Severity Of Reflux Research Articles

Once in a Bile \u2014 the Incidence of Bile Reflux Post-Bariatric Surgery

PurposeExcellent metabolic improvement following one anastomosis gastric bypass (OAGB) remains compromised by the risk of esophageal bile reflux and theoretical carcinogenic potential. No ‘gold standard’ investigation exists for esophageal bile reflux, with diverse methods employed in the few studies evaluating it post-obesity surgery. As such, data on the incidence and severity of esophageal bile reflux is limited, with comparative studies lacking. This study aims to use specifically tailored biliary scintigraphy and upper gastrointestinal endoscopy protocols to evaluate esophageal bile reflux after OAGB, sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).MethodsFifty-eight participants underwent OAGB (20), SG (15) or RYGB (23) between November 2018 and July 2020. Pre-operative reflux symptom assessment and gastroscopy were performed and repeated post-operatively at 6 months along with biliary scintigraphy.ResultsGastric reflux of bile was identified by biliary scintigraphy in 14 OAGB (70%), one RYGB (5%) and four SG participants (31%), with a mean of 2.9% (SD 1.5) reflux (% of total radioactivity). One participant (OAGB) demonstrated esophageal bile reflux. De novo macro- or microscopic gastroesophagitis occurred in 11 OAGB (58%), 8 SG (57%) and 7 RYGB (30%) participants. Thirteen participants had worsened reflux symptoms post-operatively (OAGB, 4; SG, 7; RYGB, 2). Scintigraphic esophageal bile reflux bore no statistical association with de novo gastroesophagitis or reflux symptoms.ConclusionDespite high incidence of gastric bile reflux post-OAGB, esophageal bile reflux is rare. With scarce literature of tumour development post-OAGB, frequent low-volume gastric bile reflux likely bears little clinical consequence; however, longer-term studies are needed.Clinical Trial RegistryAustralian New Zealand Clinical Trials Registry number ACTRN12618000806268.Graphical abstract

The association between laryngopharyngeal reflux and insomnia.

To evaluate the prevalence of insomnia in patients with laryngopharyngeal reflux (LPR) and to analyze the relationship between the severity of insomnia and LPR-related symptoms. We analyzed 69 patients with LPR and 61 healthy controls. The LPR was confirmed via the 24-h hypopharyngeal-esophageal multichannel intraluminal impedance pH monitoring. Reflux symptoms and sleep disturbances were assessed using the Reflux Symptom Index and Insomnia Severity Index. We compared the prevalence of insomnia between the two groups. We analyzed the relationship between reflux symptoms and severity of insomnia. The prevalence of insomnia was significantly higher in patients with LPR than in healthy controls (46.3% vs. 29.5%; p = 0.049). The severity of reflux-related symptoms was correlated with insomnia severity (rho = 0.44; p < 0.001). Patients with LPR with nighttime reflux were more likely to have sleep disturbances than patients with LPR without nighttime reflux. Patients with LPR are more likely to experience insomnia than healthy controls, and the severity of reflux symptoms was related to the severity of insomnia.

Long-term improvement of limb reflux prevalence and severity after iliac vein stent placement

BackgroundThe effect of iliac vein stenting on ipsilateral limb reflux is unknown and has remained a matter of speculation. It has been suggested that the propensity for reflux might worsen when proximal stenosis is corrected. This could allow for retrograde flow with coughing and the Valsalva maneuver, stressing the valve. We examined this hypothesis by an analysis of the long-term effects of iliac vein stenting on limb reflux using a single-center, retrospective analysis of prospectively collected data. MethodsReflux data from duplex ultrasound of 1387 limbs in 1228 patients who had undergone iliac vein stenting from 1997 to 2018 were analyzed. Of the 1387 limbs, 632 (46%) had had ipsilateral duplex ultrasound-determined valve reflux before stenting, and 747 limbs (54%) had not had reflux; data were missing for 8 limbs. Reflux status before and after stenting was available for seven individual segments for each limb in the database for analysis (total, 9653 segments). The stented patients were examined for reflux at least annually during the follow-up period (range, 1-26 years). Segmental reflux prevalence was detected using duplex ultrasound. We have referred to this as “duplex reflux” or simply “reflux.” Reflux severity was graded using (1) a reflux segmental score, assigning one point each for refluxing segments in the limb; (2) air plethysmography (venous filling index [VFI90]); and (3) ambulatory venous pressure (venous filling time [VFT]). ResultsPrestent duplex reflux was present in a combination of superficial, deep, and perforator segments. Reflux prevalence ranged from 7% of deep femoral segments to 51% at the popliteal segment. Post-stent reflux resolution varied from 21% at the femoral vein segment to 58% at the perforator segments. Reflux had completely resolved in 23% of the limbs. New-onset reflux was rare, with a median incidence of 7% for all segments at risk, with cumulative improvement (Kaplan-Meier curve) in reflux severity (segment score, VFI90, and VFT) for most limbs. These metrics were unimproved, with residual reflux in only 18%, 11%, and 6% (segment score, VFI90, and VFT, respectively) of the limbs at long-term follow-up. ConclusionsLong-term follow-up of limbs after iliac vein stenting has shown that the associated ipsilateral reflux prevalence and severity will improve in most limbs over time.

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.

Comparison of gastric-jejunum pouch anastomosis and Billroth-II reconstructions after distal gastrectomy: a propensity score matching analysis

PurposeOur study aimed to make a propensity score matching (PSM) analysis on the clinical application of gastric-jejunum pouch anastomosis (GJPA) and Billroth-II anastomosis after distal gastrectomy.MethodsWe collected clinical data from 249 patients who received distal gastrectomy from January 2016 to July 2020. According to the reconstruction method used, all patients were divided into the Billroth-II group and the GJPA group. Clinical data and operation complications were analyzed.ResultsThe clinical characteristics of the 2 groups were comparable after PSM. In the Billroth-II group, the incidence rate of delayed gastric emptying was higher than that in the GJPA group. Fewer patients suffered reflux gastritis in the GJPA group. The RGB (residue, gastritis, and bile) scores related to the severity of bile reflux into the remnant stomach, gastritis, and residue were higher in the Billroth-II group. Postoperative nutritional status and Visick classification demonstrated that postoperative subjective feelings in the GJPA group were improved significantly.ConclusionThe application of GJPA in reconstruction after distal gastrectomy is safe, economical, and reliable. This reconstruction improved the quality of life of patients. It is worth popularizing widely in clinical settings.

Laryngological presentations and patient-reported outcome measures in Ehlers-Danlos syndrome.

This study aimed to characterise the laryngological presentations of Ehlers-Danlos syndrome and conduct a preliminary exploration of patient-reported outcome measures. This paper describes a retrospective case series of patients with Ehlers-Danlos syndrome seen by the senior author between 2005 and 2019. A literature review was conducted to summarise the existing findings. Twenty-one patients met the inclusion criteria. All reported symptoms were grouped; this showed that swallowing, voice and hyolaryngeal skeletal complex problems were commonest. Patient-reported outcome measures were available for eight patients, which showed large variations in: the Reflux Severity Index (median = 25.5; range = 0-33), Eating Assessment Tool score (median = 21.5; range = 0-35) and Voice Handicap Index (median = 21.5; range = 0-104). Twelve studies met our literature review inclusion criteria, involving at least 91 patients with laryngological presentations of Ehlers-Danlos syndrome. Ehlers-Danlos syndrome patients experience musculoskeletal issues, which in the throat manifest as hyolaryngeal skeletal complex problems. Future studies with larger patient numbers are required to validate laryngological patient-reported outcome measure tools in Ehlers-Danlos syndrome.

Effect of Pistacia atlantica on the Elimination of Helicobacter pylori and Improvement of Gastric Reflux in Patients with Chronic Cough: A Randomized Clinical Trial

Background: Pistacia atlantica (P. atlantica) has been associated with beneficial medical effects on gastrointestinal complications. Objective: It was intended to assess the effects of P. atlantica in elimination of Helicobacter pylori (H. pylori) infection and amelioration of gastric reflux and chronic cough. Methods: In this clinical trial study, 100 subjects with H. pylori infection who had the symptoms of gastric reflux and chronic cough were recruited and classified into two intervention and placebo groups, continuing 50 subjects each. The intervention group was administered two 500 mg doses of P. atlantica extract each day. The H. pylori antigen load in stool samples was evaluated using ELISA. The severity of cough and gastric re flux was also determined. Results: The subjects in two groups were age and sex matched and the baseline measurements were similar on the day 0. Nonetheless, it was observed that on the day 14, there was a significant reduction of H. pylori antigen load in the intervention group compared with the placebo group (P = 0.00021). Furthermore, the intensity of chronic cough was reduced significantly in the intervention group (P = 0.0014). The gastric reflux was improved in the intervention group at the end of the study. Conclusion: P. atlantica extract was beneficial in controlling H. pylori infection. It also improved the complications of the infection, like gastric reflux and chronic cough. Hence, it is highly recommended to value natural products, along with traditional antibiotics, in ameliorating H. pylori infection.

Heterogeneity of primary and secondary peristalsis in systemic sclerosis: A new model of "scleroderma esophagus".

Although esophageal dysmotility is common in systemic sclerosis (SSc)/scleroderma, little is known regarding the pathophysiology of motor abnormalities driving reflux severity and dysphagia. This study aimed to assess primary and secondary peristalsis in SSc using a comprehensive esophageal motility assessment applying high-resolution manometry (HRM) and functional luminal imaging probe (FLIP) Panometry. A total of 32 patients with scleroderma (28 female; ages 38-77; 20limited SSc, 12 diffuse SSc) completed FLIP Panometry and HRM. Secondary peristalsis, i.e., contractile responses (CR), was classified on FLIP Panometry by pattern of contractility as normal (NCR), borderline (BCR), impaired/disordered (IDCR), or absent (ACR). Primary peristalsis on HRM was assessed according to the Chicago classification. The manometric diagnoses were 56% (n=18) absent contractility, 22% (n=7) ineffective esophageal motility (IEM), and 22% (n=7) normal motility. Secondary peristalsis (CRs) included 38% (n=12) ACR, 38% (n=12) IDCR, 19% (n=6) BCR, and 15% (n=5) NCR. The median (IQR) esophagogastric junction (EGJ) distensibility index (DI) was 5.8mm2 /mmHg (4.8-10.1) mm2 /mmHg; EGJ-DI was >8.0mm2 /mmHg in 31%, and >2.0mm2 /mmHg in 100% of patients. Among 18 patients with absent contractility on HRM, 11had ACR, 5had IDCR, and 2had BCR. Among 7 patients with IEM, 1had ACR, 5had IDCR, and 1NCR. All of the patients with normal peristalsis had NCR or BCR. This was the first study assessing combined HRM and FLIP Panometry in a cohort of SSc patients, which demonstrated heterogeneity in primary and secondary peristalsis. This complementary approach facilitates characterizing esophageal function in SSc, although future study to examine clinical outcomes remains necessary.

500 THE PATHOLOGICAL GASTROESOPHAGEAL REFLUX IN PATIENTS WITH CYSTIC FIBROSIS

Abstract The presence of gastroesophageal reflux in patients after lung transplantation rises the risk of posttransplantant complications. The aim of our study was to evaluate the severity of gastroesophageal reflux (GER) in patients with cystic fibrosis before lung transplantation. Methods 14 patients with cystic fibrosis, who refferred to our Centre, were included in this study, mean age 28,86 ± 2,5 (6 males and 8 females). The diagnosis of cystic fibrosis was established at the age of 1–5 y.o. according to clinic, sweet test and genetic tests. All patients were performed upper endoscopy, X-ray, esophageal manometry and 24 h impedance monitoring. PPI treatment was excluded for 7 days before monitoring. Pathologic GER was established when total number of refluxes in distal esophagus was more than 75, the total number of refluxes in proximal esophagus was more than 20% of those in the distal part. Results According to endoscopy, none of patients had erosions of the esophagus. Five patients had ineffective motility and one—diffuse esophageal spazm. 56% of patients had pathologic number of refluxes in distal esophagus. 80% subjects had pathologic refluxes in proximal esophagus. The mean number of total refluxes in distal part was 54,93 ± 5,7, in proximal part—27,64 ± 2,6 (it is 40% of those in distal part). The distribution of acid and non-acid refluxes in patients with pathologic refluxes was 2:1. We didn’t reveal any correlation between number of refluxes, ineffective motility and gastric emptying. Conclusion despite normal upper endoscopy, 56% of patients with cystic fibrosis have pathologic gastroesophageal reflux. Besides, the study showed high propagation of GER to proximal esophagus in 80% of subjects, which may play role in posttransplantation period.

Gastrointestinal disorders in patients with COVID-19: diagnoses and treatment during the pandemic

Background. The pandemic caused by the coronavirus disease 2019 (COVID-19) is a topic that is currently in the spotlight of the world community. The use of non-steroidal anti-inflammatory drugs (NSAIDs) in combination with new oral anticoagulants (dabigatran, rivaroxaban, apixaban, etc.) and acetylsalicylic acid by the significant number of patients during the pandemic, caused by COVID-19, raises the question about the safety of the influence of each drug on the occurrence of gastrointestinal complications. The development of algorithms to prevent damage to the gastrointestinal mucosa on the background of these drugs is becoming a priority. The purpose was to examine the presence of gastrointestinal disorders using the Gastrointestinal Symptom Rating Scale (GSRS) in convalescents after COVID-19 and to evaluate the effectiveness of esomeprazole for correction of these disorders. Materials and methods. We surveyed 92 (48 men and 44 women) convalescents after COVID-19. The mean age of individuals was (49.2±2.0) years. To conduct a survey of patients who had COVID-19, we developed a questionnaire which included patient’s passport data, age, gender. In addition, patients reported how COVID-19 was diagnosed, what drugs they were taking during treatment, and whether they needed oxygen therapy. Subsequently, convalescents after COVID-19 answered questions from the GSRS. Information was collected and the questionnaire was completed by telephone survey. Depending on the data of GSRS, esomeprazole (Ezonexa) was prescribed to patients at a dose of 20 mg 1 time per day, 30 minutes before meals, for 30 days. During the follow-up survey on day 30 of esomeprazole intake, patients re-answered the GSRS questions. Results. Thirty days after starting esomeprazole intake at a dose of 20 mg 1 time per day, 92 convalescents after COVID-19 showed a significant reduction (p&lt;0.001) in the manifestations of reflux, abdominal pain and dyspeptic syndromes compared to the results before treatment ((2.3±0.1), (4.3±0.2), (5.7±0.3) versus (4.3±0.3), (9.3±0.4), (8.6±0.6), respectively). Esomeprazole was equally effective (p&gt;0.05) in influencing the severity of reflux, abdominal pain, dyspeptic, diarrheal and constipation syndromes in both men and women: (2.3±0.1), (4.3±0.2), (5.7±0.3), (3.9±0.3), (3.0±0.1) versus (2.4±0.1), (4.2±0.2), (6.0±0.4), (4.0±0.4), (3.1±0.1), respectively. Esomeprazole was also equally effective (p&gt;0.05) in the impact on the severity of reflux, abdominal pain, dyspeptic, diarrheal and constipation syndromes among patients receiving acetylsalicylic acid and those treated with rivaroxaban: (2.5±0.2), (4.2±0.2), (5.6±0.2), (3.9±0.4), (3.1±0.1) versus (2.2±0.1), (4.4±0.3), (6.4±0.6), (4.2±0.4), (3.0±0.1), respectively. Esomeprazole at a dose of 20 mg 1 time per day was equally effective (p&gt;0.05) in relation to the dynamics of the severity of syndromes in patients receiving paracetamol and one NSAID and in those receiving paracetamol and 2 NSAIDs. In particular, in people receiving paracetamol and one NSAID, on the background of esomeprazole administration, the severity of reflux, abdominal pain, dyspeptic, diarrheal and constipation syndromes were (2.4±0.1), (4.3±0.2), (5.8±0.3), (4.1±0.3), (3.1±0.1) and in patients taking paracetamol and 2 NSAIDs— (2.1±0.2), (4.5±0.4), (6.7±0.7), (4.4±0.7), (3.0±0.1), respectively. Conclusions. Esomeprazole (Ezonexa) effectively reduces (p&lt;0.001) the severity of reflux, abdominal pain and dyspeptic syndromes in convalescents after COVID-19. The use of Esomeprazole (Ezonexa) demonstrates the same efficacy (p&gt;0.05) in men and women when receiving both ASA and rivaroxaban and during the treatment with both paracetamol and one NSAID and paracetamol and 2 NSAIDs.

Challenges in the Surgical Correction of Hiatal Hernias and Ways to Overcome Them

Abstract More than a thousand laparoscopic fundoplication operations for hiatal hernia (HH) have been performed at the Clinic of the Bashkir State Medical University over the period between 2000 and 2019 and the results of surgical treatment of 502 patients were analyzed. Our research results indicate that routine instrumental methods used in hiatal hernia diagnosis provide valuable information, however only their combined application allows us to establish the correct diagnosis in all patients. Authors propose a new original X-ray balloon method that allows to improve the quality of diagnosis of hiatal hernia significantly. Balloon X-ray allows us to establish the true dimensions of the hiatus and select the most appropriate treatment accordingly. Isolated fundoplication without plastic of esophageal opening was performed in 180 patients. Surgical correction of the hiatus was performed on 322 patients. Diaphragmcrouroraphy was carried out in 199 cases, in 123 cases mesh implants were used to support the crus of the diaphragm. In 215 cases, simultaneous surgical procedures were performed to treat multiple abdominal pathology. We studied the changes in quality of life of 100 patients with hiatal hernia before and after laparoscopic esophagofundoplication by comparing the results of the survey (questionnaires) and medical examination of the cardiac sphincter of the esophagus function. The vast majority of patients demonstrated a significant improvement in the cardiac closure function, a decrease in the frequency and severity of gastroesophageal reflux, and reduced signs of reflux esophagitis.

Determination of procalcitonin content in blood serum, urine, and ejaculate for the diagnosis of urogenital tract pathology

The determination of the concentration of procalcitonin (PCT) in blood serum and other biological fluids is used for the diagnosis and monitoring of the course of sepsis and the syndrome of a systemic inflammatory reaction. This review summarizes the data on the diagnostic value of the definition of procalcitonin in the practice of urologists and andrologists. The content of procalcitonin in such biological fluids as urine, seminal plasma is almost 10 times higher than the level of this protein in blood serum: this phenomenon is manifested in physiological conditions and in pathological processes. The relationship of clinical and laboratory indicators of inflammation with the severity of urosepsis was analyzed. Elevated serum procalcitonin levels are considered as a predictor of septic shock in patients with urolithiasis, and determine the management tactics of patients with urinary tract obstruction. The marker function of this protein was studied in inflammation in the renal parenchyma, in malignant neoplasms of the kidneys, bladder, ureter, prostate and testis; in the diagnosis of testicular torsion and orchiepididymitis. The article describes the regular changes in the level of urinary procalcitonin depending on the severity of vesicoureteral reflux, the severity of the manifestations of the inflammatory reaction. There were significant differences in the concentration of procalcitonin in seminal plasma between the groups of men with reduced and normal ejaculate fertility.

Short versus long feeding interval for bolus feedings in very preterm infants.

There is presently no certainty about the ideal feeding intervals for preterm infants. Shorter feeding intervals of, for example, two hours, have the theoretical advantage of allowing smaller volumes of milk. This may have the potential to reduce the incidence and severity of gastro-oesophageal reflux. Longer feeding intervals have the theoretical advantage of allowing more gastric emptying between two feeds. This potentially provides periods of rest (and thus less hyperaemia) for an immature digestive tract. To determine the safety of shorter feeding intervals (two hours or shorter) versus longer feeding intervals (three hours or more) and to compare the effects in terms of days taken to regain birth weight and to achieve full feeding. We used the standard search strategy of Cochrane Neonatal to run comprehensive searches in CENTRAL (2020, Issue 6) and Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions, and CINAHL on 25 June 2020. We searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. We included RCTs and quasi-RCTs comparing short (e.g. one or two hours) versus long (e.g. three or four hours) feeding intervals in preterm infants of any birth weight, all or most of whom were less than 32 weeks' gestation. Infants could be of any postnatal age at trial entry, but eligible infants should not have received feeds before study entry, with the exception of minimal enteral feeding. We included studies of nasogastric or orogastric bolus feeding, breast milk or formula, in which the feeding interval is the intervention. We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Our primary outcomes were days taken to achieve full enteral feeding and days to regain birth weight. Our other outcomes were duration of hospital stay, episodes of necrotising enterocolitis (NEC) and growth during hospital stay (weight, length and head circumference). We included four RCTs, involving 417 infants in the review. One study involving 350 infants is awaiting classification. All studies compared two-hourly versus three-hourly feeding interval. The risk of bias of the included studies was generally low, but all studies had high risk of performance bias due to lack of blinding of the intervention. Three studies were included in meta-analysis for the number of days taken to achieve full enteral feeding (351 participants). The mean days to achieve full feeds was between eight and 11 days. There was little or no difference in days taken to achieve full enteral feeding between two-hourly and three-hourly feeding, but this finding was of low certainty (mean difference (MD) ‒0.62, 95% confidence interval (CI) ‒1.60 to 0.36). There was low-certainty evidence that the days taken to regain birth weight may be slightly longer in infants receiving two-hourly feeding than in those receiving three-hourly feeding (MD 1.15, 95% CI 0.11 to 2.20; 3 studies, 350 participants). We are uncertain whether shorter feeding intervals have any effect on any of our secondary outcomes including the duration of hospital stay (MD ‒3.36, 95% CI ‒9.18 to 2.46; 2 studies, 207 participants; very low-certainty evidence) and the risk of NEC (typical risk ratio 1.07, 95% CI 0.54 to 2.11; 4 studies, 417 participants; low-certainty evidence). No study reported growth during hospital stay. The low-certainty evidence we found in this review suggests that there may be no clinically important differences between two- and three-hourly feeding intervals. There is insufficient information about potential feeding complications and in particular NEC. No studies have looked at the effect of other feeding intervals and there is no long-term data on neurodevelopment or growth.

Gastro-esophageal reflux disease (GERD) after peroral endoscopic myotomy (POEM)

Peroral endoscopic myotomy (POEM) is gaining traction as a minimally invasive treatment of achalasia. Increased reflux is reported after POEM but the incidence, type and severity of reflux are not fully understood. We aimed to study the prevalence and nature of reflux after POEM and correlate reflux with endoscopy and pH-impedance findings. This is a prospective cohort study of achalasia patients undergoing POEM since 2014. Data from Eckardt and GERD symptom scores, high-resolution oesophageal manometry (HRM) and gastroscopy were performed pre-procedure and repeated at 1-year follow-up. Data from 24-h pH-impedance, if performed, were also recorded. A standardized questionnaire was used to determine the severity and frequency of heartburn symptoms and the composite score for each patient was calculated. 58 patients underwent POEM between January 2014 and October 2018. The efficacy of POEM at 1year was 93.0%. We observed reduction of median Integrated Relaxation Pressure (IRP) from 23.5 ± 33.1mmHg to 13.4 ± 7.71mmHg (p = 0.005) and mean Eckardt score improved from 6.09 ± 2.43 points to 1.16 ± 1.70 points (p < 0.001). At 1year, 43.1% (n = 25) had symptomatic reflux. Of the 40 patients who underwent repeated gastroscopy, 60.0% (n = 24) had endoscopic evidence of oesophagitis with seven patients (18%) diagnosed with Grade C or D oesophagitis. 43.1% (n = 25) of patients had pH-impedance done post-POEM off PPIs. 14 patients (56%) had increased acid exposure. Sixteen percent of reflux episodes were acidic and 77.3% were weakly acidic. POEM was an effective treatment for achalasia. However, GERD was common after POEM with incidence of 43% on symptom score, 60% on endoscopy and 56% on pH-impedance test. Post-POEM reflux appeared to be predominantly acidic in nature. Routine surveillance for GERD after POEM is recommended.

Feasibility and Determinants of Deprescription of Proton Pump Inhibitors in Patients with Typical Reflux Symptoms

Background and Aims: Proton pump inhibitors (PPIs) are commonly used drugs in the management of reflux symptoms. These drugs are frequently overused and have side effects on long term use. The present study was undertaken to determine the feasibility and determinants of deprescription of PPI in patients with typical reflux symptoms. Materials and Methods: This retrospective study recruited all patients, &gt;18 years, with heartburn and/or regurgitation of more than 3-month duration. The severity of reflux was assessed with white light endoscopy and graded as per Los Angeles classification. All patients were advised lifestyle changes, aerobic exercises for &gt;30 min/day, and dietary modifications. Follow-up details, including symptom resolution and drug requirement, were noted at 3 months after the initial visit. Results: A total of 106 patients formed the study cohort (males 60, median age 43 years [range 18–72 years]). Reflux esophagitis was noted in 32 cases (30%). Of these patients, 8 (25%) had Grade A esophagitis and the remaining had Grade B or beyond. Three-fourths of the patients were prescribed once a day PPI. On follow-up at 3 months, PPI therapy was stopped completely in 58 (54.7%) cases. Thirty-two (30.2%) and 16 (15.1%) patients were on on-demand PPI and continuous low dose therapy, respectively. A significantly higher proportion of patients with reflux esophagitis (30/32, 93.75%) could stop PPI at the end of 3 months. The need for on-demand PPI and continuous low dose therapy was higher in patients with nonerosive reflux disease (14 cases, 19%). In univariate analysis, use of alcohol (P = 0.04), smoking (P = 0.0006), presence of diabetes mellitus (P = 0.01), and presence of hiatus on endoscopy (P = 0.03) were the factors significantly associated with continued use of PPI at the end of 3 months. In multivariate analysis, smoking was the only factor independently associated with the continuation of PPI use after 3 months. Conclusion: Deprescription of PPI was achieved in 90 cases (84.9%) at 3 months. In univariate analysis, use of alcohol, smoking, presence of diabetes mellitus, and presence of hiatus are associated with continued PPI use at 3 months. In multivariate analysis, smoking was the only factor independently associated with the continuation of PPI use after 3 months.

Dose-Effect Relationship Between Gastric Cancer and Common Digestive Tract Symptoms and Diagnoses in Anhui, China.

BackgroundEarly prevention and diagnosis are key to reducing the huge burden of gastric cancer (GC). Nearly half of the population worldwide are suffering from some form of digestive tract conditions (symptoms/diagnoses, DTCs) but their relations with GC are not well understood. We aim to explore the relationships (especially dose–effect relationships) between GC and DTCs.MethodsThis study used data from a community-based case–control study in Anhui, China during 2016–2019 and performed multivariate conditional logistic regression modeling of the associations between GC and DTCs.ResultsA total of 2255 participants (451 cases and 1804 controls) completed the study. Statistically significant relations (P<0.05) were found between GC and the presence of gastroesophageal reflux [odds ratio (OR)=1.41], odynophagia (OR=1.87), stomach discomfort (OR=1.86), poor appetite (OR=2.01) and Helicobacter pylori (H. pylori) infection (OR=4.39). When the DTCs were divided into duration grades, all these ORs presented an increasing trend (P<0.05), being 1.89 to 2.45 for gastroesophageal reflux, 1.63 to 3.78 for stomach discomfort, 2.36 to 5.29 for poor appetite, and 3.95 to 10.03 for H. pylori infection. When the DTCs were divided into severity grades, the ORs also witnessed an increasing trend (P<0.05), being 1.69 to 2.52 for gastroesophageal reflux, 2.44 to 3.56 for stomach discomfort, and 2.22 to 2.75 for poor appetite. When the DTCs were divided into duration-severity grades, the ORs displayed a much steeper increasing trend, being 0.49 to 4.96 for gastroesophageal reflux, 1.50 to 6.33 for odynophagia, 0.47 to 3.32 for stomach discomfort, and 0.40 to 10.47 for poor appetite. In contrast, the ORs for the lower DTCs were generally tested without statistical significance.ConclusionThe study revealed consistent dose–effect associations between GC and duration of gastroesophageal reflux, stomach discomfort, poor appetite, and H. pylori infection; severity of gastroesophageal reflux, stomach discomfort and poor appetite; and duration-severity of gastroesophageal reflux, odynophagia, stomach discomfort and poor appetite. These should inform future prevention, diagnosis and further research in patients with GC.

Is transoral incisionless fundoplication (TIF) an answer to post-peroral endoscopic myotomy gastroesophageal reflux? A multicenter retrospective study.

The use of peroral endoscopic myotomy (POEM) for achalasia has a high incidence of post-procedural gastroesophageal reflux (GER). Transoral incisionless fundoplication (TIF) may be an ideal endoscopic treatment. We report our experience with the use of post-POEM TIF. In this multicenter retrospective study, post-POEM patients with GER who underwent TIF were included. The study end points were: (i) technical success; (ii) safety; (iii) effectiveness (changes in symptoms, scores, proton pump inhibitor [PPI] use, pH studies). 12 patients underwent TIF after POEM, nine of whom had daily symptoms, with 91.7% requiring twice daily (BID) PPIs. Technical success was achieved in all patients. Two adverse events occurred. There were significant decreases in the percentage of patients on BID PPIs (P = 0.03), frequency of daily symptoms (P = 0.03), Reflux Severity Index questionnaire, and GERD Health-related Quality of Life scores (P = 0.03 and P = 0.003; n = 6). pH studies performed in seven of the patients showed a significant reduction in the mean DeMeester score (P = 0.05) and mean percentage acid exposure time (P = 0.04). Our experience suggests that TIF may be effective and safe in treating GER after POEM. Larger prospective trials are needed.

Stratification of pelvic venous reflux in patients with pelvic varicose veins

ObjectiveWe investigated the association between the pattern and duration of pelvic venous reflux (PVR) and pelvic pain severity in patients with pelvic varicose veins (PVVs). MethodsThe present retrospective study included 600 female patients with PVVs. Of the 600 patients, 453 had had PVVs and pelvic congestion syndrome (group 1) and 147 had had an asymptomatic disease course (group 2). Pelvic venous pain (PVP) was assessed using a visual analog scale. All the patients had undergone duplex ultrasound of the left and right renal veins, external, internal, and common iliac veins, and parametrial, uterine, gonadal, and vulvar veins (PV, UV, GV, and VV, respectively), with an assessment of their patency and diameter and the presence and duration of reflux. Reflux in the pelvic veins was considered pathologic if it lasted for >1 second. ResultsIn group 1, PVR type I (1-2 seconds), II (3-5 seconds), and III (>5 seconds or spontaneous reflux in the absence of a loading test) was found in 31%, 58%, and 11% of the patients, respectively. Moderate and severe reflux (types II and III) was associated with severe PVP (mean score, 8.3 ± 0.5) in 69% of the group 1 patients. A combination of reflux in the GV, PV, UV, and internal iliac vein was associated with severe PVP (mean score, 8.1 ± 0.3) in 51% of these patients. A combination of reflux in the PVs, UVs, and VVs was associated with moderate pain (mean score, 5.3 ± 0.2) in 49.2% of group 1. In group 2, PVR type I, II, and III was present in 95%, 4%, and 1% of the patients, respectively, and was observed in the PV only in patients with type I; in the GVs, PVs, UVs, and internal iliac veins in those with type II; and in the PVs and GVs in the patients with type III reflux. Reflux in the GVs and UVs was significantly more prevalent in group 1 than in group 2 (GVs, 51% vs 6%; P = .0001; UVs, 57% vs 7%; P = .0001). A combination of reflux in the GVs and UVs was a predictor of severe PVVs (odds ratio, 19.7; 95% confidence interval, 11.3-34.6). ConclusionsIn patients with PVVs, the presence and severity of pelvic pain will be determined by the type of PVR and its distribution in the pelvic veins. The combination of moderate to severe reflux (types II and III) in the PVs, UVs, and GVs was a predictor of severe PVP. Patients with asymptomatic PVVs were characterized by mild reflux (type I) in the PVs, with rare involvement of the GVs and UVs.

Detection of severe pulmonary hypertension based on computed tomography pulmonary angiography.

Pulmonary hypertension (PH) is often diagnosed late in the disease course. As many patients may undergo computed tomography pulmonary angiography (CTPA) for exclusion of pulmonary embolism (PE), we aimed to create a model that can detect the existence of PH and grade its severity. Consecutive patients who underwent CTPA which was negative for PE, and echocardiography study within 24h, were included. The CT parameters evaluated to assess PH were: the diameters of the main pulmonary artery (MPA), ascending aorta (AA), calculation of each heart chamber volume, and the severity of reflux of contrast material. Randomly, 70% of patients were included in the model creation group, and 30% were used to validate the model. The final study group included 740 patients, 268 male patients, median age 72years. 374 patients (51%) had PH, of them 94 (13%) had severe PH on the echocardiography. Right atrium (RA) and Left atrium (LA) volume indices were the strongest parameter to indicate PH (area under the curve, AUC = 0.738 and 0.736, respectively), while Right ventricle (RV) and RA volume indices were the strongest parameter to identify severe PH (AUC = 0.735 and 0.715, respectively) with MPA diameter being the least influential indicator (AUC = 0.623). Using the patients age, gender, and multiple CTPA parameters, we created a model for predicting the existence of severe PH. After validation, the model demonstrated 91% sensitivity and a negative predictive value of 97%. Applying our models, CTPA can be used to identify severe PH immediately after the completion of CTPA exam.

The Role of the Transdiaphragmatic Pressure Gradient (TGP) in the Pathophysiology of Proximal Reflux

IntroductionAn increased transdiaphragmatic pressure gradient (TGP) is a main element for distal gastroesophageal reflux disease (GERD). The role of TGP for proximal reflux is still unclear. This study aims to evaluate the presence, severity, and importance of proximal reflux in relationship to the TGP, comparing healthy volunteers, obese individuals, and patients with chronic obstructive pulmonary disease (COPD). MethodsWe studied 114 individuals comprising 19 healthy lean volunteers, 47 obese individuals (mean body mass index 45 ± 7 kg/m2), and 48 patients with COPD. All patients underwent high-resolution manometry and dual-channel esophageal pH monitoring. Esophageal motility, thoracic pressure (TP), abdominal pressure (AP), TGP, DeMeester score, and % of proximal acid exposure time (pAET) were recorded. ResultsPathologic distal GERD was found in 0, 44, and 57% of the volunteers, obese, and COPD groups, respectively. pAET was similar among groups, only higher for obese individuals GERD + as compared to obese individuals GERD − and COPD GERD −. pAET did not correlate with any parameter in healthy individuals, but it correlated with AP in the obese, TP in the COPD individuals, and TGP and DeMeester score in both groups. When all individuals were analyzed as a total, pAET correlated with AP, TGP, and DeMeester score. DeMeester score was the only independent variable that correlated with pAET. ConclusionsOur results show that (a) TGP is an important mechanism associated with distal esophageal acid exposure and this fact is linked with proximal acid exposure and (b) obesity and COPD both seem to be primary causes for GERD but not directly for proximal reflux.