid (HA) injection. Using the hydrodistension injection technique method, the overall success rate was commendable at 83%. The authors injected an 18% greater volume of Dx/HA in those children whose OAB symptoms were ongoing at endoscopic surgery and achieved a marginally greater (+8.7%) success rate, on early postoperative voiding cystourethrogram (VCUG) at 6-12 weeks, compared to those whose OAB symptoms had been eradicated preoperatively. After successful Dx/HA injection, the incidence of urinary tract infection was low, and 40% of the children with preoperative well-controlled OAB returned to normal voiding patterns. Is Endoscopic Injection Therapy a Reasonable Treatment Option for Low-grade Vesicoureteral Reflux in Association With Overactive Bladder?UrologyVol. 78Issue 3PreviewTo assess the clinical outcome of endoscopic injection in children with vesicoureteral reflux (VUR) and concomittant overactive bladder (OAB). Full-Text PDF ReplyUrologyVol. 78Issue 3PreviewWe agree that our study carries some limitations, including the lack of urodynamic data and objective criteria for categorizing the voiding symptoms and overactive bladder (OAB). Given our study's retrospective nature, our analysis was dependent on the information available from the chart review. Full-Text PDF

Is Endoscopic Injection Therapy a Reasonable Treatment Option for Low-grade Vesicoureteral Reflux in Association With Overactive Bladder?

To assess the clinical outcome of endoscopic injection in children with vesicoureteral reflux (VUR) and concomittant overactive bladder (OAB). A total of 41 patients with VUR and OAB underwent endoscopic injection of dextranomer/hyaluronic acid. At surgery, 13 patients had been successfully treated for their OAB (urgency with or without wetting) with behavior modification with or without anticholinergic therapy, and 28 had persistent OAB despite treatment. Voiding cystourethrogram was obtained 6-12 weeks postoperatively, and patients were followed up clinically for 1-5 years. Negative voiding cystourethrogram findings after a single treatment were seen in 34 (82.9%) of 41 patients. The radiographic success rate in patients with well-controlled OAB was 76.9% (10 of 13) compared with 85.7% (24 of 28) of those with poorly controlled OAB. The overall clinical success rate, defined as no evidence of urinary tract infection in the setting of negative voiding cystourethrogram findings, reached 78.0% (32 of 41). After successful endoscopic treatment, an unanticipated return to normal voiding patterns without the need for postoperative anticholinergic therapy was seen in 4 of the children with well-controlled OAB (40.0%) and in 4 with poorly controlled OAB (16.7%). Our data suggest that endoscopic injection is a viable treatment option for VUR in those with OAB, with postoperative rates of resolution comparable to those found in patients without OAB. Furthermore, 40.0% of children with well-controlled OAB no longer required therapy for OAB after resolution of their VUR.

Vesico-ureteral reflux and the adult male.

SUMMARY 1 Seventeen adult males with reflux, ranging in age from 21 to 75 years, are presented. Those patients with reflux secondary to neurogenic bladder or after partial cystectomy are excluded. 2 The etiological factors associated with reflux may be congenital as well as acquired. 3 In males under 45, reflux is usually due to lower urinary tract obstruction associated with chronic cystitis. The obstruction may be congenital and of such a low-grade nature that only when associated with a secondary infection does the condition become evident. Operative repair for reflux in association with a revision of the bladder neck is the recommended form of treatment. 4 In patients with reflux due to prostatic obstruction or after iatrogenic injury of the intramural ureter, in whom reflux persists despite elimination of obstruction, conservative therapy should be initially attempted. An anti-reflux procedure is indicated to prevent further deterioration of the kidney if continued renal destruction occurs.

Prevalence of Silent Gastroesophageal Reflux in Association with Recurrent Lower Respiratory Tract Infections

Gastroesophageal reflux (GER) has long been associated with pulmonary symptoms and diseases. This retrospective analysis was undertaken to determine the prevalence of GER detected by gastroesophageal scintigraphy in children with recurrent lower respiratory tract infections but none of the typical gastroesophageal symptoms of GER. A total of 312 children (mean age, 2.36 years; age range, 4 months to 11 years) were evaluated. All studies were performed using Tc-99m sulfur colloid (3.7 to 7.4 MBq; 100 to 200 microCi). Of 312 children, 108 (34.6%) had GER on gastroesophageal scintigraphy. The children were separated into four groups, depending on their age. Group 1 (119 children, younger than 1 year), group 2 (131 children, ages 1 to 3 years), group 3 (36 children, ages 3 to 6 years), and group 4 (26 children, ages 6 to 12 years) showed silent GER with prevalences of 38.7%, 37.4%, 22.2%, and 19.2%, respectively. Because physiologic GER is common in children younger than 18 months, we also analyzed the prevalence of GER in children younger than 18 months and older than 18 months of age. The prevalences of GER in these groups were 41.7% and 24.6%, respectively. A significant number of children with recurrent lower respiratory tract infection have scintigraphic evidence of GER. This high prevalence, even in children older than 18 months, cannot be ignored. Prospective studies including many patients are needed to establish the exact role of GER in these patients.

Upregulated eotaxin expression and T cell infiltration in the basal and papillary epithelium in cows' milk associated reflux oesophagitis

Background: Cows' milk sensitive reflux oesophagitis is an emerging clinical entity in children, normally indistinguishable from primary gastro-oesophageal reflux (GOR) apart from the response to dietary antigen exclusion. It is...

New trials of pharmacological therapy for endoscopy‐negative gastro‐oesophageal reflux disease

SUMMARYGastro‐oesophageal reflux disease describes patients with disease due to gastro‐oesophageal acid reflux regardless of the presence or absence of oesophagitis. In patients with endoscopy‐positive reflux disease, symptoms and complications occur due to reflux in association with clear‐cut oesophagitis, that is, mucosal breaks evident in the distal oesophagus with endoscopy. On the other hand, in patients with endoscopy‐negative reflux disease, symptoms and complications due to reflux occur in the absence of clear‐cut mucosal breaks. Most investigations of reflux disease therapy have focused on endoscopy‐positive disease. This is, at least in part, owing to the relative ease and reproducibility of disease staging; both disease severity and resolution can be endoscopically defined and graded. These studies indicate that erosive oesophagitis is a chronic condition, subject to relapse within 6 months following the cessation of healing therapy in as many as 80% of patients. Both the potency of anti‐secretory therapy required for healing and the certainty of relapse are proportional to the severity of endoscopically‐defined oesophagitis. Few reliable data exist on treatment efficacy in endoscopy‐negative disease because of a paucity of data on its natural history and inconsistency in defining outcome measures. Nonetheless, disease morbidity, with its associated impairment in quality of life, is determined by symptoms of reflux disease, irrespective of the presence or absence of oesophagitis, and symptom control is a prime objective of therapy for reflux disease.

Gastroesophageal reflux in association with the Sandifer syndrome.

Eight children presenting with the Sandifer syndrome (with neck contorsion, radiologic studies of the cervical spine and normal neurologic exploration) have been studied in relation to gastro-esophageal reflux (GER). In the eight cases barium swallow, 24 h pH-metering, manometry, endoscopy and biopsy were made, presenting pathological GER. The barium swallow was pathologic in 62% of them. The pH-metering in 37%. The lower esophageal sphincter pressures were decreased in 37%, with esophageal motility alteration in 75%. Signs of macro and/or microscopic esophagitis were found in 62%. Three patients received surgical treatment and the rest medical treatment, with improvement of the neck contorsion in all cases. We have attempted to evaluate which one of the functional explorations for the GER diagnosis is better in this kind of patients, and we have demonstrated that the most frequently found alteration is the esophageal dysmotility.

Reflux-induced renal parenchymal injury: evaluation by urinary enzyme management

The urinary enzymes N-acetyl-B-D-glucosaminidase (NAG) and gamma-glutamyltransferase (GGT) were measured in four paediatric cohorts. Group 1 (21 children) suffered from severe vesico-ureteric reflux (VUR), group 2 (9 children) had active e urinary sepsis without reflux, group 3 constituted the control group (84 children), and group 4 comprised 21 children who had undergone successful endoscopic corrective surgery for VUR. Excretion of both NAG and GGT was significantly greater in group 1 than in groups 2 and 3 (P < 0.05). Within group 1, those with reflux in association with a single ureteric system demonstrated greater enzyme excretion than those with reflux in a duplex moiety (P < 0.05). Following surgical correction of reflux (group 4), there was a significant reduction in urinary enzyme excretion (P < 0.001). A spectrum of renal tubular damage exists in association with VUR. Urinary enzyme measurement is an invaluable technique in the evaluation of such renal damage in reflux, and in quantitatively assessing the efficacy of treatment.

Duodenogastric Reflux Demonstrated by Cholescintigraphy in Peptic Ulcer Disease and Chronic Gastritis

Duodenogastric (D-G) reflux is commonly associated with peptic ulcer disease and chronic gastritis. To determine D-G reflux in association with each disease entity, we studied 43 chronic gastritis patients and 21 peptic ulcer patients with cholescintigraphy. Scoring (0 to 3+) was judged by the amount of Tc-99m diethylacetanitanilido-IDA (EHIDA) in the stomach. In the chronic gastritis group, 5, 16, 10, and 12 patients scored 3+, 2+, 1+, and 0, respectively. In the peptic ulcer disease group 6, 2, and 13 patients scored 2+, 1+, and 0, respectively. Thirty-nine of the 64 patients (60.9%) were positive for D-G reflux. D-G reflux occurred in 31 of 43 (72.09%) of chronic gastritis patients and in 8 of 21 (38.1%) patients with peptic ulcer disease. D-G reflux was significantly higher in the chronic gastritis group (P = 0.0009). Chronic gastritis patients were more likely to have more marked D-G reflux than peptic ulcer disease (P = 0.048). The authors conclude that cholescintigraphy is noninvasive and objectively demonstrates D-G reflux in chronic gastritis and peptic ulcer disease and that chronic gastritis is more closely associated with D-G reflux than peptic ulcer disease.

The Multicystic Dysplastic Kidney and Contralateral Vesicoureteral Reflux: Protection of the Solitary Kidney

The diagnosis of multicystic renal dysplasia is confirmed by a combination of sonography and radionuclide scan. If the contralateral kidney is normal by these criteria, further radiological examination is often omitted. We prospectively studied 29 patients with a diagnosis of multicystic renal dysplasia by voiding cystourethrography to determine the condition of the solitary contralateral kidney. Eight patients (28%) were found to have contralateral vesicoureteral reflux, of whom 6 had normal ultrasound examinations and would not have undergone further radiographic study based on ultrasound criteria alone. Contralateral vesicoureteral reflux in association with multicystic renal dysplasia puts solitary kidneys at risk for pyelonephritic scarring. Therefore, voiding cystourethrography should be performed as part of the initial evaluation of all infants with multicystic renal dysplasia.

Enterocystoplasty and Reflux Nephropathy in the Canine Model

Correction of vesicoureteral reflux at enterocystoplasty is often recommended to prevent the development of reflux nephropathy. Children with enterocystoplasty who require intermittent self-catheterization invariably have asymptomatic bacteriuria. In patients with persistent vesicoureteral reflux after enterocystoplasty the risk of renal damage from this asymptomatic bacteriuria is unknown. Detubularized ileocystoplasty was performed in 17 dogs with either direct nontunneled reimplantation or unroofing of the intramural tunnel and incision of the ipsilateral hemitrigone to create vesicoureteral reflux. Fluoroscopic urodynamic studies were performed 1 month later and unilateral vesicoureteral reflux was present in 6 dogs. All animals had low intravesical pressure and excretory urograms were performed to exclude obstruction. The 6 dogs with reflux were euthanized 3 months postoperatively and the kidneys were examined for histological evidence of pyelonephritis. In 5 of 6 dogs bacterial bladder colonization and subsequent renal pelvic colonization developed on the side of the vesicoureteral reflux. All of these animals had histological evidence of pyelonephritis in the refluxing kidney, whereas only 1 of 6 nonrefluxing control kidneys had any evidence of pyelonephritis (p = 0.031). Our results suggest that vesicoureteral reflux in association with enterocystoplasty leads to chronic upper tract infection and pyelonephritis in a majority of animals, despite creation of a low pressure urinary reservoir. Correction of vesicoureteral reflux at enterocystoplasty should be considered to prevent upper tract damage.

Effect of Unilateral Vesicoureteric Reflux on Renal Growth and the Uptake of 99mTc DMSA by the Kidney. An Experimental Study in the Minipig

The influence of unilateral vesicoureteric reflux (VUR) on renal growth and the uptake of 99mTc DMSA by the kidney has been investigated in a 2-kidney model in the growing minipig over a period of approximately 5 months. Animals with reflux in association with low voiding pressures and normal bladder function (n = 5), as well as those with raised voiding pressures and abnormal bladder function (n = 7), were investigated with appropriate non-refluxing controls (n = 12). Urinary infection and renal scarring were avoided since these factors may affect kidney function and growth independently. Statistical tests of difference failed to demonstrate any effect of VUR on renal growth or renal uptake of 99mTc DMSA even in the presence of elevated voiding pressures and abnormal detrusor function.

Effects of Vesicoureteric Reflux on Renal Growth and Function as Measured by GFR, Plasma Creatinine and Urinary Concentrating Ability: An Experimental Study in the Minipig

Summary— The influence of vesicoureteric reflux (VUR) on renal growth and function measured by glomerular filtration rate (GFR), plasma creatinine concentration and urinary concentrating ability has been examined in a simple one-kidney model in the growing minipig over a period of approximately 5 months. Animals with reflux in association with low voiding pressures and normal bladder function (n=6), as well as those with raised voiding pressures and abnormal bladder function (n=5), were investigated together with appropriate non-refluxing controls (n=12). Urinary infection and renal scarring were avoided since these factors may affect kidney function and growth independently. Statistical tests of difference failed to demonstrate any effect of VUR on 51Cr EDTA GFR or renal growth even in the presence of elevated voiding pressures and abnormal detrusor function. However, a significant association between VUR and reduced urinary concentrrating ability was shown.

Effects of vesicoureteric reflux on renal growth and function as measured by GFR, plasma creatinine and urinary concentrating ability. An experimental study in the minipig.

The influence of vesicoureteric reflux (VUR) on renal growth and function measured by glomerular filtration rate (GFR), plasma creatinine concentration and urinary concentrating ability has been examined in a simple one-kidney model in the growing minipig over a period of approximately 5 months. Animals with reflux in association with low voiding pressures and normal bladder function (n = 6), as well as those with raised voiding pressures and abnormal bladder function (n = 5), were investigated together with appropriate non-refluxing controls (n = 12). Urinary infection and renal scarring were avoided since these factors may affect kidney function and growth independently. Statistical tests of difference failed to demonstrate any effect of VUR on 51Cr EDTA GFR or renal growth even in the presence of elevated voiding pressures and abnormal detrusor function. However, a significant association between VUR and reduced urinary concentrating ability was shown.

Vesicoureteric reflux in patients with bladder tumours.

In the course of treatment of 224 patients with bladder neoplasms over an 18-year period, 44 patients were noted to have associated vesicoureteric reflux, bilateral in 12 and unilateral in 32. Reflux was suspected in 8 patients because of associated ureterotrigonal abnormalities such as paraureteric diverticulum, complete duplication of the ureter and gaping ureteric orifice, and it was diagnosed by micturating cystography obtained before the bladder tumour was treated. In the remaining 36 patients reflux developed after treatment of the bladder tumours. In most patients with reflux the clinical course was benign, but it caused recurrent pyelonephritis in 9 cases and secondary struvite calculi in 2. Five patients had antirefluxing ureteric reimplantation to control episodes of recurrent pyelonephritis. The pathogenesis and implications of vesicoureteric reflux in association with bladder tumours are discussed.

Gastroesophageal reflux in association with congenital heart disease.

The clinical course of 19 infants with severe respiratory symptoms associated with the presence of both congenital heart disease and gastroesophageal reflux is described. Down Syndrome or central nervous system disease was present in 12 of the 19 infants. The identification of reflux as a major or additional cause of the respiratory complications was often overlooked. Medical therapy alone was successful in only one of the 19 patients. Early repair or palliation of the cardiac malformation with or without subsequent antireflux surgical procedure was associated with relief of the symptoms in 13 patients.

Reflux in Complete Duplication in Children

Reflux is the most common abnormality associated with complete ureteral duplication. Several authors have emphasized early surgical correction of reflux when it occurs in duplicated systems because of a negligible success rate in non-operative therapy. Our practice has been to judge an orifice with reflux on its own merit, that is position, appearance and submucosal tunnel length. Realizing that this philosophy is not in total agreement with most of the literature on reflux in ureteral duplication we have reviewed 59 cases to ascertain whether our non-operative approach has justification. In this study early operation was elected in 61 per cent of those patients with reflux in association with total duplication. However, in 48 per cent of patients followed with nonoperative surveillance reflux has either stopped spontaneously or is medically stable.

Diffuse pulmonary fibrosis and hiatus hernia.

Six patients presenting with initially obscure pulmonary fibrosis are described. Reasons are given for attributing the condition to chronic aspiration pneumonitis from gastro-oesophageal reflux in association with hiatus hernia, supported by lung histology in three cases. Study of a further series of 143 cases of hiatus hernia suggests a 4% incidence of this insidious complication in addition to any more acute bronchopulmonary episodes. This possibility should be remembered in the differential diagnosis of any patient with pulmonary fibrosis of doubtful origin, as the advanced condition bears a poor prognosis.