Reflux Testing Research Articles

Motility Abnormalities in Patients with NCCP on PPI Therapy with Negative Reflux Testing

Motility Abnormalities in Patients with NCCP on PPI Therapy with Negative Reflux Testing

Vesicourethral Reflux in Pediatrics With Hypermobility Syndrome

SubjectivesPrevalence of benign joint hypermobility syndrome (BJHMS) without systemic disease seems to be high in children. Little literature is currently available related to urinary tract diseases in patients with BJHMS. Here, we report an association between the urinary tract disease and BJHMS.MethodsWe conducted a prospective case series study of 62 pediatric patients with musculoskeletal pain to detect urinary tract diseases in Tehran, Iran from October 2009 to October 2010. The Brighton criteria score was used to diagnose BJHMS. The collected data included age, gender, grading of vesicoureteral reflux (VUR), ultrasonography findings, urodynamic results and biochemical tests. Voiding cystourethrography was used for detection and grading of VUR.ResultsVUR was observed in 60% of patients with BJHMS. However, sonography was normal in 66.7% of patients. The most common grading of reflux was grade II of VUR (37.5%). Seventy percent of patients with BJHMS and neurogenic bladder had failure to thrive.ConclusionOur findings showed an increased frequency of VUR in patients with BJHMS. We suggest that Infants and children with BJHMS should be screened for VUR.

Should Acid Suppressive Therapy Improve Chronic Cough? (Chest 2013;143:605-612)

Gastroesophageal reflux disease (GERD) may cause laryngopharyngeal reflux, which results in mucosal exposure of the pharynx, larynx, or pulmonary system to the different components of the gastric refluxate, and so provokes symptoms including throat discomfort, hoarseness, globus pharyngeus and chronic cough. Chronic cough, defined as a cough lasting more than 8 weeks, is a common problem in primary care. The most common etiology of chronic cough in adults is upper airway cough syndrome secondary to postnasal drip, asthma, or GERD.1 Kahrilas et al2 has recently reported a systemic review regarding response of chronic cough to acid suppressive therapy in patients with GERD.2 A systemic search of Pubmed and Embase was conducted, which included placebo-controlled clinical trials reporting data on the effect of acid suppressive therapy on chronic cough in patients with GERD or laryngopharyngeal reflux by objective measures and/or reflux symptoms. Finally, they reviewed nine randomized controlled trials that treated patients with acid suppression. Among them, 8 trials used proton pump inhibitors (PPIs; daily or bid for 8-16 weeks),while 1 trial used ranitidine. Therapeutic gain was greater in patients with pathologic esophageal acid exposure (mean 21.5%; range, 12.5-35.8%) than in those without pathologic esophageal acid exposure (range, 0.0-8.6%). Patients with heartburn were excluded from the 2 studies which included patients without acid exposure. The mean placebo response rate was 13.8%. Although study design and subjective outcomes were variable in each study, the authors concluded that a therapeutic benefit for acid suppressive therapy in patients with chronic cough cannot be dismissed. It would be much more effective in selective patients who are favorable to therapy based on symptoms or reflux testing.

A Clinical Comparison of Laparoscopic Nissen and Toupet Fundoplication for Gastroesophageal Reflux Disease

To compare the advantages and disadvantages of laparoscopic Nissen and Toupet fundoplication in the treatment of gastroesophageal reflux disease (GERD) and their indications. From June 2001 to December 2011, 383 patients with GERD were randomized into two groups according to the last number in their hospitalization number. Overall, 215 patients underwent laparoscopic Nissen fundoplication, and 168 underwent laparoscopic Toupet fundoplication. No conversions to laparotomy or deaths were observed, and the symptoms disappeared completely postoperatively in both groups. Average follow-up was 5.6 years. No recurrence of symptoms was observed in the Nissen group. Eighteen patients experienced recurrence of symptoms in the Toupet group and were administered acid-suppressing drugs. Esophageal manometry and acid reflux testing were performed 4 months postoperatively, with normal results in both groups. The cure rate of esophageal inflammation was 88.4% in the Nissen group and 67.7% in the Toupet group. Four days postoperatively, the incidences of dysphagia and abdominal distension were significantly higher in the Nissen group compared with the Toupet group (28.4% and 16.7%, respectively); the difference between the two groups significantly decreased 1 year postoperatively (1.5% and 0.8%, respectively). In the short term, the incidence of dysphagia was significantly lower after Toupet fundoplication, but the difference decreased significantly with extension of the postoperative recovery period. For patients with moderate to severe GERD, the laparoscopic Nissen fundoplication may be optimal; for elderly patients or for patients with significantly reduced esophageal peristalsis detected in preoperative examinations, the laparoscopic Toupet fundoplication should be considered.

Ambulatory Reflux Monitoring in GERD – Which Test Should be Performed and Should Therapy be Stopped?

Diagnosing gastroesophageal reflux disease (GERD) often entails using a combination of patient symptoms, response to proton pump inhibitors (PPI), upper endoscopy, and ambulatory reflux testing. Each of these has limitations of which the clinician must be aware when managing patients with reflux symptoms. Ambulatory reflux monitoring, in particular, can potentially document the true presence of pathologic GERD. Consequently, reflux testing is often necessary in our evaluation of patients with reflux symptoms, and can be useful in distinguishing etiologies driving a lack of response to PPI therapy. Reflux testing results can be also used to guide appropriate PPI prescribing and clinical decision making for appropriate or unnecessary therapy. This review focuses on the limitations of our current diagnostic paradigm and highlights how reflux testing can be helpful in the diagnosis and management of patients with poor response to PPI therapy.

Response of Chronic Cough to Acid-Suppressive Therapy in Patients With Gastroesophageal Reflux Disease

Epidemiologic and physiologic studies suggest an association between gastroesophageal reflux disease (GERD) and chronic cough. However, the benefit of antireflux therapy for chronic cough remains unclear, with most relevant trials reporting negative findings. This systematic review aimed to reevaluate the response of chronic cough to antireflux therapy in trials that allowed us to distinguish patients with or without objective evidence of GERD. PubMed and Embase systematic searches identified clinical trials reporting cough response to antireflux therapy. Datasets were derived from trials that used pH-metry to characterize patients with chronic cough. Nine randomized controlled trials of varied design that treated patients with acid suppression were identified (eight used proton pump inhibitors [PPIs], one used ranitidine). Datasets from two crossover studies showed that PPIs significantly improved cough relative to placebo, albeit only in the arm receiving placebo fi rst. Therapeutic gain in seven datasets was greater in patients with pathologic esophageal acid exposure (range, 12.5%-35.8%) than in those without (range, 0.0%-8.6%), with no overlap between groups. A therapeutic benefit for acid-suppressive therapy in patients with chronic cough cannot be dismissed. However, evidence suggests that rigorous patient selection is necessary to identify patient populations likely to be responsive, using physiologically timed cough events during reflux testing, minimal patient exclusion because of presumptive alternative diagnoses, and appropriate power to detect a modest therapeutic gain. Only then can we hope to resolve this vexing clinical management problem.

Management of Apparent Life-Threatening Events in Infants: A Systematic Review

To determine in patients who are well-appearing and without a clear etiology after an apparent life-threatening event (ALTE): (1) What historical and physical examination features suggest that a child is at risk for a future adverse event and/or serious underlying diagnosis and would, therefore, benefit from testing or hospitalization? and (2) What testing is indicated on presentation and during hospitalization? Systematic review of clinical studies, excluding case reports, published from 1970 through 2011 identified using key words for ALTE. The final analysis was based on 37 studies; 18 prospective observational, 19 retrospective observational. None of the studies provided sufficient evidence to fully address the clinical questions. Risk factors identified from historical and physical examination features included a history of prematurity, multiple ALTEs, and suspected child maltreatment. Routine screening tests for gastroesophageal reflux, meningitis, bacteremia, and seizures are low yield in infants without historical risk factors or suggestive physical examination findings. Some historical and physical examination features can be used to identify risk in infants who are well-appearing and without a clear etiology at presentation, and testing tailored to these risks may be of value. The true risk of a subsequent event or underlying disorder cannot be ascertained. A more precise definition of an ALTE is needed and further research is warranted.

Correlation between Ambulatory 24 Hour Dual Probe pH Monitoring and Reflux Finding Score, Reflux Symptom Index in the Laryngopharyngeal Reflux

Received June 25, 2013 Revised August 3, 2013 Accepted August 19, 2013 Address for correspondence Kyung Tae, MD Department of OtolaryngologyHead and Neck Surgery, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul 133-792, Korea Tel +82-2-2290-8585 Fax +82-2-2293-3335 E-mail kytae@hanyang.ac.kr Background and ObjectivesZZA 24-hour ambulatory dual probe for pH monitoring is the most specific and sensitive test for laryngopharyngeal reflux (LPR) disease. However, the use of this probe is not well tolerated in some patients due to discomfort and the invasive nature of the procedure. Thus, the diagnosis of LPR is usually made according to symptomatic responses to empirical treatment using a proton-pump inhibitor for patients with high score of reflux symptom index (RSI) and reflux finding score (RFS). The aim of this study is to evaluate the relationship between the RSI and RFS and pH monitoring using a 24-hour ambulatory dual probe, and determine the role of RSI and RFS in the diagnosis of LPR. Subjects and MethodZZWe studied 100 patients who underwent pH monitoring using a 24hour dual probe because of laryngopharyngeal reflux related symptoms or laryngoscopic findings. The various parameters of the 24-hour dual probe pH monitoring were compared with the scores of RSI and RFS. ResultsZZIn 24-hour dual probe pH monitoring, 64 of 100 patients tested positive for LPR. The mean of RSI score was significantly higher in the positive LPR group than in the negative group. However, RFS did not differ between the two groups. RSI scores were significantly associated with the reflux number in the upright position of the 24-hour dual probe pH monitoring. There was no correlation between RFS and the parameters of the 24-hour dual probe pH monitoring. ConclusionZZRSI can be a reliable diagnostic tool for laryngopharyngeal reflux disease instead of the 24-hour ambulatory dual probe pH monitoring. Korean J Otorhinolaryngol-Head Neck Surg 2013;56:706-10

Testing for laryngopharyngeal reflux in exhaled breath condensate: a pilot study

Testing for laryngopharyngeal reflux in exhaled breath condensate: a pilot study

Role of Measuring Proximal Reflux Events in the Evaluation of Patients with Upper Esophageal/Pharyngeal Symptoms

Purpose: Upper esophageal/pharyngeal symptoms such as hoarseness and chronic cough are commonly attributed to gastroesophageal reflux. There is an increasing demand from ENT physicians to assess the presence of proximal reflux events. It is unknown if these symptoms are related to reflux. Whether identifying these events will confirm reflux as a cause of these symptoms is unknown. Objective: To determine 1) whether a higher rate of proximal reflux events is found in patients with upper esophageal/pharyngeal symptoms compared to patients with lower esophageal symptoms and 2) whether there is less evidence of reflux by number of reflux events or acid exposure on pH/impedance testing in patients with upper esophageal/pharyngeal symptoms than those with lower symptoms as might be expected if upper symptoms are unrelated to reflux. Methods: A retrospective review of pH/Impendence studies in a single center between May 2010 and November 2011 was performed. Subjects with mixed symptoms (upper and lower) were excluded. A positive reflux test was defined as greater than expected time of esophageal acid exposure and/or number of reflux events. Results are presented as mean ± standard deviation (SD). A student t-test was used to compare means of ordinal variables and linear regression was used to assess correlation between proximal symptoms and proximal events. Results: Eighty-nine patients met the study criteria. Demographics: mean age 46.4 ± 16.3; 40.4% of the subjects were male. 44.9% were on no proton pump inhibitor (PPI), 18% on daily dose PPI and 37.1% on double dose PPI. Of the 89 patients, 23 (26%) had upper symptoms and 65 (74%) had lower symptoms. There was no difference in demographics with respect to gender, age or medication in these two groups. Comparison of reflux events in the two groups is shown in Table 1. A logistic regression model showed no correlation between proximal symptoms and proximal reflux events. Even the subset of patients with a high upper symptom index (>0.5) failed to show a significantly greater number of proximal reflux events. Overall, abnormal pH/ Impedance testing was seen in 56.6% of patients with upper symptoms compared to 55.1% in patients with lower symptoms (P=0.53).Table 1: Comparison of reflux eventsConclusion: Since the rate of a positive reflux test was similar in patients with upper and lower symptoms, our data suggest that upper symptoms are part of a reflux complex but the lack of correlation of proximal reflux events and upper esophageal/pharyngeal symptoms indicates that these symptoms are not related directly to increased acid exposure in upper esophagus. Measurement of the frequency of proximal reflux events does not add any useful information to a standard pH/impedance study.

Wireless ‘mini’ multichannel intraluminal impedance-pH: what is the optimal design of a miniature wireless device?

Catheter-based methods for multichannel intraluminal impedance-pH monitoring are invasive and uncomfortable. The current alternative is a wireless system that clips to the esophageal mucosa, but which only measures pH. A shorter two-site wireless sensor that detects impedance and pH, and can be clipped to the esophagus, would be desirable. This study compares sensor positions and separations to determine the optimal configuration of a two-site wireless sensor. Records of 20 patients (10 on and 10 off proton pump inhibitor) who had ambulatory reflux testing with a multichannel intraluminal impedance-pH system (Sandhill Scientific Inc., Highlands Ranch, CO, USA) with six impedance and two pH sensors were reviewed. An investigator was blinded to four combinations of impedance channels plus pH. He read a 3-hour postprandial section from each of the combinations (total of 80 studies) and marked reflux episodes. Results were compared with his own interpretation of the full tracing. Two hundred and two total reflux episodes were analyzed, 113 acid (pH < 4) and 89 nonacid (pH > 4). Mean and median numbers of total reflux episodes were calculated. In the full study, the interpreter detected a mean of 10 reflux episodes per study. In the 5 cm and 7 cm, 3 cm and 7 cm, and 3 cm and 5 cm studies, the interpreter found a mean of 8.1, 11.1, and 9.8 reflux episodes per study, respectively. One-way analysis of variance yielded a P-value of 0.43. The trend of these preliminary findings suggests that the 3 cm and 5 cm site is the most sensitive and the 5 cm and 7 cm is the least, with the 3 cm and 7 cm site perhaps as the preferred location. The lack of a significant difference, at the very least, suggests that any of the 'mini' locations could be used. The small number of observations could have resulted in a Type II statistical error.

Military Otolaryngology and Blast Injuries

Program Description: Globus pharyngeus (globus) is a sensory abnormality of the throat affecting 4% to 6% of the population. To date, the etiology of globus still remains poorly elucidated, although many theories have evolved. There is no consensus regarding the diagnosis and management for these patients. This miniseminar is intended to concisely cover the following: review all of the key elements of evaluation, examination, diagnosis, and management of patients with globus; consider key points in history-taking and physical examination; evaluate all possible etiologies for globus sensation, including laryngopharyngeal reflux, cricopharyngeal/upper esophageal and esophageal pathology, thyroid pathology, and others; summarize the literature supporting or refuting all diagnostic modalities for patients with globus, including but not limited to esophagram, endoscopy, reflux testing, and manometry; and propose a practical management algorithm for treating patients with globus.

Reproducibility of Salivary Pepsin: Clinic versus Home

Objective: Pepsin immunoassay of saliva samples is a potential objective test for reflux and extra-esophageal reflux (EER). This study aims to assess the reproducibility of pepsin samples in a clinical cohort study. Method: Saliva samples were obtained following a standardized protocol on 3 occasions. Subjects expectorated pharyngeal secretions in an upright position in clinic, and on 2 mornings following recumbence and sleep. All samples were frozen for storage and Western blot immunoassay for pepsin was performed. Results: From 70 subjects, 59 first samples completed showed the prevalence of pepsin (+) was 26%. Of 34 subjects who returned the home collected sample, only 6% of the 2nd samples were positive and none of the 3rd samples were positive. 46.3% of the subjects had elevated Reflux Symptom Index (RSI) but the correlation with pepsin (+) was not significant. Conclusion: Our study was unable to produce consistent results of pepsin assays in a nonlaryngology clinical setting. Salivary pepsin assay is a conceptually promising non-invasive test for EER; however the timing and logistics of sample collection in order to be a feasible clinical test may need further studies and adjustments.

Apparent Life-Threatening Events

Apparent Life-Threatening Events

Adverse outcomes associated with gastroesophageal reflux disease are rare following an apparent life‐threatening event

To evaluate for adverse outcomes associated with gastroesophageal reflux disease (GERD) following an apparent life-threatening event (ALTE) and potential risk factors of these outcomes. Retrospective cohort study of well-appearing infants (<12 months) admitted for ALTE. Patients were followed for adverse outcomes associated with GERD (including aspiration pneumonia, failure-to-thrive, or anti-reflux surgery), second ALTE, or death. Risk factors evaluated included: age, prematurity, gender, previous event, diagnosis of GERD, gastrointestinal (GI) testing positive for gastroesophageal reflux, length of stay (LOS), and neurologic impairment diagnosed in follow-up. Four hundred sixty-nine patients met inclusion criteria, mean age was 45 days, 110 (22%) were premature. Patients were followed for an average of 7.8 years; 3.8% of all patients had an adverse outcome associated with GERD. The only significant risk factors were a longer LOS, and development of neurological impairment. A diagnosis of GERD and positive reflux testing during the initial hospitalization were not associated with adverse outcomes associated with GERD. Adverse outcomes associated with GERD are rare following an ALTE. Patients who developed neurological impairment and a longer initial LOS were at higher risk for developing these outcomes. Positive testing for gastroesophageal reflux during hospitalization for ALTE did not predict adverse outcomes associated with GERD.

Exam 1: Many Patients Continue Using Proton Pump Inhibitors After Negative Results From Tests for Reflux Disease

Many Patients Continue Using Proton Pump Inhibitors After Negative Results From Tests for Reflux DiseaseClinical Gastroenterology and HepatologyVol. 10Issue 6PreviewAmbulatory reflux testing is used to evaluate symptoms of gastroesophageal reflux disease (GERD) refractory to protein pump inhibitors (PPIs). We investigated the prevalence of PPI use in patients with negative results from Bravo pH or multichannel intraluminal impedance-pH (MII-pH) tests and factors that might predict the use of PPIs. Full-Text PDF

Many Patients Continue Using Proton Pump Inhibitors After Negative Results From Tests for Reflux Disease

Ambulatory reflux testing is used to evaluate symptoms of gastroesophageal reflux disease (GERD) refractory to protein pump inhibitors (PPIs). We investigated the prevalence of PPI use in patients with negative results from Bravo pH or multichannel intraluminal impedance-pH (MII-pH) tests and factors that might predict the use of PPIs. We analyzed data from patients who had undergone Bravo pH monitoring or MII-pH testing at Northwestern University, without evidence of reflux disease. Demographics, endoscopy findings, pathology results, and provider recommendations were obtained via chart review. Eligible patients (n = 90) were contacted by telephone, and a cross-sectional survey was administered with questions about symptom severity, demographics, medication use, and health behaviors. Patients were compared by current PPI use, and statistical analyses were performed by using SAS version 9.2 software. Thirty-eight patients (42.2%) reported current PPI use despite a negative result from a pH study. Only 17 patients (18.9%) recalled being instructed to stop taking PPIs; chart review showed documented instructions to stop PPI therapy for 15 patients (16.7%). There were no significant differences in demographic or clinical characteristics among patients compared by current PPI use. Patients taking a PPI were more likely than those not taking a PPI to report troublesome symptoms that affected their daily life, as measured by a questionnaire for the diagnosis of GERD (the GerdQ). More than 42% of patients with negative results from pH monitoring studies continue PPI therapy despite physiological data that they do not have GERD.

Extraesophageal gastroesophageal reflux disease (GERD) symptoms are not more frequently associated with proximal esophageal reflux than typical GERD symptoms

Extraesophageal (EE) symptoms such as cough and throat clearing are common in patients referred for reflux testing, but are less commonly associated with gastroesophageal reflux disease (GERD). Patients with reflux associated EE symptoms often lack typical GERD symptoms of heartburn and regurgitation. Our aim was to compare the frequency of proximal esophageal reflux between esophageal (typical) symptoms and EE (atypical) symptoms. Combined multichannel intraluminal impedance-pH (MII-pH) tracings were blinded by an investigator so that symptom markers were relabeled with a number without disclosure of symptom type. We selected 40 patients with at least five reflux-related symptom events for one of four symptoms (heartburn, regurgitation, cough, or throat clearing). A blinded investigator analyzed all 200 reflux episodes, reporting the proximal esophageal extent of the reflux for all symptoms. The percentage of symptom-related reflux extending proximally to 17 cm above the LES was similar among all four symptom types. At least 50% of all symptoms were associated with proximal esophageal reflux to 17 cm, with regurgitation having the highest frequency at 60%. Our data indicate that EE symptoms are not more frequently associated with proximal esophageal reflux than typical esophageal symptoms.

Testing for gastroesophageal reflux in the 21st century

The following on testing for gastroesophageal reflux in the 21st century contains commentaries on wireless pH monitoring; extension of pH recording duration to 48 or 96 h; extraesophageal GERD syndromes, diagnosis paradigms, and related investigating tools; off- or on-PPI reflux monitoring in the preoperative setting; and the potential influence of PPIs on reflux parameters.

Evidence of extraesophageal reflux in idiopathic subglottic stenosis

Idiopathic subglottic stenosis (iSGS) is a disease predominantly of females that, by definition, has no known etiology. Collagen-vascular disease, localized trauma, extraesophageal reflux (EER), and hormonal alterations have all been postulated as potential etiologies of iSGS. It is hypothesized that iSGS is a reflux mediated disease and that evidence of EER exists in affected patients. Case-control study. Patients with iSGS were identified prospectively over a 2.5-year period (2007-2010). During their endoscopic management, biopsies of the subglottic scar and postcricoid area were evaluated for the presence of pepsin, an indicator of exposure to gastric refluxate. Control patients had similar biopsies while undergoing operative management for disease unrelated to reflux. Charts of both patients and controls were reviewed for clinical history of reflux, pH-metry, and laboratory testing for collagen-vascular disease. Twenty-two patients with iSGS were treated. All patients were female. No patient had serology positive for collagen-vascular disease. Thirteen (59%) patients with iSGS had pepsin present in their larynx or trachea. Control patients did not have detectable pepsin in their tissue (P = .041). Dual probe 24-hour pH studies were performed in 10 (45%) patients. These studies were positive for EER in seven patients but this did not statistically correlate to the presence of pepsin in their tissue (P = 1.0). iSGS is a disease almost exclusively of women. EER is implicated in the development of iSGS. Pepsin is detectable in the subglottic scar and larynges of patients with iSGS. Standard pH-metry may be inadequate in predicting degree of EER in patients with iSGS.