Supine Reflux Research Articles

Oesophageal pain: A tough nut to crack the role of high resolution manometry guided segmental oesophageal myotomy

Introduction: Oesophageal motility disorders (OMDs) are a recognized cause of pain in 25-33% of patients with non-cardiac chest pain. The understanding of these disorders based on standard multichannel oesophageal manometry has improved with high resolution oesophageal manometry (HROM). This could facilitate selection of treatment modality including identifying those suitable for surgical myotomy while preserving oesophageal function. Material and methods: This discussion is based on a 65 year old lady with a 17 year history of oesophageal pain due to Nutcracker oesophagus. Persistence of symptoms despite medical management using proton pump inhibitors, calcium channel blockers, nitrates, endoscopic pneumatic dilatation & Botulinum toxin injection prompted re-referral to our specialist unit and analysis of residual oesophageal function using HROM. This revealed a segment of nutcracker oesophagus in the mid oesophagus with significant supine reflux. Result: Surgical treatment with trans-hiatal open focused oesophageal myotomy with preservation of lower oesophageal sphincter and floppy Nissen fundoplication led to satisfactory and complete resolution of symptoms. Discussion: HROM provides a clearer classification of the functional abnormalities and their co-relation to symptoms. This allows application of the best available treatment modality including surgery to achieve symptomatic relief with preservation of residual oesophageal function. Conclusion: Limited evidence is currently available on the comparative benefits of available treatment modalities for OMDs. HROM provides greater insight into OMDs and the benefits of available treatment modalities allowing selection of optimal treatment modality and preserving oesophageal function while achieving relief of the patients distressing symptoms.

Clinical characteristics, esophageal motility and acid exposure in elderly patients with gastroesophageal reflux disease

Objectlve To review the clinical characteristics,esophageal motility and acid exposure in elderly patients with gastroesophageal reflux disease (GERD).Methods Two hundred and sixty patients aged 18 -81 years were diagnosed as gastroesophageal reflux disease from 2005 to 2011 in outpatient clinic,the patients were divided into elderly group ( ≥ 60 y) and control group ( ＜ 60 y).The incidence of esophagitis,severity of esophagitis,esophageal motility and esophageal acid exposure were analyzed and compared between two groups.Results The incidence of esophageal hiatal hernia,non-typical reflux symptoms and extra-esophageal symptoms in elderly group were higher than that of control group(45.1％ vs.30.6％,36.3％ vs.27.2％ and 37.1％ vs.25.2％,P =0.016,0.005 and 0.037,respectively).There was no significant difference in esophagitis incidence between two group (55.8％ vs.50.3％,P =0.250).The incidence of esophagitis graded as LA-B to LA-D were higher in elderly group( 19.5％ vs.10.2％ and 8.8％ vs.2.7％,P =0.034 and 0.030,respectively).The percentage of upright acid clearance time,supine reflux time of pH ＜4 and the DeMeester score of elderly group were higher than those of control group (P =0.000,0.006 and 0.001,respectively).Lower esophageal sphincter pressure (LESP) of elderly group was lower than that of control group ( 13.36 ±6.39 vs.15.57 ±7.01,P =0.009).Conclusion In comparison with young and middle-aged patients,the elderly GERD patients have lower esophageal motility,longer esophageal acid exposure time and higher frequency of severer esophagitis. Key words: Gastroesophageal reflux; Esophageal pH Monitoring; Retrospective studies

PTU-190 Isolated upright oesophageal acid exposure is associated with less favourable outcomes after laparoscopic anti-reflux surgery

IntroductionWith the increasing use of antireflux surgery since the widespread dissemination of the laparoscopic approach, preoperative indicators to predict success could reduce the number of patients with a poor outcome....

Effect of bed head elevation during sleep in symptomatic patients of nocturnal gastroesophageal reflux

Nocturnal gastro-esophageal reflux causes heartburn and sleep disturbances impairing quality of life. Lifestyle modifications, like bed head elevation during sleep, are thought to alleviate the symptoms of gastroesophageal reflux. We tested the hypothesis that bed head elevation might decrease recumbent acid exposure compared to sleeping in a flat bed. Patients of symptomatic nocturnal reflux and documented recumbent (supine) reflux verified by esophageal pH test entered the trial. On day 1, baseline pH was measured while the patient slept on a flat bed. Then patients slept on a bed with the head end elevated by a 20-cm block for the next 6 consecutive days from day 2 to day 7. The pH test was repeated on day 2 and day 7. Each patient acted as his own control. Twenty of 24 (83.3%) patients with mean age of 36 ± 5.5 years completed the trial. The mean (± SD) supine reflux time %, acid clearance time, number of refluxes 5 min longer and symptom score on day 1 and day 7 were 15.0 ± 8.4 and 13.7 ± 7.2; P = 0.001, 3.8 ± 2.0 and 3.0 ± 1.6; P = 0.001, 3.3 ± 2.2 and 1.0 ± 1.2; P = 0.001, and 2.3 ± 0.6 and 1.5 ± 0.6; P = 0.04, respectively. The sleep disturbances improved in 13 (65%) patients. Bed head elevation reduced esophageal acid exposure and acid clearance time in nocturnal (supine) refluxers and led to some relief from heartburn and sleep disturbance.

Long term medical management of gastro-esophageal reflux disease: How long and when to consider surgery?

Gastro-esophageal reflux disease is a chronic, long standing disease. Spontaneous remission of GERD is rare and conservative management including life style modification measures is unlikely to relieve symptoms. Majority of patients with reflux disease require long-term acid suppressants. Proton pump inhibitors are the choice of drugs in management of these patients. The end point of treatment is not clear. Duration of treatment is individual based. The symptoms may be intermittent or on most days of the week. The treatment is therefore either a short course which may be for 8 to 12 weeks or 6 months, or continuous, intermittent or 'on-demand' basis. The maintenance therapy is with the lowest proton pump inhibitor (PPI) dose necessary for adequate symptom relief. Whether long-term PPI actually alters the natural history of reflux disease other than to reduce the incidence of peptic stricture is not known. Reported adverse effects due to PPI include Clostridium difficile colitis and bacterial gastroenteritis, osteoporosis, and vitamin B12 deficiency. Anti-reflux surgery is indicated for youngsters, those not willing for long-term PPI i.e. for years, large volume refluxers, especially the supine refluxers and bile refluxers.

Clinical utility of 24 hour pharyngeal pH monitoring for hoarseness

Objective: To evaluate the contribution of 24 hour pharyngeal pH monitoring of patient presenting with symptoms of hoarseness, globus, throat clearing, and sore throat. Study Design: Retrospective case study. Setting: Tertiary laryngology practice. Materials and Methods: Results of 167 pharyngeal pH studies performed for complaints of hoarseness, globus, and throat clearing in an outpatient private practice setting from 5/09-12/09 were analyzed for pharyngeal reflux pattern and severity. Patient records were reviewed for chief complaint, symptom duration, ten item Voice Handicap Index (VHI-10) and Reflux Symptom Index (RSI) scores. Nonparametric testing was used to compare symptom duration, VHI-10 scores, and RSI scores between those patients with and without abnormal pharyngeal pH studies. Results: 71 studies (43%) were normal with zero events below pH 5.5. 32 studies (19%), or 33% of all positive studies showed supine pharyngeal reflux only. 46 studies or 48% of all positive studies showed combination upright daytime reflux events and supine reflux. 18 studies or 19% of all positive studies had only upright events. There was no significant difference in presenting symptoms, symptom duration, or severity scores in the patients that had negative vs. positive pharyngeal pH studies. Conclusion: 24 hour pharyngeal pH study eliminates the diagnosis of reflux in a significant percentage of patients with hoarseness. Severity or duration of symptoms of hoarseness, globus, or throat clearing does not reliably predict presence of reflux.

The Pattern of Esophageal Acid Exposure and Esophageal Pressure Morphology in Patients With Hiatus Hernia

Introduction Gastro-oesophageal reflux disease (GORD) generally presents as pathological Upright, Supine or Bi-positional reflux. Hiatus hernia (HH) and dysmotility are common in chronic GORD. However, in the presence of HH, it is unclear how age, severity of oesophageal acid exposure and dysmotility are related to the different postural types of GORD. Methods From March 2006 to July 2010, 1242 patients with GORD symptoms had high resolution manometry (HRM; Manoscan 360, Sierra) and 24-h catheter-based pH-monitoring (Slimline™, Medtronic) performed. 124 consecutive patients with both pathologic reflux and HH were collected. Patients were classified as Upright (n = 24), Supine (n = 38) or Bi-positional (n = 62) predominant reflux. Total (TR > 4.2%), upright (UR > 8.15%) and supine (SR > 3.45%) reflux parameters were used to classify GORD into position subtypes. HH was defined as Type II (lower oesophageal sphincter (LOS)-crural diaphragm (CD), 1–2 cm) and Type III (LOS-CD > 2 cm) in accordance with the Chicago Classification. Student9s t test, χ 2 tests and Mann–Whitney-U test were used for statistical analysis. Results Mean ±SD age was 54 ± 14 years (range 16–85 years; 64 males). Patients with Bi-positional reflux (57 years) were older than those with Supine (49 years) (p = 0.013) or Upright reflux (53 years) (p = 0.04). Furthermore the severity of oesophageal acid exposure (TR, UR and SR) was greater in the Bi-positional (18.1%, 17.6%, 19.7%) than Supine (8.6%, 4.8%, 14.8%) (p Conclusion In patients with manometry-proven HH who present with symptoms suggestive of GORD, Bi-positional and Supine reflux predominance are associated with more severe disease and are more likely to be associated with failed peristalsis. Furthermore Bi-positional reflux disease is more common with increasing age as is Type III HH.

Prevalence of and impact of pantoprazole on nocturnal heartburn and associated sleep complaints in patients with erosive esophagitis

Studies in the United States have revealed that gastroesophageal reflux disease (GERD) patients often suffer from nocturnal symptoms, sleep disturbance, and impaired quality of life. In a large subset of patients, these symptoms persist in spite of acid suppressive therapy. The aim of the present study was to assess the prevalence of heartburn and associated sleep complaints and the response to standard medical therapy with pantoprazole in primary and secondary care esophagitis patients in Belgium. Questionnaires were provided to consecutive patients presenting to primary and secondary care physicians with esophagitis. The questionnaire evaluated the presence of typical reflux symptoms, alarm symptoms, risk factors, and sleep quality impairment as a result of reflux episodes. Results are shown as mean ± standard deviation and compared by Student's t-test or chi-square test. A total of 4061 primary and 5261 secondary care patients (50% female, mean age 53 ± 0.2 years, body mass index of 25.7 ± 0.1 kg/m(2) ) were recruited. Eighty-four percent of patients reported sleep disturbance attributable to nighttime reflux, including typical nighttime supine reflux symptoms (72%), difficulties to fall asleep (39%), waking up during the night (45%), morning fatigue (35%), and reflux symptoms when waking up in the morning (47%). Mild, moderate, or severe nighttime heartburn were reported by, respectively, 30, 35, and 12%, and these numbers were 26, 28, and 6% for nighttime regurgitation. Alcohol (19%), smoking (22%), higher esophagitis grades (grades 2, 3, and 4 in, respectively, 31, 7, and, 7%), alarm symptoms (27%), and more severe heartburn and regurgitation during daytime were all significantly associated with all dimensions of sleep disturbance (P < 0.0001). Obesity was only related to symptoms in supine position and when waking up (P < 0.0001). After 1.4 ± 0.0 months of treatment with pantoprazole, any sleep disturbance had improved in more than 75% of patients, with resolution of nighttime heartburn and regurgitation in, respectively, 75 and 83%. The majority of patients presenting with reflux symptoms and esophagitis in primary or secondary care experience nighttime heartburn and regurgitation, and sleep disturbance by nighttime symptoms is present in 84%. Smoking, alcohol use, higher grades of esophagitis, more severe typical reflux symptoms during daytime, and the presence of alarm symptoms are risk factors for GERD-related sleep disturbance. On standard therapy with pantoprazole, nighttime symptoms improved in more than 75%. These observations support a direct relationship between GERD and sleep disturbance.

The pattern of oesophageal acid exposure and oesophageal pressure morphology in patients with hiatus hernia

<h3>Introduction</h3> Gastro-oesophageal reflux disease (GORD) generally presents as pathological Upright, Supine or Bi-positional reflux. Hiatus hernia (HH) and dysmotility are common in chronic GORD. However, in the presence of HH, it is unclear how age, severity of oesophageal acid exposure and dysmotility are related to the different postural types of GORD. <h3>Methods</h3> From March 2006 to July 2010, 1242 patients with GORD symptoms had high resolution manometry (HRM; Manoscan 360, Sierra) and 24-h catheter-based pH-monitoring (Slimline™, Medtronic) performed. 124 consecutive patients with both pathologic reflux and HH were collected. Patients were classified as Upright (n = 24), Supine (n = 38) or Bi-positional (n = 62) predominant reflux. Total (TR &gt; 4.2%), upright (UR &gt; 8.15%) and supine (SR &gt; 3.45%) reflux parameters were used to classify GORD into position subtypes. HH was defined as Type II (lower oesophageal sphincter (LOS)-crural diaphragm (CD), 1–2 cm) and Type III (LOS-CD &gt; 2 cm) in accordance with the Chicago Classification. Student9s t test, χ² tests and Mann–Whitney-U test were used for statistical analysis. <h3>Results</h3> Mean ±SD age was 54 ± 14 years (range 16–85 years; 64 males). Patients with Bi-positional reflux (57 years) were older than those with Supine (49 years) (p = 0.013) or Upright reflux (53 years) (p = 0.04). Furthermore the severity of oesophageal acid exposure (TR, UR and SR) was greater in the Bi-positional (18.1%, 17.6%, 19.7%) than Supine (8.6%, 4.8%, 14.8%) (p &lt; 0.001) or Upright (8.5%, 12.8%, 1.1%) (p &lt; 0.001) reflux group. Total supine reflux episodes in the Supine group were fewer in number (54) compared to the total upright reflux episodes in the Upright group (127) (p &lt; 0.001), although the total reflux time was similar in both positions (124 min supine vs 127 min upright; p = NS). Although there was no significant difference in the mean peristaltic wave contractility and velocity between the three groups, the % of successful peristalsis was higher in the Upright (65%) than Supine (54%) or Bi-positional (52%) GORD group (p = 0.008 and p = 0.001, respectively). Patients with Type III HH were older (mean age 57 years; n = 71) than Type II HH (mean age 50 years; n = 53) (p = 0.013). There was no difference in HH length between the GORD position subtypes (range 2.0–8.4 cm). Although there was no difference in TR, UR and SR, the LOS basal pressure was lower in Type III (8.9 mmHg) than Type II (12.0 mmHg) HH patients (p = 0.05). <h3>Conclusion</h3> In patients with manometry-proven HH who present with symptoms suggestive of GORD, Bi-positional and Supine reflux predominance are associated with more severe disease and are more likely to be associated with failed peristalsis. Furthermore Bi-positional reflux disease is more common with increasing age as is Type III HH.

Study of the influence of hiatus hernia on gastroesophageal reflux.

To explore whether the presence of a sliding hiatus hernia influences gastroesophageal reflux. Endoscopy and 24 h pH monitoring were performed for 197 outpatients with gastroesophageal reflux symptoms. Of the 197 patients with symptoms of gastroesophageal reflux, patients with hiatus hernia accounted for 36%. The incidence of esophagitis in patients with hiatus hernia was significantly higher than that in patients without hiatus hernia. The results of 24 h pH monitoring showed that 84 patients had physiological reflux, 37 had pathological reflux without esophagitis, 64 had reflux esophagitis and 12 had physiological reflux concomitant with esophagitis. All the patients with hiatus hernia had a longer percentage time with supine reflux and a higher frequency of episodes lasting over 5 min at night compared to those without hiatus hernia. The incidence of combined daytime and nocturnal reflux in patients with hiatus hernia was significantly higher than that in patients without hiatus hernia. Pathological reflux and reflux esophagitis in some patients with symptoms of gastroesophageal reflux represent two different stages of gastroesophageal reflux disease. Pathological reflux is the first stage, in which the lower esophageal sphincter is incompetent but the esophageal mucosal resistance effectively prevents regurgitated acid from damaging the esophageal mucosa. Reflux esophagitis represents the second stage, in which the aggression of the regurgitated acid is so strong that the esophageal mucosa fails to resist it and the epithelium of the esophagus is damaged. Patients with hiatus hernia have a high incidence of combined daytime and nocturnal reflux, with the latter being responsible for esophagitis.

Randomized Open-label Trial to Assess the Impact of Dosage Timing of Omeprazole/Sodium Bicarbonate (Zegerid 40 mg) on Healing of Severe Reflux Esophagitis: A Progress Report: 2010 Presidential Poster

Purpose: Twice daily proton pump inhibitor (PPI) therapy is commonly recommended to heal severe reflux esophagitis. For optimal efficacy, patients are currently advised to take their PPI on an empty stomach 20 to 60 minutes before a meal - which can be a cumbersome process. Administration of a single nightly PPI regardless of meal time might increase adherence, and hence efficacy in healing esophagitis. Aim: To compare the efficacy of 8 weeks immediate-release omeprazole/sodium bicarbonate (IR-OME), taken either before breakfast or before bedtime, on healing severe esophagitis. Methods: Prospective open-label single-blinded cohort study of outpatients with LA Grade C or D reflux esophagitis randomized to IR-OME 40 mg taken 20 to 60 minutes before breakfast or before bedtime. Esophagogastroduodenoscopy (EGD) was performed at baseline and after 8 weeks of study medication. A 24-hour pH study was offered at the time of the follow-up EGD regardless of endoscopic findings. Results: To date, 88 subjects have been recruited of which 77 have completed the study [53 (69%) male, mean age 58 (SD 13, range 22 to 86), LA grades C=49, D=28]. Forty-one subjects were allocated to the morning dose and 47 to the bedtime dose (with 2 and 6 dropping out of each arm, respectively). Of 38 completed subjects (C=23, D=15) randomized to morning PPI, 32 (84%) had healed at 8 weeks. The 6 with persistent esophagitis all showed improvement in severity by one or two grades. Of 39 completed subjects (C=26, D=13) randomized to bedtime PPI, 33 (85%) healed. Four of 6 improved, one had the same grade, and one worsened in severity. 18 of 77 (23%) underwent pH testing while on study medication. Six discontinued study medication prior to pH probe placement and were excluded from subgroup analysis. Of the 12 subjects who underwent pH testing while on IR-OME (8 with standard probe, 4 with Bravo), 7 were on the morning dose of whom 6 (86%) showed normalization of their pH parameters. One subject on morning PPI demonstrated acid reflux (5.5% overall, 1.9% upright, 9.9% supine). Five subjects on bedtime PPI consented to pH testing; three (60%) with normalization of pH parameters. Amongst 4 subjects on morning vs. 4 on bedtime PPI each with gastric pH measurement obtained, there was no obvious difference for PPI effect on pH < 4 (mean 19.5, range 11.4-32% vs. 17.5, 0.2-52%). Conclusion: Both morning and bedtime dosing of IR-OME are highly and similarly effective in resolving severe LA grade C and D erosive reflux esophagitis at 8 weeks. Bedtime dosing was just as effective as morning dosing in controlling gastric acid production. Too few esophageal pH observations have been collected to comment on differences in nocturnal supine reflux between morning and bedtime dosing schedules. Disclosure: Dr Romero - Consultant: Santarus, and grant support for this project from Santarus. Dr Jung - won a travel award to attend DDW 2010 from Santarus. This research was supported by an industry grant from Santarus, Inc.

W1070 Non-Acid Reflux Burden is a Predictor of Bacterial Lung Infections

typical (HB/reg.) (23%) or extra-esophageal (77%) symptom complex (cough-38%, chest pain-30%, hoarseness-22%, asthma-5%, post nasal drip 5%) underwent 48 hour Bravo pH monitoring on week off acid suppressive therapy. % time pH 5.5%, upright > 8.0% and supine > 3.0%. pH profile as well as demographic data (age, gender, BMI) were compared. Results: 216/296 (73%) pts had abnormal esophageal acid exposure: 95/216 (44%) in both upright and supine positions; 82/216 (38%) in the upright only and 39/216 (18%) in the supine only positions. The median (interquartile) number of reflux events was significantly (p<0.001) higher in pts with upright and supine reflux [86 (59 to106)] than those with supine only [52(37 to 73)] or upright only [62 (43 to 93)] reflux pattern. HB and regurgitation were significantly (p=0.03) higher in those with supine only reflux than upright only group. Prevalence of abnormal esophageal acid exposure was similar in those with chief complaint of HB/reg (65%) to those with extra-esophageal symptom's with (54%) or without (68%) concomitant HB/reg. (p=0.3). Conclusions: 1) Reflux disease defined physiologically by abnormal esophageal acid exposure off acid suppressive therapy is common (73%) in pts referred with extra-esophageal symptom's and occurs most commonly in the upright position. 2) The widely held notion that pts with extra-esophageal symptoms without concomitant HB/regurgitation are less likely to have reflux should be re-evaluated.

Prevalência da doença do refluxo gastroesofágico em pacientes com fibrose pulmonar idiopática

To determine the prevalence of gastroesophageal reflux disease (GERD) and to evaluate its clinical presentation, as well as the esophageal function profile in patients with idiopathic pulmonary fibrosis (IPF). In this prospective study, 28 consecutive patients with IPF underwent stationary esophageal manometry, 24-h esophageal pH-metry and pulmonary function tests. All patients also completed a symptom and quality of life in GERD questionnaire. In the study sample, the prevalence of GERD was 35.7%. The patients were then divided into two groups: GERD+ (abnormal pH-metry; n = 10) and GERD- (normal pH-metry; n = 18). In the GERD+ group, 77.7% of the patients presented at least one typical GERD symptom. The pH-metry results showed that 8 (80%) of the GERD+ group patients had abnormal supine reflux, and that the reflux was exclusively in the supine position in 5 (50%). In the GERD+ and GERD- groups, respectively, 5 (50.0%) and 7 (38.8%) of the patients presented a hypotensive lower esophageal sphincter, 7 (70.0%) and 10 (55.5%), respectively, presenting lower esophageal dysmotility. There were no significant differences between the groups regarding demographic characteristics, pulmonary function, clinical presentation or manometric findings. The prevalence of GERD in the patients with IPF was high. However, the clinical and functional characteristics did not differ between the patients with GERD and those without.

Randomized Open-Label Trial to Assess the Impact of Dosage Timing of Omeprazole/Sodium Bicarbonate (Zegerid 40 mg) on Healing of Severe Reflux Esophagitis: Preliminary Results

Purpose: Nighttime gastroesophageal reflux is important in the development of reflux esophagitis. For optimal efficacy, patients requiring proton pump inhibitor (PPI) therapy are advised to take their medication on an empty stomach 20 to 60 minutes before a meal which can be cumbersome. We hypothesized that immediate-release omeprazole/sodium bicarbonate (IR-OME), taken at bedtime, offers an alternative option for treatment of esophagitis. To test our hypothesis, we aimed to compare the percentage of subjects with severe esophagitis who achieve complete endoscopic resolution after 8 weeks of treatment with different dosage times: morning vs. bedtime. Methods: This is a prospective randomized open-label cohort study of outpatients with esophagitis. Subjects were educated about reflux disease and the proper technique and timing of the medication. Esophagogastroduodenos-copy (EGD) was performed at baseline and after 8 weeks of study medication. A 24-hour pH study was offered at the time of the follow-up EGD, regardless of endoscopic findings. The goal is to treat 100 subjects (morning N=50, bedtime N=50). Results: To date, 58 subjects have been recruited of which 46 have completed the study [31 (67%) male, mean age 58 (SD 12.5, range 22 to 81), LA grades C=28, D=18]. Twenty-two subjects were allocated to the morning dose and 29 to the bedtime dose (with 1 and 4 dropping out of each arm, respectively). Of 21 subjects (C=10, D=11) randomized to morning IR-OME, 15 (71%) had healed at 8 weeks. The 6 with persistent esophagitis all demonstrated improvement in severity by one or two grades. Of 25 subjects (C=18, D=7) randomized to bedtime IR-OME, 19 (76%) healed (p=0.74). Four of 6 improved, one had the same grade, and one worsened in severity. Ten of 46 (22%) subjects accepted the offer to undergo pH testing while on study medication. Four discontinued the study medication prior to placement of the pH probe and were excluded from this subgroup analysis. Of the 6 subjects who underwent pH testing while on IR-OME, 5 were on the morning dose; 4 (80%) with normalization of pH parameters. One subject on morning IR-OME demonstrated acid reflux (5.5% overall, 1.9% upright, 9.9% supine). Only one subject on IR-OME at bedtime consented to pH testing; their time with acid in the esophagus was normal (0.8% overall, 1.6% upright, 0% supine). Conclusion: These preliminary results suggest that both morning and bedtime dosing of IR-OME are effective in resolving severe LA grades C and D erosive reflux esophagitis at 8 weeks. Too few pH observations have been collected to comment on differences in nocturnal supine reflux between morning and bedtime dosing schedules. Disclosure: Dr Alexander Consulting Meritigae Pharmacia and Wyeth; Research Funding - Merck, Novartis, and Glaxo Smith Kline. Dr Romero - Grant/Research Support and Consultant, Santarus, makers of omeprazole/sodium bicarbonate (Zegerid). No disclosures for: Drs Dawn Francis, Tushar Dabade, Adil Abdalla, Rayna Grothe, Vikneswaran Namasivayam, Kee Wook (Kevin) Jung, Michael Crowell, Felicity Enders, Amindra Arora, Joseph Murray, Steven Adamson, Ramona DeJesus, Andrew Majka, John Patt, Matthew Lohse, Judith McElhiney, Virender Sharma, Kaiser Lim, Ganapathy Prasad, or Angela O'Neil, or Mrs Debra Geno, Mary Fredericksen, or Nancy Diehl. Santarus provided study medication and financial support to conduct the study.

The Preoperative Reflux Pattern as Prognostic Indicator for Long-Term Outcome After Nissen Fundoplication

We set out to investigate the impact of the preoperative reflux pattern on long-term outcome after Nissen fundoplication. Recent studies disagree on whether patients with pathological upright reflux should be discouraged from undergoing surgery. A total of 338 patients underwent Nissen fundoplication. Of these, 234 of 289 patients had pathological acid exposure on preoperative 24-h esophageal pH monitoring and their reflux was classified as pathological upright (n=81), supine (n=55), or bipositional (n=98). Clinical outcomes and results of endoscopy, manometry, and 24-h pH monitoring were compared before surgery, and at 3 months and 5 years after surgery. Patients with pathological upright and supine reflux had similar preoperative reflux parameters. In patients with pathological bipositional reflux, however, preoperative total acid exposure was higher than that in patients with upright or supine reflux (18.3% vs. 10.7 and 7.5%; P<0.001 and P<0.001). Prevalence of esophagitis was higher in patients with bipositional reflux than in those with upright reflux, both before (64.0 vs. 45.6%; P=0.035) and 3 months after surgery (16.0 vs. 3.5%; P=0.018). Before surgery, mean lower esophageal sphincter (LES) pressure was lower compared with the upright and supine reflux groups (1.0 vs. 1.5 and 1.6 kPa; P=0.007 and 0.005, respectively). The increase in quality of life, reduction of symptoms, use of acid-suppressing drugs, total acid exposure, and esophagitis were independent of reflux pattern at 3 months and 5 years after surgery (all P<0.05). Prevalence of recurrent pathological acid exposure was higher in the bipositional group than in the upright group (40.9 vs. 10.7%; P=0.013). Surgical reintervention was significantly more common in bipositional reflux patients (20.0 vs. 8.9% for upright and 4.1% for supine). All three pathological reflux patterns respond favorably to Nissen fundoplication in the long term. Patients with pathological bipositional reflux, however, suffer from more severe disease with higher chance of recurrence and reoperation.

American Gastroenterological Association Institute Technical Review on the Management of Gastroesophageal Reflux Disease

American Gastroenterological Association Institute Technical Review on the Management of Gastroesophageal Reflux Disease

The Prevalence of Gastroesophageal Reflux in Patients with Paradoxical Vocal Fold Motion

Purpose: Paradoxical vocal fold motion (PVFM) is an inappropriate adduction of the true vocal folds, which causes airway obstruction and inspiratory stridor. PVFM may lead to wheezing and is often mistaken for asthma, and patients are treated with glucocorticoids and beta-agonists inappropriately. There is a body of evidence stating that irritation of the vocal folds may cause or exacerbate PVFM. One-third of PVFM patients have been shown to report GERD symptoms, but studies to evaluate PVFM patients with pH monitoring have all been small (<10 subjects). We studied patients with PVFM to determine the prevalence of GERD in this population as diagnosed by esophagogastroduodenoscopy (EGD) or 48-hour esophageal acid monitoring. Methods: Patients diagnosed with PVFM by flattened inspiratory loop on pulmonary function testing underwent EGD with BRAVO capsule placement at 6 cm proximal to SCJ. All patients abstained from acid suppression agents (PPI's, H2RA's) for 7 days prior to the EGD. 48 hours of pH monitoring was performed with the BRAVO capsule. Patients were considered to have a diagnosis of GERD if they had any evidence of erosive esophagitis on EGD or if they had a positive Johnston-Demeester (JD) score (>22) during the second 24-hour period of pH monitoring by BRAVO capsule. Results: 32 patients (20 females, mean age 42 + 16 yrs) with PVFM completed the study. 31% (10/32) of subjects had a positive JD score, 50% of which had significant combined upright and supine reflux. On EGD, 18.8% (6/32) had evidence of esophagitis. Two subjects with esophagitis had a normal JD score. In this study the prevalence of GERD in PVFM was 37.5% (12/32, 95% CI 21.1–56.3%). Of GERD positive subjects, 50% (6/12) had evidence of esophagitis and 50% had atypical or no symptoms of GERD. GERD pos and GERD neg groups were similar in mean age (43 + 16 yrs vs. 41 + 16 yrs, P= 0.708) and sex (female, 50% of GERD pos vs. 70% of GERD neg, P= 0.452). Conclusion: GERD prevalence in this study was 37.5%. This suggests a high prevalence of GERD in the PVFM population. Because of this, PVFM patients should be studied for GERD, especially since many are asymptomatic. This may also suggest that GERD plays a role in the pathogenesis of PVFM.

A pilot study on diagnosing laryngopharyngeal reflux disease by pH monitoring in laryngopharynx

To analyze the significance of pH monitoring and reflux symptom index (RSI) in the diagnosis of laryngopharyngeal reflux disease (LPRD) and the characteristics of LPRD in symptoms and pH monitoring. RSI questionnaire survey and laryngopharyngeal pH monitoring were conducted on. 31 patients with laryngopharyngeal reflux-related symptoms, 15 males aged (50 +/- 13) years and 16 females aged (48 +/- 11) years, Gastroscopy was conducted on 13 patients to detect reflux esophagitis. The patients with the RSI scores > or = 13 were suspected as with LPRD and those with the reflux times > or = 7 or reflux area index (RAI) > or = 6.3 were diagnosed as with LPRD. McNemar test and Kappa test were performed on the RSI scores and reflux area indexes. Seventeen patients met the pH criteria. There were 8 patients suffering from voice disorders, 17 from clearing throat, 13 from excess throat mucus, 11 from dysphagia, 9 from cough after eating or with supine posture, 9 from dyspnea, 13 from cough, 12 from foreign body sensation, and 14 from digestive symptoms with the foregoing symptoms' mean scores of 1.4, 3.1, 2.1, 2.0, 1.1, 1.6, 1.8, 2.9, and 2.9 respectively. The P value with McNemar test on pH monitoring and RSI scoring was 0.289, and the P value with kappa test was 0.007. RSI was correlated with RAI(r(s) = 0.302, P = 0.049), reflux time (r(s) = 0.454, P = 0.005), and reflux time percentage (r(s) = 0.439, P = 0.007), but not correlated with the reflux frequency (r(s) = 0.252, P = 0.086). Supine reflux was seen in only 7 of the 224 reflux events in 17 patients, lasting only 96 seconds during the 84.6 minutes' supine acid exposure time. The common symptoms of LPRD are clearing throat, digestive symptoms, excess throat mucus, and foreign body sensation. Laryngopharyngeal pH monitoring and RSI scoring have the same value in diagnosing LPRD. Acid exposure in laryngopharynx is correlation to patients' self-report symptom. Almost all reflux events occur when the patients are in upright position.

Prevalence of Gastroesophageal Reflux Disease in Patients with Non-Cardiac Chest Pain Presenting to the Emergency Department

Purpose: This study prospectively evaluated the prevalence of Gastroesophageal reflux disease (GERD) in Non-Cardiac Chest Pain (NCCP) patients in the ED Methods: Patients were deemed to have NCCP after evaluation by an emergency physician. Exclusion criteria were: recent history of ischemic events ( < 6 months); proton pump inhibitors use, pregnancy; active psychiatric or unstable medical conditions. Study patients underwent upper endoscopy with placement of the wireless Bravo pH capsule (Medtronic Inc., Shoreview, MN) within two weeks of the initial ED visit. Esophageal, gastric or duodenal lesions were noted. The intraesophageal pH readings were recorded for 48 hours. An abnormal pH study was defined as the total% time pH < 4 of over 4 percent on at least one of the two days of study. The prevalence of esophageal acid exposure abnormalities and their corresponding 95% confidence intervals were calculated. Results: We screened 138 consecutive patients with NCCP in four months, 56 patients met exclusion criteria, 82 were eligible and 31 patients consented and participated. There were 19 (61%) females and 12 (39%) males, 9 (29%) Caucasians, 10 (32%) Hispanics, 10 (32%) African Americans and 2 (6%) Asians. The average age was 47 (range 31 to 63) years. Endoscopic findings in the 16 patients were: 3 (19%) had erosive esophagitis, and 3 (19%) had non-erosive esophagitis. Three pH studies were excluded due to premature capsule release, and 28 studies were analyzed. Abnormal esophageal acid exposure were seen in 16 patients (57.1%, CI: 37.0%∼77.3%) on one of the two days of monitoring. On day one, 7 out of 12 males (58%) and 6 out of 19 (32%) females had abnormal esophageal acid exposures; on day two, 6 males (50%) and 7 females (37%) were had abnormal studies. Women had both supine and upright reflux: 6 out of 6 (100%) on day one and 5 out of 7 (71%) on day two had both supine and upright reflux. In contrast, men had less supine reflux: 3 out of 7 (43%) day one and 4 out of 6 (67%) on day two had supine reflux, 6 out of 6 (100%) on day one and 6 out of 7 (86%) on day two had upright reflux. Conclusion: We found a 57% prevalence of GERD in NCCP patients presenting to the ED with more women than men with NCCP seen in the ED. Potential gender differences in esophageal acid exposures warrant further investigation.

Nocturnal Reflux Episodes Following the Administration of a Standardized Meal. Does Timing Matter?

Prospective evidence supporting lifestyle modifications, including avoidance of late evening meals, for gastroesophageal reflux disease (GERD) sufferers is lacking. The aim of this study was to determine the difference of supine esophageal acid exposure in patients consuming an early or late standard meal relative to bedtime. This is a prospective, randomized unblinded crossover trial. Thirty-two patients with typical reflux symptoms were enrolled and randomized to consume a standard meal either at 6 h or 2 h prior to going to bed for 2 consecutive nights. Acid exposure was measured for 48-h using a Bravo wireless pH system. Reflux symptom frequency and severity were recorded. Thirty patients successfully completed the study (63% male, 70% white, mean age 46 [24-74], mean body mass index [BMI] 28 kg/m(2)[18-40]). EGD revealed esophagitis in 37% and hiatal hernia (HH) in 47% of patients. Following the late evening meal, there was significantly more supine reflux (P= 0.002) when compared to the early meal. Significantly more supine reflux was also noted following the late evening meal in patients with HH, in overweight individuals (25 </= BMI </= 29.9), and those reporting heartburn as their chief complaint. Patients with esophagitis had more supine reflux following both the late and early evening meals. There was no significant difference in total symptom score between the 2 days. GERD patients consuming a late-evening meal had significantly greater supine acid reflux compared to when they consumed an early meal, especially in overweight patients, and in patients with esophagitis or HH. These findings support the recommendations to our GERD patients to eat dinner early and to lose weight.