Significant Gastroesophageal Reflux Research Articles

Case 1: New onset of seizures in a five-year-old girl

A five-year-old girl with a history of repaired tetralogy of Fallot and esophageal atresia presented to the emergency department after an unexplained spell, which her father described as jerking movements of her arms with her eyes closed. The episode lasted for 3 min. After the episode, she was floppy and proceeded to vomit. She appeared pale and sleepy with mild hypotonia. Her height was 98 cm (less than the fifth percentile) and her weight was 14.4 kg (less than the fifth percentile). Her weight for height was normal (between the 25th percentile and the 50th percentile) and her records showed a normal growth velocity. Her hemoglobin level was 79 g/L with a low mean corpuscular volume, and her liver enzyme and electrolyte levels were normal. Her blood glucose level was 1.8 mmol/L. She was treated with intravenous dextrose and recovered. Her parents reported that after her gastric pull-up surgery for esophageal atresia at six months of age, she had developed significant gastroesophageal reflux disease with poor gastric emptying. At two-and-a-half years of age, the gastric pull-up was revised and a ‘twist’ in the pull-up was noted with kinking at the level of the diaphragm. She was gastric tube-fed until six months of age, jejunal tube-fed until two-and-a-half years of age and nasogastric tube-fed until four years of age. Once oral feeds were started, she became a picky eater and had frequent dizzy spells. She felt weak at variable times during the day which resolved after a brief nap. On the day of the seizure she had eaten as usual. She was not taking any medications. A referral to the endocrinology department resulted in further testing, which revealed the diagnosis.

Congenital esophageal stenosis associated with esophageal atresia: new concepts

Congenital esophageal stenosis (CES) is suspected by a fixed intrinsic narrowing of the esophagus that affects the normal swallowing mechanism. The diagnosis is only confirmed by histopathologic picture, which may show fibromuscular disease (FMD) or tracheobronchial remnants (TBR). The latter involves ciliated pseudo stratified columnar epithelium, seromucous glands or cartilage each alone or in combination. The aim of this study is to document the usefulness of histologic picture of surgical specimens obtained from the lower esophageal pouch (LEP) during primary repair in detecting cases of CES associated with esophageal atresia (EA) with or without tracheoesophageal fistula (TEF). Over an 8-year period, 57 consecutive cases operated upon for EA with or without TEF were subjected for histologic examination of surgical specimens obtained from the tip of the LEP. Cases that histologically showed FMD or TBR were included. The usefulness of this histologic picture as a diagnostic and therapeutic aid is assessed. Methods of treatment and outcome were also reviewed. Eight patients out of 57 (14%) had a histologic picture suggestive of CES, two with FMD, four with TBR without cartilage and two with cartilage. Out of 57 patients, 23 developed strictures, six of them had positive biopsies suggestive of CES. One patient with TBR without cartilage did not have stricture. Another case of pure atresia had LEP resection and gastric pull up showed cartilage involving the whole lower esophagus. Excluding the case of pure EA with gastric pull up, all patients suffered from feeding problems and recurrent aspiration. Fluoroscopic barium studies showed late onset minor dysmotility in five patients and late onset major dysmotility in two. All cases studied showed significant gastro-esophageal reflux (GER). Stricture was seen at the anastomotic site extending distally in the two fibromuscular cases and one case with cartilage, at the anastomotic site in three cases with TBR without cartilage. Anti reflux surgical procedures were performed in four patients without benefit in two patients with major dysmotility. Dilatation was successful in the three patients with TBR without cartilage. One patient with cartilage had resection of the anastomotic site and required frequent dilatations and is now doing well. A case of FMD did not improve after frequent dilatations and myotomy together with Nissen's fundoplication and required resection while the other case of FMD responded partially to dilatations. Cartilage in cases of CES requires surgical resection. Those with TBR without cartilage may not develop stricture. If stricture develops, it responds well to dilatation and patients have good clinical outcomes. Unlike isolated CES, GER is a significant feature in CES with EA. Anti reflux procedures should be avoided before definitive surgery for the stricture and if necessary a partial wrap with gastrostomy is recommended. CES should be considered in the etiology of anastomotic stricture. Taking a surgical specimen routinely from the tip of the LEP during primary esophageal repair for histologic studies is highly recommended.

The cumulative incidence of significant gastrooesophageal reflux in patients with oesophageal atresia with a distal fistula—a systematic clinical, pH-metric, and endoscopic follow-up study

Background and Aim Gastrooesophageal reflux (GER) is common in patients with oesophageal atresia (OA). Complicated GER often manifests itself early after the primary repair (PR) and frequently requires antireflux surgery (ARS). How many patients will be later affected is unknown. We conducted an objective long-term follow-up for the cumulative incidence of OA-associated GER based on pH-metry and histology. Materials and Methods Sixty-one consecutive patients with their native oesophagus, who underwent PR for OA with a distal fistula from 1989 to 2004, were included. These children were grouped according to the Spitz classification with 77% as type I, 20% as type II, and 3% as type III. Significant heart disease, tracheomalacia, or gastric outlet obstruction occurred in 18.0 %, 9.8%, and 17.3% respectively, and a wide gap between esophageal segments occurred in 13.1%. Endoscopy and pH-metry at 1 year were followed up by endoscopy and selective pH-metry at 3, 5, and 10 years. Gastrooesophageal reflux was considered significant (sGER) when a patient underwent ARS, endoscopic biopsies disclosed at least moderate oesophagitis, or when total or preprandial reflux index were greater than 10% or 5%, respectively, with or without long (>5 minutes) reflux periods). Significant GER was considered resolved if, without need for ARS or medication, pH-metry or biopsies returned to normal and the patient was symptomless for at least 3 years. Results The incidence of sGER/(number of assessed patients) at 6 months, 1 year, 3 years, 5 years, and 10 years was 16.3% (61), 39.3% (61), 44.2% (52), 51.2 % (43), and 44.4% (27). Overall, 28/61 (45.9%) of patients had sGER, and 18/28 (64.3%) patients underwent ARS. In one patient, sGER resolved during the follow-up. Conclusion The number of children with sGER associated with OA more than doubled from 6 months to 1 year after PR. Thereafter, there is a progressive increase in the incidence of sGER with age up to 5 years. Spontaneous resolution of sGER is rare.

IS GASTROESOPHAGEAL REFLUX DISEASE MORE PREVALENT IN PATIENTS WITH MONOCLONAL GAMMOPATHY OF UNDETERMINED SIGNIFICANCE?

Background The prevalence of clinically significant gastroesophageal reflux (GERD) in the general population varies between 3 and 6%. We observed GERD to be one of the major complaints of our patient population with monoclonal gammopathy of unknown significance (MGUS). There is no literature available on the incidence of GERD in MGUS. Moreover, there have been conflicting reports on the prevalence of Helicobacter pylori and MGUS. Objective To study the incidence and relationship of GERD, H. pylori, and MGUS. Methods We identified 394 patients with MGUS at Veterans Affairs Medical Center, Kansas City, diagnosed over the last 20 years. The control group consisted of patients with chronic lymphocytic leukemia (CLL) followed over the same period (20 years) at the same institution. Charts on these patients were reviewed for endoscopic findings, pathologic biopsies, and H. pylori staining on histology. Results Forty-one percent (162/394) of patients with MGUS were noted to have moderate to severe symptoms of GERD compared with 10% (47/460) in the control group. The median age of the patients was similar in both groups. Sixty percent (97/162) of MGUS patients with GERD underwent endoscopies compared with 25% (12/47) of patients in the control group. Histology was positively stained for H. pylori in 27.8% patients (27/97) in MGUS and 25% (3/12) of the control group. We found no correlation between H. pylori positivity and type or level of monoclonal protein in MGUS. In addition, we observed no change in immunoglobulin levels following treatment and eradication of H. pylori in MGUS patients. Conclusion At our institution, patients with MGUS have a higher prevalence of GERD. Our findings need to be confirmed and verified in further prospective studies. No correlation was seen between H. pylori infection and MGUS.

Diagnosis of Gastro-Oesophageal Reflux in Preterm Infants: Sonography vs. pH-Monitoring

Objectives: To compare the ultrasound examination with pH-metry in order to evaluate the diagnostic accuracy of sonography for diagnosis of gastro-oesophageal reflux (GOR) in preterm infants. Methods: A prospective study was conducted on 31 premature infants <34 weeks with clinically diagnosed GOR. First, they underwent 24-hour pH-monitoring; successively, the sonographic assessment was performed within 12 h after pH-monitoring. The two operators who performed the pH-monitoring and sonography respectively, were unaware of each other’s results. Results: Twenty-one patients (67.7%) had significant GOR with a reflux index >5 (GOR group). The median (range) reflux index in this group was 9.19% (6.04–20.1). Ten newborns (32.3%) did not have significant GOR with a reflux index <5. Sonography was positive for GOR in 8 patients (25.8%); all 8 infants with sonographic diagnosis of GOR had a reflux index >5. Therefore, sonographic diagnosis did not produce false positives. Sonography was negative in 23 newborns (74.2%); 13 of these were positive to pH-monitoring and may therefore be considered as false negatives. Respect to continuous 24-hour pH-monitoring, sonography showed a specificity of 100% but a very low sensitivity of 38% with a positive prediction value of 100% and a negative prediction value of 43%. Conclusions: Sonography should not replace 24-hour pH monitoring for detecting GOR in preterm infants. However, sonography has a very high specificity and a positive predictive value of 100%. When clinicians suspect GOR in preterm infants, it could be useful for selection of cases to refer for pH-metry.

GERD, Helicobacter pylori and MGUS-Is There a Relationtionship?.

Background: The prevalence of clinically significant gastro esophageal reflux (GERD) in the general population varies between 3–6%. We have observed GERD to be one of the major complaints of our patient population with monoclonal gammopathy of unknown significance (MGUS). There is no literature available on the incidence of GERD in MGUS. However, there have been conflicting reports on the prevalence of helicobacter pylori (H. pylori) and MGUS.Objective: To study the incidence and relationship of GERD, H. pylori and MGUS.Methods: We identified all patients diagnosed with MGUS at the Kansas City VA Medical Center over the last 20 years. Out of the 417 patients identified with MGUS, 394 patients fulfilled the inclusion criteria. All patients with GERD were evaluated by gastroenterologists at our institution who determined their diagnostic and therapeutic management. Charts on these patients were then reviewed for endoscopic findings, pathological biopsies, H. pylori staining on histology, serum protein electrophoresis with immunofixation (SPEP/IFE), immunoglobulin levels, and bone marrow biopsies.Results: In this study, 41% patients with MGUS were noted to have moderate to severe symptoms of GERD (162/394). The median age of patients with and without GERD was similar (72 versus 71 years). Endoscopies were performed on 60% of the patients with GERD (97 of 162). Histology was positively stained for H. pylori in 27.8% patients (27/97). We did not find any correlation between H. pylori positivity and the type or level of monoclonal protein. In addition, we observed no change in immunoglobulin levels following treatment and eradication of H. pylori.Conclusion: The incidence of GERD is significantly higher in patients with MGUS than in the general population. In our study, no correlation was seen between H. pylori infection and MGUS.

An infant with long gap oesophageal atresia: A case report

The survival rate and outcomes of infants born with oesophageal atresia have improved significantly attributable to the growing body of knowledge in managing infants with this congenital anomaly. However, after surgical repair of the defect, the quality of life is impinged upon in varying degrees by the morbidity associated with this anomaly, the most common complications being oesophageal stricture and gastro-oesophageal reflux. Team collaboration is essential to achieve the desired positive outcomes. In the pre- and postoperative periods, stringent attention to prevent airway complications and to provide optimal nutrition for growth is pivotal. After oesophageal anastomosis, establishing oral feeding is paramount; but this may be a long and difficult process in the presence of oesophageal stricture and significant gastro-oesophageal reflux. Parental participation, support and education are critical in enabling independence and confidence in the care of their infant. Furthermore, meticulous discharge planning is crucial for transition from hospital to home.

Clinically significant gastro-oesophageal reflux following oesophageal flap repair for oesophageal atresia and tracheo-oesophageal fistula

Clinically significant gastro-oesophageal reflux (GOR) following oesophageal atresia and tracheo-oesophageal fistula (OA/TOF) repair is commonly considered normal sequela after repair. A retrospective review of patients operated on by two consultants was undertaken. All patients underwent oesophageal tailoring and augmentation for reconstruction of their oesophagus. The presence of clinically significant GOR was confirmed by contrast swallows, 24 hour pH study and endoscopy. Clinically significant GOR occurred in 7 (13%) of the 54 patients operated for OA and TOF. Two patients responded to non-surgical management. Four children (one with extensive tracheo-bronchomalacia and one with CHARGE association) had anti-reflux surgery (three Nissen and one Thal). We believe that oesophageal tailoring and augmentation for reconstruction of the oesophagus has the advantage of creating a more uniform oesophagus thus avoiding swallowing difficulty, bolus obstruction and the need of oesophageal dilatations too often accepted as integral to the problem following OA repair.

“Silent” Gastroesophageal Reflux in Patients with Unexplained Sleep Complaints

Purpose: Patients with gastroesophageal reflux (GER) commonly report poor sleep, and it has been established that the arousals from sleep are frequently associated with acid mucosal contact via GER. It has also been shown that individuals with significant GER exacerbating respiratory symptoms may frequently be without complaints of heartburn. We posed the question of whether a substantial portion of individuals with sleep complaints, without significant heartburn, experience “silent” reflux during sleep. Methods: 104 individuals with documented sleep complaints at least three nights per week were randomized after a two-week run in period with recorded sleep diaries. 81 subjects completed two polysomnographic sleep evaluations including distal esophageal pH separated by 10–21 days. Results: Of the 81 subjects studied, 26% had reflux (pH < 4 for more than 30 sec) on at least one night. Of the participants with reflux, 21% had more than 4% acid contact time (ACT), 25% had at least one event that lasted more than five minutes and the average ACT was 28%. The average duration of each reflux episode was 34.4 minutes. Almost all (94%) of the recorded reflux events were associated with an arousal or awakening. An historical comparison group of symptomatic GERD patients with concomitant sleep complaints had an average ACT of only 12% (p < .05). Conclusions: 1. A substantial portion of individuals with sleep complaints, and without significant heartburn symptoms, revealed “silent reflux” during sleep. 2. “Silent reflux” may be the cause of sleep disturbances in individuals with unexplained sleep disorders.

Gastroesophageal Reflux (Symptomatic and Silent): A Potentially Significant Problem in Patients With Cystic Fibrosis Before and After Lung Transplantation

The significance of gastroesophageal reflux (GER) and aspiration are unclear in cystic fibrosis (CF) and may contribute to declining lung function before and after lung transplantation (LTx). We sought to establish whether GER occurs in patients with CF on the LTx waiting list and after LTx. We then investigated whether GER correlates with patients' symptoms. Adults with CF on the waiting list and after LTx were prospectively recruited. Completion of a valid, structured symptom questionnaire was followed by ambulatory, dual-probe, 24-hour esophageal pH monitoring. Twenty-four patients were studied, including 11 (6 males) in the pre-LTx group and 13 (9 males) in the post-LTx group. The pre-LTx group was 29.3 +/- 8.2 years of age, and the post-LTx group was 32.7 +/- 8.2 years of age. DeMeester score (normal value <14.7) was 36.6 +/- 22.3 for the pre-LTx group and 40.0 +/- 37.3 for the post-LTx group. Proximal esophageal acid exposure was significantly higher in both CF groups compared with normal. Symptom scores (normal <4, range -2 to 18) were: pre-LTx group, 5.8 +/- 6.5; post-LTx group, 7.7 +/- 5.4. Percent forced expiratory volume in 1 second (FEV1%) predicted was: pre-LTx group, 31.3 +/- 7.8; post-LTx group, 65.2 +/- 29.3. In the pre-LTx group, 10 of 11 (90.9%) patients had significant GER on monitoring, including 4 (40%) with symptomatic GER and 6 (60%) with silent GER. In the post-LTx group, 11 of 13 (84.6%) had significant GER on monitoring, including 9 (82%) with symptomatic GER and 2 (18%) with silent GER. GER, symptomatic and silent, is a significant problem in CF. This condition should be aggressively treated and surgery should be considered if GER persists on re-testing.

The effect of acid suppression on sleep patterns and sleep‐related gastro‐oesophageal reflux

Several studies have demonstrated that night-time gastro-oesophageal reflux affects sleep quality, and thereby impairs daytime functioning. To determine whether treatment with a proton-pump inhibitor (rabeprazole) would improve both objective and subjective measures of sleep. Individuals with complaints of significant gastro-oesophageal reflux disease were studied by polysomnography and 24-h pH monitoring on two separate nights. On one occasion, participants received 20 mg rabeprazole b.d., and on another they received placebo. Both study conditions were preceded by a week of treatment with either rabeprazole or placebo. The order of treatments was randomized. Rabeprazole significantly reduced overall acid reflux, but it did not significantly reduce night-time acid contact. Rabeprazole treatment significantly improved subjective indices of sleep quality. There were no significant differences on objective measures of sleep between placebo and rabeprazole treatment. Consistent with other studies of pharmacological treatments for gastro-oesophageal reflux, subjective measures of sleep improved with heartburn medication but objective measures were not affected.

Does postoperative pH monitoring predict complicated gastroesophageal reflux in patients with esophageal atresia?

Gastroesophageal reflux (GER) is common after repair of esophageal atresia with a distal tracheoesophageal fistula (EATOF). In a retrospective study we assessed whether early 18-h pH monitoring can predict the development of EATOF-associated gastroesophageal reflux. During 1980-1997, 90 consecutive patients had primary repair for EATOF. Development of GER was classified as favorable if the patient developed no esophagitis or mild esophagitis and needed no antireflux medication, and as unfavorable if the patient developed moderate or secondary esophagitis or required an antireflux procedure. Patients who developed unfavorable GER outcome before pH monitoring or needed secondary reconstruction or those whose endoscopic follow-up data were insufficient were excluded. Eighteen-hour pH monitoring was considered pathologic if esophageal pH was <4 more than 10% of the recorded time or 5% of the recorded time minus 2 h after each meal, or if there were more than three preprandial reflux periods lasting longer than 5 min. A total of fifty patients were included into the study. pH monitoring was performed at the median age of 9.2 (range 2.5-95.0) months and classified as pathologic in 10 and normal in 40 patients. After a median follow-up of 59 (0.3-217.6) months, nine of 10 (90%) patients with pathologic pH monitoring and five of 40 (12.5%) patients with normal pH monitoring developed unfavorable outcomes ( p<.05). We conclude that early pH monitoring predicts the development of significant GER, but because 12.5% of patients with normal early pH monitoring also developed significant GER, early pH monitoring alone does not rule out the development of significant GER.

P0758 LAPEG (LAPAROSCOPIC ASSISTED PERCUTANEOUS ENDOSCOPIC GASTROSTOMY): TOWARDS A SAFER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY PLACEMENT

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) is a popular procedure for gastrostomy tube placement. There are known complications of PEG placement, particularly inadvertent puncture of the intestine. In addition, a small but significant subset will develop significant gastroesophageal reflux disease and need subsequent fundoplication. Previous PEG placement often requires repositioning of the gastrostomy or impairs the possibility of performing a subsequent laparoscopic fundoplication. Methods: Since 1999 we have used Laparoscopic Assisted Percutaneous Endoscopic Gastrostomy (LAPEG) for patients requiring gastrostomy tubes. A 2 mm video assisted laparoscope is placed percutaneously through the umbilicus. A site on the abdominal wall, 1.5 cm below the right costal margin mid clavicular line, is chosen for gastrostomy site. CO2 pneumoperitoneum is established. Endoscopy is carried out and the light source is identified in the stomach by the laparoscope. A site for gastrostomy is chosen in the mid body of the stomach 1 cm superior to the gastroepiploic arcades. This site is punctured percutaneously and a standard “pull technique” is used for PEG placement, visualizing the entire procedure through the laparoscope. Results: From 1999–2003, this technique was used in 9 patients with mean age of 8 years (range 2–20 years). All were successfully completed as described above. Complications consisted of 1 retained bolster (buried bumper), which was salvaged by endoscopic assisted replacement of the gastrostomy tube. One patient needed subsequent fundoplication. Fundoplication, when necessary, were performed laparoscopically without having to take down or reposition the previously placed gastrostomy tube. Conclusion: LAPEG eliminates risk of intestinal injury during PEG placement. The gastrostomy tube can be placed strategically in the stomach, so that laparoscopic manipulation of the esophageal hiatus can be subsequently performed as well as assuring that adequate fundus is available for a fundoplication without need to reposition the gastrostomy tube.

LAPEG (Laparoscopic Assisted Percutaneous Endoscopic Gastrostomy): Towards a Safer Percutaneous Endoscopic Gastrostomy Placement

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) is a popular procedure for gastrostomy tube placement. There are known complications of PEG placement, particularly inadvertent puncture of the intestine. In addition, a small but significant subset will develop significant gastroesophageal reflux disease and need subsequent fundoplication. Previous PEG placement often requires repositioning of the gastrostomy or impairs the possibility of performing a subsequent laparoscopic fundoplication. Methods: Since 1999 we have used Laparoscopic Assisted Percutaneous Endoscopic Gastrostomy (LAPEG) for patients requiring gastrostomy tubes. A 2 mm video assisted laparoscope is placed percutaneously through the umbilicus. A site on the abdominal wall, 1.5 cm below the right costal margin mid clavicular line, is chosen for gastrostomy site. CO2 pneumoperitoneum is established. Endoscopy is carried out and the light source is identified in the stomach by the laparoscope. A site for gastrostomy is chosen in the mid body of the stomach 1 cm superior to the gastroepiploic arcades. This site is punctured percutaneously and a standard pull technique is used for PEG placement, visualizing the entire procedure through the laparoscope.Results: From 1999-2003, this technique was used in 9 patients with mean age of 8 years (range 2-20 years). All were successfully completed as described above. Complications consisted of 1 retained bolster (buried bumper), which was salvaged by endoscopic assisted replacement of the gastrostomy tube. One patient needed subsequent fundoplication. Fundoplication, when necessary, were performed laparoscopically without having to take down or reposition the previously placed gastrostomy tube.Conclusion: LAPEG eliminates risk of intestinal injury during PEG placement. The gastrostomy tube can be placed strategically in the stomach, so that laparoscopic manipulation of the esophageal hiatus can be subsequently performed as well as assuring that adequate fundus is available for a fundoplication without need to reposition the gastrostomy tube.

Childhood gastroesophageal reflux symptoms in adult patients.

Gastroesophageal reflux (GER) and its esophageal (esophagitis, Barrett's esophagus) and extraesophageal (asthma, laryngeal disease) disease manifestations (GERD) are increasing common problems in children and adults. There are virtually no published longitudinal outcome studies that describe the natural history of childhood-onset GER throughout a person's lifetime. The aim of this study was to compare the frequency of recalled childhood reflux symptoms in adult patients currently with and without GER symptoms. Four hundred adult patients were classified as refluxers (225 patients; 57%), nonrefluxers (154 patients; 38%), and those who claimed to not know if they had reflux (21 patients; 5%; excluded from analysis). Subjects were given a questionnaire asking them to recall childhood symptoms attributed to GER. Of the 225 refluxers, 141 (63%) recalled at least one childhood symptom, compared with 54 of the 154 nonrefluxers (35%) ( < 0.001). Adult refluxers were more likely to recall having developed GER symptoms at an earlier age, beginning at infancy and developing statistically significant GER compared with nonrefluxers after age 11. Adults suffering from GER were far more likely than nonrefluxers to recall having experienced GER symptoms during childhood. Well-designed, population-based epidemiologic studies are needed to more accurately assess the extent of GER in the overall population and the extent of its impact on health care in the United States.

Fat Laden Macrophages in Tracheal Aspirates as a Marker of Reflux Aspiration: A Negative Report

ABSTRACTObjectivesRefluxed gastric material aspirated into the lungs is an important cause of acute and chronic pulmonary disease. Currently, the presence of fat‐laden macrophages (FLM) in tracheobronchial secretions of children is a conventional marker for reflux aspiration. However, this assay is limited by its apparent lack of specificity. The aim of this study was to reevaluate the role of this assay in diagnosing reflux aspiration.MethodsThe tracheal aspirates of sixty‐four consecutive children with clinically significant gastroesophageal reflux undergoing upper gastrointestinal endoscopy under general anesthesia, and 34 other children from the routine operative schedule were evaluated. Both groups were further subdivided on the basis of presence or absence of associated respiratory symptoms. After intubation, tracheal aspirates were collected, fixed, and stained for FLM. By grading the amount of intracellular fat present, a semiquantitative lipid index was computed. Tracheal aspirates with a lipid index of 100 or greater were considered positive.ResultsTwenty‐four of the 64 children with reflux symptoms and 14 of 34 children without reflux symptoms were positive for FLM. Sixteen of 37 children with both gastroesophageal reflux and respiratory symptoms and 10 of 26 children negative for both tested positive for FLM. The mean lipid index of the subgroup of children with both reflux and respiratory symptoms was not significantly different from that of the subgroup that was negative for both conditions. Despite computing a semiquantitative lipid index, an index of 100 or greater only had a sensitivity of 38% and specificity of 59%.ConclusionAssay of FLM in the tracheal aspirates of children considered at risk of reflux aspiration is not a sensitive or specific as a marker for reflux aspiration.

Assay of tracheal pepsin as a marker of reflux aspiration.

Aspiration of gastric contents is a relatively common cause of acute and chronic pulmonary disease. However, a reliable method of diagnosing recurrent aspiration is currently lacking. The aim of this study was to determine whether the presence of gastric pepsin in tracheal aspirates of infants and children might be used as a reliable marker of the microaspiration of refluxed gastric contents. Ninety-eight children undergoing general anesthesia and tracheal intubation participated in the study. Sixty-four of 98 children underwent endoscopy for clinically significant gastroesophageal reflux. Thirty-four children from routine operative lists were nonreflux controls. These two groups were further subdivided based on the presence or absence of associated respiratory symptoms. After endotracheal intubation, tracheal aspirates were obtained and subsequently assayed for gastric pepsin using a fluoroscein isothiocyanate casein. Pepsin was detected in 7 of 27 children with reflux symptoms alone and in 7 of 8 of those with chronic respiratory symptoms. In addition, pepsin was present in 31 of 37 children with a history of both reflux and chronic respiratory symptoms. Tracheal pepsin was not detected in any of the 26 children without gastroesophageal reflux or respiratory symptoms. Tracheal pepsin was found significantly more frequently in children with reflux symptoms than in those without, particularly in children with both reflux and respiratory problems. Tracheal pepsin assay as a reliable marker of gastroesophageal reflux aspiration.

Fat laden macrophages in tracheal aspirates as a marker of reflux aspiration: a negative report.

Refluxed gastric material aspirated into the lungs is an important cause of acute and chronic pulmonary disease. Currently, the presence of fat-laden macrophages (FLM) in tracheobronchial secretions of children is a conventional marker for reflux aspiration. However, this assay is limited by its apparent lack of specificity. The aim of this study was to reevaluate the role of this assay in diagnosing reflux aspiration. The tracheal aspirates of sixty-four consecutive children with clinically significant gastroesophageal reflux undergoing upper gastrointestinal endoscopy under general anesthesia, and 34 other children from the routine operative schedule were evaluated. Both groups were further subdivided on the basis of presence or absence of associated respiratory symptoms. After intubation, tracheal aspirates were collected, fixed, and stained for FLM. By grading the amount of intracellular fat present, a semiquantitative lipid index was computed. Tracheal aspirates with a lipid index of 100 or greater were considered positive. Twenty-four of the 64 children with reflux symptoms and 14 of 34 children without reflux symptoms were positive for FLM. Sixteen of 37 children with both gastroesophageal reflux and respiratory symptoms and 10 of 26 children negative for both tested positive for FLM. The mean lipid index of the subgroup of children with both reflux and respiratory symptoms was not significantly different from that of the subgroup that was negative for both conditions. Despite computing a semiquantitative lipid index, an index of 100 or greater only had a sensitivity of 38% and specificity of 59%. Assay of FLM in the tracheal aspirates of children considered at risk of reflux aspiration is not a sensitive or specific as a marker for reflux aspiration.

Assay of Tracheal Pepsin as a Marker of Reflux Aspiration

ABSTRACTObjectivesAspiration of gastric contents is a relatively common cause of acute and chronic pulmonary disease. However, a reliable method of diagnosing recurrent aspiration is currently lacking. The aim of this study was to determine whether the presence of gastric pepsin in tracheal aspirates of infants and children might be used as a reliable marker of the microaspiration of refluxed gastric contents.MethodsNinety‐eight children undergoing general anesthesia and tracheal intubation participated in the study. Sixty‐four of 98 children underwent endoscopy for clinically significant gastroesophageal reflux. Thirty‐four children from routine operative lists were nonreflux controls. These two groups were further subdivided based on the presence or absence of associated respiratory symptoms. After endotracheal intubation, tracheal aspirates were obtained and subsequently assayed for gastric pepsin using a fluoroscein isothiocyanate casein.ResultsPepsin was detected in 7 of 27 children with reflux symptoms alone and in 7 of 8 of those with chronic respiratory symptoms. In addition, pepsin was present in 31 of 37 children with a history of both reflux and chronic respiratory symptoms. Tracheal pepsin was not detected in any of the 26 children without gastroesophageal reflux or respiratory symptoms. Tracheal pepsin was found significantly more frequently in children with reflux symptoms than in those without, particularly in children with both reflux and respiratory problems.ConclusionTracheal pepsin assay as a reliable marker of gastroesophageal reflux aspiration.

Gastrointestinal complications of Russell-Silver syndrome: a pilot study.

Russell-Silver syndrome (RSS) is a genetic syndrome with clinical manifestations of intrauterine and postnatal growth retardation, normal head circumference, body asymmetry, and distinctive facial appearance. We followed an infant diagnosed with RSS who had occurrence of multiple gastrointestinal complications. Although there are a number of published reports describing gastrointestinal problems associated with RSS, specific gastrointestinal diseases have not been recognized as major features. We hypothesize that gastrointestinal complications may be more frequent in RSS cases than previously reported. To address our hypothesis, we developed a pilot study of RSS cases to identify and characterize associated gastrointestinal complications. Surveys were distributed by MAGIC, a support group for individuals with RSS. Surveys included information on the objective and subjective characteristics used to diagnose RSS, as well as descriptions of gastrointestinal problems. Completed surveys were returned on 135 individuals. We used strict diagnostic guidelines to determine affected status of children reported in our survey. Of the 135 surveys completed, 65 were determined to have clear-cut RSS. The diagnoses were made without knowledge of the gastrointestinal symptoms of any of the subjects. Of the 65 subjects with "clear cut" RSS, 50 (77%) had gastrointestinal symptoms. Major specific symptoms included gastroesophageal reflux disease (34%), esophagitis (25%), food aversion (32%), and failure to thrive (63%). A common theme in gastrointestinal complications of RSS is significant gastroesophageal reflux that includes esophagitis and food aversion. Results of this survey suggest that there is an association of gastrointestinal complications with RSS that should be addressed in diagnosis as well as management protocols for children with this condition.