Simultaneous Esophageal pH Monitoring Research Articles

Software improvement for evaluation of laryngopharyngeal pH testing (Restech) - a comparison between DataView 3 and 4.

BACKGROUNDWhen gastroesophageal reflux contents reach above the upper esophageal sphincter, patients may, in addition to typical reflux symptoms, present with atypical, extraesophageal symptoms related to laryngopharyngeal reflux (LPR). Surgical treatment of LPR has shown to lead to 70% symptom improvement, however no gold standard for the diagnosis of LPR exists. In 2007, the Restech Dx-pH was released as a valid method to measure acid exposure above the upper esophageal sphincter. Recently, a new software update was introduced for analysis of measured pH data and calculation of composite scores. The effect of the changes applied to the new software version have not yet been analyzed.AIMTo compare results generated by DataView 3 to the most recently released DataView 4.METHODSAll patients with gastroesophageal reflux disease symptoms were seen in a specialized surgical outpatient clinic for gastrointestinal function testing. Retrospective chart review was performed of all patients presenting with suspected gastroesophageal reflux disease and extraesophageal reflux symptoms, who underwent laryngopharyngeal pH monitoring using the Restech Dx-pH system (Respiratory Technology Corp., Houston, TX, United States) and simultaneous esophageal pH monitoring. DataView 3 and DataView 4 were used to evaluate Restech studies obtained. Diary entries such as mealtimes, supine and upright periods, and symptoms were entered manually to ensure accuracy and precise conversion of data between both software versions. Paired t test was performed for statistical analysis of results.RESULTSA total of 174 patients (63.8% female) met inclusion criteria, all suffering from extraesophageal reflux symptoms as well as typical gastroesophageal reflux disease symptoms. Mean RYAN score upright was 48.77 in DataView 3 compared to 22.17 in DataView 4, showing a significant difference (aP = 0.0001). Similar results were shown for supine period (mean RYAN Score DataView 3 5.29 vs 1.42 in DataView 4, cP = 0.0001). For upright periods 80 patients showed a decrease of value of the RYAN score with a mean of -58.9 (mean 51.1% decrease). For supine position 25 patients showed a decrease of value of the RYAN score with a mean of -15.13 [range (-153.44)–(-0.01)], which equals a mean decrease of value of 44.5%. Ten patients showed no oropharyngeal acid exposure in DataView 3, but mild/moderate (n = 7) or severe (n = 3) acid exposure in DataView 4. Correlation with positive esophageal pH measurement was improved in all 10 patients.CONCLUSIONResults of both software versions cannot be compared to each other. However, our data suggests that DataView 4 may be an improvement of the Restech pH measurement in the evaluation of LPR.

Therapeutic mechanism of diaphragm training at different periods in patients with gastroesophageal reflux disease

To explore the effects of postprandial diaphragm training (DT) on esophageal acid exposure, esophageal motility and proximal gastric volume at different postprandial periods in patients with gastroesophageal reflux disease (GERD). Thirty GERD patients and 9 healthy subjects (HS) with matched demographic characteristics were enrolled from June 2005 to June 2006 at Peking Union Medical College Hospital. Esophageal manometry with a Dent sleeve catheter and simultaneous esophageal pH monitoring were recorded in a 30-min fasting period and a 120-min postprandial period. The GERD patients were divided into 3 groups: 9 patients received diaphragm training at 1(st) hour after meal (group DT1 h) and another 10 at 2(nd) hour after meal (group DT2 h) whereas no diaphragm training after meal in 11 (group NDT). Ultrasonic imaging of proximal gastric volume was undertaken at 0, 30, 60, 90 and 120 min after meal. (1) The percentage time with pH<4 in group DT1 h was lower than that in group NDT in the 120-min postprandial period (0.2% (0-4.1%), 6.6% (2.2%-18.2%), P < 0.05) and no significant difference of esophageal acid exposure was observed between groups DT2 h and NDT (3.7% (0.1%-17.8%), 6.6% (2.2%-18.2%), P > 0.05) . (2) Esophagogastric junction (EGJ) and crural diaphragm pressures at the 1(st) hour after meal in group DT1 h were both significantly higher than those in group NDT during diaphragm training ((44.4 ± 8.1) vs(16.2 ± 4.5) mm Hg, (38.2 ± 4.2) vs (9.8 ± 4.5) mm Hg, 1 mm Hg = 0.133 kPa, both P < 0.05). EGJ and crural diaphragm pressures at the 2(nd) hour after meal in group DT2 h were significantly higher than those in group N-DT during diaphragm training ((53.2 ± 7.5) vs (14.0 ± 3.7) mm Hg, (48.2 ± 6.3) vs (8.9 ± 2.7) mm Hg, both P < 0.05). There was no change of lower esophageal sphincter pressure (all P > 0.05). (3) After test meal, the groups DT1 h, DT2 h and N-DT had similar proximal stomach volume (all P > 0.05). Diaphragm training at the 1(st) hour after meal might reduce the 120-min postprandial esophageal acid exposure in GERD patients. The reduction in esophageal acid exposure may result from enhanced antireflux barrier of EGJ function. Therefore postprandial diaphragm training provides a new approach to conservative treatment of GERD.

The effect of baclofen on nocturnal gastroesophageal reflux and measures of sleep quality: a randomized, cross‐over trial

Baclofen, a GABA(b) agonist, has been shown to reduce episodes of gastroesophageal reflux (GER). To determine if baclofen would significantly reduce reflux during sleep, and also improve objective and subjective measures of sleep. Twenty-one individuals with complaints of nighttime heartburn at least twice a week and a Carlsson GERD score of at least 5 were studied. Patients underwent polysomnography (PSG) and simultaneous esophageal pH monitoring on two occasions separated by approximately 1 week in a cross-over design. The night of each polysomnographic study, patients consumed a refluxogenic meal. Baclofen (40 mg) or placebo was given in random order 90 min prior to the start of the PSG. Baclofen significantly reduced the number of reflux events compared with placebo. Upright and recumbent acid contact times were both reduced by baclofen vs placebo, but the differences were not significant. Regarding sleep outcomes, several variables were significantly improved by baclofen. Total sleep time and sleep efficiency increased, and wake after sleep onset decreased in the baclofen condition compared with placebo. Proportion of Stage 1 sleep was also significantly decreased on baclofen. In addition to reducing the number of reflux events during sleep, baclofen significantly improved several measures of sleep in patients with documented GER and sleep disturbances. Baclofen could therefore be considered as a useful adjunct therapy to proton pump inhibitors (PPIs) in patients with nighttime heartburn and sleep disturbance who continue to have heartburn and/or sleep complaints despite PPI therapy.

Effect of “White Diet” During Bile Monitoring With Bilitec 2000 on Esophageal pH-Metry in Patients With Gastroesophageal Reflux Disease

With introduction of the Bilitec 2000 device, intraluminal bile monitoring has become a standard technique for evaluation of patients with gastroesophageal reflux disease and symptoms of bile reflux. A specific "white diet" excluding colored food is necessary to provide correct measurements. The influence of this specific diet on simultaneous esophageal pH monitoring is unknown. Forty patients with reflux symptoms were studied prospectively. Meal times and supine and erect phases of measurement were recorded in a standardized fashion using a patient protocol. Esophageal 24-hour pH monitoring with administration of a "colorless" diet (water, milk, potatoes, fish, chicken) was started on day 1, followed by esophageal 24-hour pH-metry with intake of a normal diet on day 2. Data from the two successive pH measurements were compared. The prevalence of a pathologic esophageal pH-metry was significantly higher during intake of a normal diet compared with a colorless diet (P=0.025). During total and upright phases, administration of a white diet led to significant reduction in the percentage of time with a pH less than 4 (P </= 0.01), the total number of reflux episodes (P </= 0.001), and the DeMeester's score (P=0.01). This difference was exclusively found in patients with a normal pH-metry (group 1, n=13) and pathologic upright reflux (group 2, n=12). No change in reflux pattern was found in patients with isolated supine reflux (group 3, n=7) and combined upright and supine reflux (group 4, n=8). In patients with a pathologic upright reflux pattern, administration of a white diet results in a significant modification of esophageal pH-metry. Data derived from simultaneous esophageal pH and bile monitoring should be interpreted with care.

PH Monitoring in the Distal and Proximal Esophagus in Symptomatic Infants

ABSTRACTBackgroundStandard distal esophageal pH monitoring data are sometimes within normal ranges in children with clinically suspected gastroesophageal reflux disease. Therefore, the authors hypothesized that the amount of acid reflux reaching the proximal esophagus may be greater in some subgroups of patients than in healthy controls or in other subgroups of patients.MethodsThe parameters of 24‐hour pH monitoring in the proximal part of the esophagus were analyzed in 120 symptomatic infants in who the reflux parameters in the lower esophagus were clearly within normal ranges (reflux index &lt; 5.0%). The infants were classified into four patient groups: excessive regurgitation (n = 41); inconsolable crying (n = 31), apparent life‐threatening event (ALTE) (n = 18), and chronic respiratory disorders (n = 30). The control group consisted also of 120 infants. The following parameters were calculated: reflux index, the number of reflux episodes, the number of reflux episodes lasting longer than 5 minutes, the duration of the longest reflux episode, and the acid clearance time (ACT, duration of reflux episodes divided by number of reflux episodes).ResultsThe patients with chronic respiratory disorders were significantly older than the patients in the other groups and the controls. In the distal esophagus, there was no statistically significant difference between the reflux parameters. As could be expected, every parameter was statistically (paired t test, Wilcoxon signed‐rank test) significantly smaller in the proximal than in the distal esophagus, except for the ACT in infants who presented with inconsolable crying. In the proximal esophagus, there was no statistically significant difference between the different patient subgroups or controls, except for the number of reflux episodes in the group with chronic respiratory disorders and the group with inconsolable crying, applying one‐way analysis of variance. As determined by applying the Mann‐Whitney test, the number of reflux episodes in the upper esophagus was significantly higher in the group with chronic respiratory disorders than in the other patient groups and controls. Therefore, the authors' data do not support the hypothesis that reflux reaching the proximal esophagus is a frequent cause of ALTE. However, the data may suggest that the number of reflux episodes reaching the proximal esophagus in children with chronic respiratory disorders and with distal pH monitoring data within normal ranges may be increased. Whether this finding reflects reality or a statistical coincidence, or is influenced by the older age of this patient group, needs further evaluation.ConclusionsIn theory, dual simultaneous esophageal pH monitoring in the distal and proximal esophagus may increase the diagnostic accuracy of pH monitoring in infants. Our results do not support a substantial advantage of a systematic application of this new technique, especially not in infants presenting with ALTE, excessive regurgitation, or inconsolable crying. In the subgroup of patients with chronic respiratory disorders, more data are needed before conclusions can be determined and recommendations can be made.

PH monitoring in the distal and proximal esophagus in symptomatic infants.

Standard distal esophageal pH monitoring data are sometimes within normal ranges in children with clinically suspected gastroesophageal reflux disease. Therefore, the authors hypothesized that the amount of acid reflux reaching the proximal esophagus may be greater in some subgroups of patients than in healthy controls or in other subgroups of patients. The parameters of 24-hour pH monitoring in the proximal part of the esophagus were analyzed in 120 symptomatic infants in who the reflux parameters in the lower esophagus were clearly within normal ranges (reflux index < 5.0%). The infants were classified into four patient groups: excessive regurgitation (n = 41): inconsolable crying (n = 31), apparent life-threatening event (ALTE) (n = 18), and chronic respiratory disorders (n = 30). The control group consisted also of 120 infants. The following parameters were calculated: reflux index, the number of reflux episodes, the number of reflux episodes lasting longer than 5 minutes, the duration of the longest reflux episode, and the acid clearance time (ACT, duration of reflux episodes divided by number of reflux episodes). The patients with chronic respiratory disorders were significantly older than the patients in the other groups and the controls. In the distal esophagus, there was no statistically significant difference between the reflux parameters. As could be expected, every parameter was statistically (paired t test, Wilcoxon signed-rank test) significantly smaller in the proximal than in the distal esophagus, except for the ACT in infants who presented with inconsolable crying. In the proximal esophagus, there was no statistically significant difference between the different patient subgroups or controls, except for the number of reflux episodes in the group with chronic respiratory disorders and the group with inconsolable crying, applying one-way analysis of variance. As determined by applying the Mann-Whitney test, the number of reflux episodes in the upper esophagus was significantly higher in the group with chronic respiratory disorders than in the other patient groups and controls. Therefore, the authors' data do not support the hypothesis that reflux reaching the proximal esophagus is a frequent cause of ALTE. However, the data may suggest that the number of reflux episodes reaching the proximal esophagus in children with chronic respiratory disorders and with distal pH monitoring data within normal ranges may be increased. Whether this finding reflects reality or a statistical coincidence, or is influenced by the older age of this patient group, needs further evaluation. In theory, dual simultaneous esophageal pH monitoring in the distal and proximal esophagus may increase the diagnostic accuracy of pH monitoring in infants. Our results do not support a substantial advantage of a systematic application of this new technique, especially not in infants presenting with ALTE, excessive regurgitation, or inconsolable crying. In the subgroup of patients with chronic respiratory disorders, more data are needed before conclusions can be determined and recommendations can be made.

Comparison of simultaneous esophageal pH monitoring and scintigraphy in infants with gastroesophageal reflux : V. Tolia, L. Kuhns, and R.E. Kauffman. Am J Gastroenterol 88:661–664, (May), 1993

Comparison of simultaneous esophageal pH monitoring and scintigraphy in infants with gastroesophageal reflux : V. Tolia, L. Kuhns, and R.E. Kauffman. Am J Gastroenterol 88:661–664, (May), 1993

Evaluation of Reflux Episodes During Simultaneous Esophageal pH Monitoring and Gastroesophageal Reflux Scintigraphy in Children

SummaryGastroesophageal pH monitoring and reflux scintigraphy were simultaneously performed in 65 children, who were being investigated for suspected gastroesophageal reflux disease. The aim of the study was to compare, peak per peak, the information provided by the two techniques during a 1‐h simultaneous‐recording period. During this period, 123 reflux episodes were recorded with both techniques, but only six occurred simultaneously. Significantly more reflux episodes were recorded on scintigraphy (n = 88; p &lt; 0.05), particularly during the first half‐hour period (n = 62), if compared with the number of pH drops greater than 1 unit, even at pH levels higher than 4 (n = 41; p &lt; 0.05). It is concluded that the two techniques explore differently the reflux phenomenon.

Composition of gastro-oesophageal refluxate.

Fifty two patients with abnormal acid gastro-oesophageal reflux were studied by simultaneous oesophageal pH monitoring and continuous aspiration for 16 hours. Aspirates (from discrete two hour periods) were analysed for volume, pH, bile acids (conjugated and unconjugated), trypsin, and pepsin. The results were compared with pH changes and degree of oesophagitis. Patients with oesophagitis had greater acid reflux than those without, but patients with stricture and Barrett's oesophagus had similar acid reflux to those with uncomplicated erosive oesophagitis. Pepsin concentrations were highest in patients with stricture and Barrett's oesophagus particularly during nocturnal periods. Conjugated bile acids were detected in 75% of patients, mainly during the night, but only 2% of aspirates contained concentrations likely to be cytotoxic. Unconjugated bile acids were not detected, and trypsin was seldom found. Reflux oesophagitis is caused by acid and pepsin. Bile acids and trypsin are probably unimportant.

Simultaneous esophageal pH monitoring and scintigraphy during the postprandial period in patients with severe reflux esophagitis

To compare reflux events detected by intraesophageal pH monitoring with that of scintigraphy, we simultaneously performed both techniques along with esophageal manometry in nine patients with severe reflux esophagitis. Two hundred eighteen reflux events were detected in the recumbent posture after a meal during a 40-min interval. Both techniques simultaneously detected only 23% of all reflux events. Scintigraphy alone detected 61% of all reflux events as opposed to 16% for pH monitoring. Of those reflux events diagnosed only by scintigraphy, more occurred while the intraesophageal pH was less than 4 (ie, during an acid-clearing interval) than while the intraesophageal pH was greater than 4 (ie, when intragastric contents were neutralized by the meal). Most reflux events occurred during periods of stable, but low LES pressure. While reflux events diagnosed by scintigraphy significantly decreased during the second of two 20-min postprandial intervals, those by pH monitoring tended to increase. That simultaneous scintigraphy and pH monitoring agreed on less than 1/3 of all reflux events not only underscores the fact that both techniques measured different physical components of the esophageal refluxate (ie, volume vs acid concentration, respectively), but also were influenced by different physiologic events such as the ingestion of a meal, gastric emptying, and esophageal acid clearance.

Investigation into the Barrier Action of an Alginate Gastric Reflux Suppressant, Liquid Gaviscon®

The barrier properties of an alginate antireflux agent (Liquid Gaviscon®, Reckitt and Colman, UK) were investigated using a portable cadmium telluride detector worn on the chest wall over the oesophagus to detect the reflux of radiolabelled food, with simultaneous oesophageal pH monitoring. A crossover study was performed in 12 healthy nonpatient volunteers.