Spontaneous Reflux Research Articles

757: Bladder Pressure at Onset of Vesicoureteral Reflux is an Independent Predictor of Spontaneous Reflux Resolution

757: Bladder Pressure at Onset of Vesicoureteral Reflux is an Independent Predictor of Spontaneous Reflux Resolution

Cocaine-Induced Acute Hepatitis and Thrombotic Microangiopathy

1. Ranieri VM, Suter PM, Tortorella C, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. JAMA. 1999;282:54-61. 2. Kahrilas PJ, Dodds WJ, Dent J, et al. Effect of sleep, spontaneous gastroesophageal reflux, and a meal on upper esophageal sphincter pressure in normal human volunteers. Gastroenterology. 1987;92:466-471. 3. Brochard L, Isabey D, Piquet J, et al. Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask. N Engl J Med. 1990;323:1523-1530. 4. Fagevik Olsen M, Wennberg E, Johnsson E, et al. Randomized clinical study of the prevention of pulmonary complications after thoracoabdominal resection by two different breathing techniques. Br J Surg. 2002;89:1228-1234.

Lack of Association Between Esophageal Acid Sensitivity Detected by Prolonged pH Monitoring and Bernstein Testing

Heartburn, a common medical symptom, is thought to be the result of acid reflux into the esophagus. Perfusion of the esophagus with exogenous acid (Bernstein test) in susceptible individuals causes heartburn. Temporal correlation between heartburn and pH drop in the esophagus from endogenous acid, as reflected by a positive symptom index (SI), provides further evidence of a correlation between acid in the esophagus and heartburn. We tested the relationship between heartburn and acid in the esophagus by determining the SI and Bernstein test results in the same individual. Ninety-three patients with heartburn underwent 24-h pH monitoring and Bernstein testing. A Bernstein score that included the severity of heartburn and the time of heartburn onset during Bernstein test was calculated. The relationship between SI, Bernstein test, and Bernstein score was determined. Fifty-eight patients reported symptoms during the prolonged pH recording. A positive SI was detected in 27 patients. Forty-nine patients had a positive Bernstein test. There was no correlation between the patients with a positive SI and positive Bernstein test results. There was no correlation between SI and Bernstein score. A positive Bernstein test within 5 min of acid infusion did not predict heartburn during spontaneous reflux episodes of >/=5 min. The lack of association between symptoms induced by acid perfusion of the esophagus compared with symptoms following spontaneous reflux in the same individual suggests that the heartburn following acid perfusion and spontaneous heartburn are induced by different stimuli.

Cardiac Arrest after Injection of Ropivacaine for Posterior Lumbar Plexus Blockade

Cardiac Arrest after Injection of Ropivacaine for Posterior Lumbar Plexus Blockade

The diaphragm: two physiological muscles in one.

To the respiratory physiologist or anatomist the diaphragm muscle is of course the prime mover of tidal air. However, gastrointestinal physiologists are becoming increasingly aware of the value of this muscle in helping to stop gastric contents from refluxing into the oesophagus. The diaphragm should be viewed as two distinct muscles, crural and costal, which act in synchrony throughout respiration. However, the activities of these two muscular regions can diverge during certain events such as swallowing and emesis. In addition, transient crural muscle relaxations herald the onset of spontaneous acid reflux episodes. Studying the motor control of this muscular barrier may help elucidate the mechanism of these episodes. In the rat, the phrenic nerve divides into three branches before entering the diaphragm, and it is possible to sample single neuronal activity from the crural and costal branches. This review will discuss our recent findings with regard to the type of motor axons running in the phrenic nerve of the rat. In addition, we will outline our ongoing search for homologous structures in basal vertebrate groups. In particular, the pipid frogs (e.g. the African clawed frog, Xenopus laevis) possess a muscular band around the oesophagus that appears to be homologous to the mammalian crural diaphragm. This structure does not appear to interact directly with the respiratory apparatus, and could suggest a role for this region of the diaphragm, which was not originally respiratory.

Trasplante renal en una mujer con gestación gemelar complicada con CIR grave

Summary We present the clinical case of a 36 year old woman who had a previous kidney transplant with a spontaneous twin pregnancy and bilateral reflux. The pregnancy progressed without complications until the appearance of a severe foetal growth retardation which required ending the pregnancy. We present this case and make a review of renal transplant and gestation.

Adolescent varicocele: Treatment by antegrade sclerotherapy

Background/Purpose: The most effective treatment for adolescent varicocele is still debated, although the same treatment methods used for adults have also been used in children. Since 1991 at the Pediatric Surgery Operative Unit of “S. Camillo” Hospital in Rome a multidisciplinary protocol has been established according to which percutaneous retrograde scleroembolization was suggested as the first therapeutic option. Surgery (retroperitoneal ligation) was reserved for select cases. The author now presents his personal experience with alternative-approach antegrade sclerotherapy. Methods: Since February 1998, as an alternative to percutaneous retrograde sclerosis and surgical ligation, antegrade sclerotherapy has been performed in 92 varicocele patients, 65 of whom were 11 to 19 years of age. In this group, the indication for treatment was grade III varicocele with spontaneous continual reflux, which worsened with the Valsalva maneuver. Twenty patients had recurrent varicocele after other treatments. Results: At a mean follow-up of 9 months, the clinical recovery rate was 92.6%. Conclusions: Antegrade sclerotherapy is an intermediate treatment because of its invasive nature and success rate compared with more commonly used percutaneous retrograde sclerosis and Palomo procedures in adolescents. In particular, this method is highly effective and well-accepted by patients with recurrent varicocele. J Pediatr Surg 36:1546-1550. Copyright © 2001 by W.B. Saunders Company.

Severe asthma: definition and mechanisms.

Severe asthma: definition and mechanisms.

Excess gastroesophageal reflux in patients with hiatus hernia is caused by mechanisms other than transient LES relaxations

Background & Aims: Esophageal acid exposure is higher in gastroesophageal reflux disease (GERD) patients with hiatus hernia than in those without. We investigated the effect of a sliding hiatus hernia on the mechanisms underlying spontaneous gastroesophageal reflux over 24 hours. Methods: Twelve GERD patients with and 10 GERD patients without hiatus hernia were studied for 24 hours. Combined esophageal pH and manometric recordings of the pharynx, lower esophageal sphincter (LES), and stomach were performed using a multiple-lumen assembly incorporating a Dent sleeve connected to a portable water-perfused manometric system and a pH glass electrode. Results: Patients with hiatus hernia had greater esophageal acid exposure (7.6% vs. 3.3%; P < 0.01) and more reflux episodes (3.1 vs. 1.8/h; P < 0.001) than those without. LES pressure, the incidence of transient LES relaxations (TLESRs), and the proportion of TLESRs associated with acid reflux were comparable in both groups. Both groups had equal numbers of reflux episodes associated with TLESRs and swallow-associated prolonged LES relaxations. Patients with hiatus hernia had more reflux associated with low LES pressure, swallow-associated normal LES relaxations, and straining during periods with low LES pressure. Conclusions: The excess reflux in GERD patients with hiatus hernia compared with those without is caused by malfunction of the gastroesophageal barrier during low LES pressure, swallow-associated normal LES relaxations, deep inspiration, and straining.GASTROENTEROLOGY 2000;119:1439-1446

Effect of spontaneous gastroesophageal reflux events on respiration in humans

pressure amplitudes in the distal half of the esophageal body following wet swallows. S significantly increased pressure amplitudes in the proximal esophagus (striated muscle). The decrease in amplitudes of distal esophageal body contractions due to S lasted at least 8 hours in 2 of 3 subjects. Because of these observations we suggested a beneficial role of S in patients with NCCP due to motility disorders such as diffuse esophageal spasm, nutcracker esophagus, hypertensive LES and vigorous achalasia. 4 such patients (2 female, 2 male) were investigated. They had similar qualitative motility changes as in healthy subjects. When S was given on a pm basis to relieve symptoms 2 of 4 subjects reported reproducable improvement or relief of their symptoms.

An ambulant porcine model of acid reflux used to evaluate endoscopic gastroplasty

BACKGROUNDThere is a lack of suitable models for testing of therapeutic procedures for gastro-oesophageal reflux disease. Endoscopic sewing methods might allow the development of a new less invasive surgical approach...

Riboflavin to treat nucleoside analogue-induced lactic acidosis

Fetal blood was obtained by transabdominal cardiac puncture. In each case, a detailed transvaginal ultrasound was done to confirm gestational age and to assess spontaneous and reflex fetal movements. Written consent was obtained from each woman after receiving complete information on the procedure. This study was approved by the University College London Hospitals Committee on the Ethics of Human Research. The fetal samples were collected between 5 and 20 min following intravenous (IV) administration of a bolus of 3 mg/kg of propofol (Diprivan 1%, Zeneca, Macclesfield, UK) to the mother. Peripheral maternal venous blood was collected simultaneously. Anaesthesia was maintained by spontaneous breathing of 70% nitrous oxide with 0·5–1% isoflurane in oxygen via a laryngeal mask. The propofol concentration was determined by high-performance liquid chromatography with fluorescence. The method has a lower limit of sensitivity of 0·1 g/mL and the intra-assay and interassay coefficients of variation were both 5%. No spontaneous fetal movements or reflux responses were observed in any case during the time interval between induction of anaesthesia and the surgical procedure or during the sampling procedure. Propofol was detected in all maternal and fetal serum samples. No propofol was found in coelomic or amniotic fluid samples at any stage of gestation. Propofol concentration decreased exponentially with time in both maternal (r=0·73, p<0·0001) and fetal (r=0·58, p<0·0001) serum. Maternal serum concentration of propofol was always higher than fetal serum concentration. In 14 matched samples, the mean propofol concentration was 1·96 g/mL (95% CI 1·49–2·42) in maternal serum and 0·90 g/mL (95% CI 0·68–1·11) in fetal serum. Over the 20 min interval between injection and sampling, little change was observed in the fetal/maternal propofol concentration ratio. This finding can be explained by the fact that propofol binds 97–98% to albumin, which is in much lower concentration in fetal serum during the first half of pregnancy. Overall, the pharmacodynamics of propofol found in pregnant women at 12–18 weeks of gestation are similar to those described at term 1–3 indicating that our data can be extrapolated to the period of gestation between 24 and 37 weeks and that our model can be used to study the placental transfer of other analgesic drugs in early pregnancy. Propofol has no known teratogenic effect in humans and our results also indicate that, during short maternal general

Upper Esophageal Sphincter Function During Antegrade and Retrograde Transit

The striated musculature of the UES, along with the cricoid and thyroid cartilages, the hyoid bone, their ligaments, and the supra- and infrahyoid musculature form a functional unit that selectively controls the opening and closing of the esophageal inlet. At rest, upper esophageal tone acts as a barrier against both entry of air into the esophagus and regurgitation of materials coming from the proximal esophagus. However, reflexive responses of the sphincter offer no substantial protection against regurgitation of stomach contents that cause substantial esophageal distension. Although esophageal distention can experimentally induce sphincter contraction, this potential protective reflex against esophago-pharyngeal reflux has not been observed during spontaneous gastroesophageal reflux episodes. Furthermore, owing to the effects of gaseous distention, regurgitation may be more likely when acid and gaseous contents gastroesophageal reflux together. Modulation of the timing and the extent of sphincter opening during swallowing is intimately correlated with the volume and physical properties of the bolus, along with coordinated activity of the tongue, pharyngeal constrictors, and hyoid musculature, which suggests continuous sensory feedback throughout the pharyngeal swallow.

Atropine inhibits gastric distension and pharyngeal receptor mediated lower oesophageal sphincter relaxation

Background—Atropine decreases the frequency of transient lower oesophageal sphincter relaxation (TLOSR) through an unknown mechanism. Gastric distension and pharyngeal receptor excitation are two possible sources for the afferent stimulus responsible...

The management of unilateral poorly functioning kidneys in patients with posterior urethral valves.

There is no uniform agreement on how to manage the unilateral nonfunctioning or poorly functioning kidney associated with posterior urethral valves. We studied the results of treatment of our patients to make recommendations regarding management of these kidneys. We reviewed the records of 13 boys with a history of posterior urethral valves and a unilateral nonfunctioning or poorly functioning kidney, defined as less than 10% of total renal function on 99mtechnetium dimercapto-succinic acid renal scans. Variables investigated included pyelonephritis, hypertension, vesicoureteral reflux, nephroureterectomy, ureteral reimplantation and spontaneous cessation of reflux. We also evaluated how the management of abnormal urodynamic parameters influenced the results of reimplantation or medically induced cessation of reflux. Three of the 6 boys with grade 5 reflux ipsilateral to the poorly functioning kidney required nephroureterectomy at a mean age of 21 months because of recurrent urinary tract infections. Another 4 boys underwent successful ureteral reimplantation, including 2 who had bilateral grade 5 reflux, and 2 who had ipsilateral grade 4 reflux, and grade 3 (1) and grade 2 (1) contralateral reflux. Of 4 boys ipsilateral grade 3 reflux in 3 and bilateral grade 5 reflux in 1 disappeared without surgery after treatment of urodynamic abnormalities. Two patients with poorly functioning kidneys and no reflux did not undergo surgery. Overall 10 of the 13 poorly functioning renal units were not removed, and these patients were free of pyelonephritis and hypertension. Ureteral reimplantation (4 ipsilateral and 3 contralateral) was performed only after urodynamic abnormalities were addressed. All reimplantations were successful. Based on our results we believed that unilateral poorly functioning kidneys in patients with posterior urethral valves can be safely preserved in select patients without hypertension and pyelonephritis. Reimplantation to correct reflux may be preferable to nephroureterectomy in specific situations, such as when contralateral function is suboptimal and the contralateral ureter needs reimplantation. When indicated, reimplantation can be performed successfully if abnormal urodynamic parameters are addressed preoperatively. In fact, treating abnormal urodynamic findings may lead to spontaneous reflux resolution.

The Management of Unilateral Poorly Functioning Kidneys in Patients With Posterior Urethral Valves

Purpose There is no uniform agreement on how to manage the unilateral nonfunctioning or poorly functioning kidney associated with posterior urethral valves. We studied the results of treatment of our patients to make recommendations regarding management of these kidneys. Materials and Methods We reviewed the records of 13 boys with a history of posterior urethral valves and a unilateral nonfunctioning or poorly functioning kidney, defined as less than 10% of total renal function on [99m] technetium dimercapto-succinic acid renal scans. Variables investigated included pyelonephritis, hypertension, vesicoureteral reflux, nephroureterectomy, ureteral reimplantation and spontaneous cessation of reflux. We also evaluated how the management of abnormal urodynamic parameters influenced the results of reimplantation or medically induced cessation of reflux. Results Three of the 6 boys with grade 5 reflux ipsilateral to the poorly functioning kidney required nephroureterectomy at a mean age of 21 months because of recurrent urinary tract infections. Another 4 boys underwent successful ureteral reimplantation, including 2 who had bilateral grade 5 reflux, and 2 who had ipsilateral grade 4 reflux, and grade 3 (1) and grade 2 (1) contralateral reflux. Of 4 boys ipsilateral grade 3 reflux in 3 and bilateral grade 5 reflux in 1 disappeared without surgery after treatment of urodynamic abnormalities. Two patients with poorly functioning kidneys and no reflux did not undergo surgery. Overall 10 of the 13 poorly functioning renal units were not removed, and these patients were free of pyelonephritis and hypertension. Ureteral reimplantation (4 ipsilateral and 3 contralateral) was performed only after urodynamic abnormalities were addressed. All reimplantations were successful. Conclusions Based on our results we believe that unilateral poorly functioning kidneys in patients with posterior urethral valves can be safely preserved in select patients without hypertension and pyelonephritis. Reimplantation to correct reflux may be preferable to nephroureterectomy in specific situations, such as when contralateral function is suboptimal and the contralateral ureter needs reimplantation. When indicated, reimplantation can be performed successfully if abnormal urodynamic parameters are addressed preoperatively. In fact, treating abnormal urodynamic findings may lead to spontaneous reflux resolution.

Gastro-oesophageal reflux in patients with coronary artery disease: how common is it and does it matter?

To investigate the influence of spontaneous gastro-oesophageal reflux (GOR) on symptoms and cardiac ischaemia in patients with coronary artery disease. Simultaneous 24-h ambulatory oesophageal pH, 7-lead electrocardiographic (ECG) monitoring and symptom diary in patients taking their usual anti-anginal medication. Regional cardiothoracic unit and gastroenterology unit of a teaching hospital. Twenty-four patients (20 males, 4 females, mean age 59 years) with post-myocardial infarction angina and angiographically proven coronary artery disease. Quantitation of acid gastro-oesophageal reflux (% total time pH < 4, number of reflux episodes, duration of reflux episodes), identification of ST segment elevation or depression of 1 mm or more on 24-h ECG recording and occurrence of chest pain ("heartburn' or "angina') within 5 min of GOR or ischaemic ST segment shift. There were 568 episodes of GOR, 28 of which were symptomatic. Abnormal GOR (% total time pH < 4 greater than 7%) occurred in 9 (38%) of the patients; all reflux parameters were increased in nitrate users compared to non-users (P < 0.05). Ischaemic ST-segment shift was seen on 113 occasions. Of a total of 41 chest pain episodes, 20 were related to GOR ("angina' with 8, "heartburn' with 12), while 8 coincided with both GOR and ST depression together ("angina' in 5, "heartburn' in 3). In addition to these eight episodes, coincidence of ST depression with GOR occurred on another nine occasions (all asymptomatic). GOR is common in patients with coronary artery disease and may be increased by drug therapy; GOR may occasionally be associated with myocardial ischaemia, but this is uncommonly symptomatic; GOR-induced pain is sometimes mistaken for angina. These effects were uncommon overall, but frequent in a few individuals and should be considered in the evaluation of patients with persistent chest pain despite seemingly adequate antianginal treatment.

What technique should I try if spontaneous reflux does not occur?

What technique should I try if spontaneous reflux does not occur?M S LevineAudio Available | Share

Microsurgical treatment of varicocele in adolescents.

Between March 1990 and November 1992, 22 adolescents with varicocele, 13 unilateral left and 4 bilateral, are presented. They were all treated with microsurgical techniques by shunting the venous drainage by means of a spermatic inferior epigastric end-to-side anastomosis. The results achieved have been optimum with the clinical disappearance of varicose veins in 100% of the cases and the elimination of the spontaneous reflux of the interna spermatic vein in 100% of the patients shown by echodoppler. This technique enables the establishment of an immediate and physiological testicular venous drainage fundamental for testicular growth and development.

The pathophysiology of gastro-oesophageal reflux disease: an overview.

Gastro-oesophageal reflux disease (GORD) is a multifactorial disease. Although it is primarily a motility disorder, several other disturbances can interfere and contribute to determine the severity of symptoms and the degree of lesions. In normal subjects, as in patients with pathological reflux, nearly all the episodes of reflux obey one of the following three mechanisms: (a) a transient complete relaxation of the lower oesophageal sphincter (TLOSR), (b) a transient increase in intra-abdominal pressure which overcomes the resistance of the antireflux barrier ('stress reflux') and, (c) a spontaneous reflux through a permanently hypotonic sphincter. Gastric distension is the major factor that can induce TLOSRs. Whereas, at rest, the diaphragm probably plays little role in cardial competence, diaphragmatic contraction may help prevent reflux in conditions resulting in increased abdominal pressure such as during physical activity and abdominal staining. The presence of a hiatal hernia increases susceptibility to reflux. A delayed gastric emptying may also facilitate reflux and represents a factor of resistance to antireflux therapy. Most studies in humans have shown that motor abnormalities remain unchanged after healing of oesophagitis. Acid and pepsin are the most noxious agents of the upper gastrointestinal secretions that can participate in the pathogenesis of oesophagitis. However, there is no evidence that patients with reflux have greater acid secretion than subjects without reflux. The clearance function is a two-stage phenomenon requiring first a reduction in volume by peristalsis and then chemical neutralization by saliva. Primary peristalsis is mainly responsible for the clearance of acid in both the upright and the supine positions. It takes longer to clear acid in patients with non-reducing hiatal hernia. The layer of mucus which carpets the mucosa comes from the saliva and also from the submucosal glands of the oesophagus. The paracellular pathway is the major route by which mucosal HCl enters and then damages the oesophageal epithelium. Only a minority of acid reflux episodes are accompanied by symptoms. The acid exposure during the time period that precedes a reflux episode (i.e. the acid burden) is a key factor determining whether that reflux episode will be symptomatic or asymptomatic.