Upright Reflux Research Articles

PHoenix score: development and validation of a novel approach to decrease the number of inconclusive GERD diagnoses

BackgroundThe Johnson–DeMeester composite score (DMS) is the historical gold standard for diagnosing gastroesophageal reflux disease (GERD). The Lyon Consensus outlines criteria for diagnosing GERD by pH monitoring, defining normal acid exposure time (AET) as < 4% and pathological as > 6%, presenting diagnostic uncertainty from 4 to 6%. We aimed to (i) calculate the proportion of borderline studies defined by total AET alone that are reclassified as normal or pathological by the DMS, (ii) determine the importance of supine AET for reclassification, and (iii) propose a new classification system using a composite score that considers positional changes.MethodsThis single-center, retrospective, observational study analyzed data from patients with an overall total AET from 2 to 6% on 48-h pH monitoring (Bravo pH capsule). Preselected predictors (supine and upright AET) were included in a model to create a composite score (i.e., pHoenix score) using the regression coefficients. The model was internally validated, and discriminative ability was tested against the DMS and compared to the total AET.ResultsWe identified 114 patients (80 [70.2%] women; median age, 55 years). Using the total AET, 26 (22.8%) were classified as normal and 88 (77.2%) as borderline; however, using the DMS, 45 (39.5%) were classified as normal and 69 (60.5%) as pathological. The new pHoenix score demonstrated strong discriminative ability (AUC: 0.957 [95% CI 0.917, 0.998]) with high sensitivity and specificity (lower threshold, 94.4% and 79.2%; upper threshold, 87 and 95.8%). Compared to the total AET alone, the pHoenix score significantly decreased the proportion of inconclusive cases (77.2% vs. 13.2%, p < 0.001).ConclusionTotal AET has low sensitivity to identify pathological reflux as it disregards supine versus upright reflux. The pHoenix score improves the distinction between normal and pathological cases and reduces ambiguity, offering an alternative approach to diagnosing GERD that addresses the limitations of using total AET alone or the DMS.Graphical abstract

Medium-term clinical efficacy of endoscopic antireflux mucosectomy on laryngopharyngeal reflux: a retrospective multicenter cohort study

Studies on the effect of antireflux mucosectomy (ARMS) on laryngopharyngeal reflux disease (LPRD) are lacking. We conducted a multicenter retrospective study to explore the clinical efficacy of ARMS on LPRD. We retrospectively analyzed the data of patients diagnosed with LPRD by oropharyngeal 24-hour Dx-pH monitoring who underwent ARMS. The effects of ARMS on LPRD were evaluated by comparing the 36-Item Short-Form Survey (SF-36), reflux symptom index (RSI), and 24-hour Dx-pH monitoring scores before and 1 year after surgery. Patients were divided into groups according to gastroesophageal flap valve (GEFV) grade to explore the effect of GEFV on prognosis. One hundred eighty-three patients were included in the study. The oropharyngeal pH monitoring results showed that the effective rate of ARMS was 72.1% (132/183). After surgery, the SF-36 score was higher (P= .000), RSI score was lower (P= .000), and the symptoms of constant throat clearing; difficulty swallowing food, liquids, and pills; coughing after eating or after lying down; troublesome or annoying cough; and breathing difficulties or choking episodes were significantly improved (P< .05). Upright reflux was dominant in GEFV grade I to III patients, and the SF-36, RSI, and upright Ryan index scores were significantly improved after surgery (P<.05). In GEFV grade IV patients, regurgitation was dominant in the supine position, and the above evaluation indexes were worse after surgery (P< .05). ARMS is effective for LPRD. The GEFV grade can predict the prognosis of surgery. ARMS is effective in GEFV grade I to III patients, but the effect is not exact in GEFV grade IV patients and may even be aggravated.

Effects of diaphragmatic breathing on the pathophysiology and treatment of upright reflux: a randomized controlled trial

Patients with upright reflux have predominantly nonerosive esophagitis and can be successfully treated with non-pharmacological treatments. In some studies, diaphragmatic breathing reduced acid exposure and improved gastroesophageal reflux disease (GERD) symptoms in reflux patients. Further investigation is needed to assess the mechanism of action and efficacy of Diaphragmatic breathing.&#x0D; We summarize the @GIJournal discussion held on March 17, 2021 during which we discussed the article by Halland et Al titled “Effects of diaphragmatic breathing on the pathophysiology and treatment of upright reflux: a randomized controlled trial.” Key findings were reviewed by our expert Dr. Magnus Halland (MH) and the session was moderated by Dr Linda Nguyen (LN).

Diagnosing Laryngopharyngeal Reflux: A Comparison between 24-hour pH-Impedance Testing and Pharyngeal Probe (Restech) Testing, with Introduction of the Sataloff Score

The purpose of this study was to compare the diagnostic utility of pH monitoring using 24-hour esophageal pH-Impedance (HEMII-pH) testing versus pharyngeal pH (Restech) testing (Respiratory Technology Corporation, Houston, Texas) for diagnosing laryngopharyngeal reflux (LPR). Retrospectively, patients were reviewed who had completed a Reflux Symptom Index (RSI) survey and stroboscopy within 60 days before or after undergoing simultaneous esophageal pH-Impedance monitoring and Restech testing. Reflux Finding Score (RFS) was determined by 4 blinded observers. 80.45% of patients were on anti-reflux medications at the time of study and had incomplete response to treatment for reflux. Improvement on reflux treatment was determined by evaluating presenting pre-pH monitoring RFS, post treatment RFS, and improvement of symptoms. Pearson correlation coefficients were calculated to assess relationships among RSI, RFS, and test results from HEMII-pH and Restech tests. Eighty-seven patients were included in the analysis. The inter-rater reliability of the RFS determination was 74.57%, and the intra-rater reliability was 67.00%. Subjects who had a positive RYAN Score had a significant correlation with RFS (r of 0.222 and p-value of 0.0492). There was no correlation between RFS and number or percent time of reflux events, longest event, total number of events, or percent of time at alkaline pH for either HEMII-PH or Restech test. RSI correlated better with HEMII-pH test than with Restech for percent time spent in both upright (r of 0.226 and p-value of 0.029) and supine position (r of 0.261 and a p-value of 0.032). Restech correlated better with total patient symptom Scores including cough, heartburn, burping, and throat clearing, with a r of 0.242 and a p-value of 0.048. Restech detected more percent time in reflux for total reflux, supine reflux, and upright reflux (p-value less than 0.0001). Restech also detected longer event times than Impedance (p-value of less than 0.0001).When diagnosis of LPR is based on the definition of CRC, the Sataloff Score test had 70.45% sensitivity and 80.95% specificity. The RYAN Score had a sensitivity of 72%, and a specificity of 56.45%, and the Wu Score had a sensitivity of 62.16%, and specificity of 54.05%. When the Sataloff and Wu Score were used together, the sensitivity was 71.45%, specificity 100%, positive predictive value of 100%, and a negative predictive value of 59.46%. The amount of time of reflux events correlates with symptoms better than the number of events. The HEMII-pH test was able to detect more events of pH<4 than Restech, possibly because there might have been more acid events below than above the upper esophageal sphincter, while Restech detected more total events. Restech recorded longer event times than HEMII-pH test. Since length of time correlates with RFS (probably reflecting laryngeal inflammation), and since laryngeal clearance of acid is more similar to pharyngeal than esophageal clearance, this finding might prove valuable clinically. The Sataloff Score has a sensitivity of 70.45%, and a specificity of 80.95% and appears useful clinically to detect mild to moderate that is missed by the RYAN Score. A combination of Sataloff Score and Wu Score may be clinically valuable to identify LPR with an increased sensitivity of 71.45% and increased specificity of 100%. The Wu Score is not yet available for the general clinical use, but the Sataloff Score is.

ESOPHAGEAL FUNCTIONAL DISORDERS IN THE PRE-OPERATORY EVALUATION OF BARIATRIC SURGERY.

Obesity is an independent risk factor for esophageal symptoms, gastroesophageal reflux disease (GERD), and motor abnormalities. When contemplating bariatric surgery, patients with obesity type III undergo esophagogastroduodenoscopy (EGD) and also esophageal manometry (EMN), and prolonged pHmetry (PHM) as part of their pre-operative evaluation. Description of endoscopy, manometry and pHmetry findings in patients with obesity type III preparing for bariatric surgery, and correlation of these findings with the presence of typical GERD symptoms. Retrospective study in which clinical symptoms of GERD were assessed, focusing on the presence of heartburn and regurgitation. All patients underwent EMN, PHM and most of them EGD. 114 patients (93 females-81%), average age 36 years old, average BMI of 45.3, were studied. Typical GERD symptoms were referred by 43 (38%) patients while 71 (62%) were asymptomatic. Eighty two patients (72% of total) underwent EGD and 36 (42%) evidenced esophageal abnormalities. Among the abnormal findings, hiatal hernia was seen in 36%, erosive esophagitis (EE) in 36%, and HH+EE in 28%. An abnormal EMN was recorded in 51/114 patients (45%). The main abnormality was a hypotensive lower esophageal sphincter (LES) in 32%, followed by ineffective esophageal motility in 25%, nutcracker esophagus in 19%, IEM + hypotensive LES in 10%, intra-thoracic LES (6%), hypertensive LES (4%), aperistalsis (2%) and achalasia (2%). Among the 43 symptomatic patients, 23 (53%) had abnormal EMN and 31/71 asymptomatic cases (44%) also presented this finding (P=0.30). PHM showed abnormal reflux in 60/114 patients (53%), with a predominance of bi-positional reflux (42%), followed by supine reflux (33%) and upright reflux (25%). Abnormal PHM was found in 26/43 symptomatic cases (60%) and also among 34/71 asymptomatic cases (48%) (P=0.19). Manometric abnormalities were common in obesity type III patients, the most frequent being hypotensive LES, followed by IEM. Most patients were asymptomatic. There was no correlation between the finding of motor abnormalities and the presence of symptoms. More than half the patients had abnormal reflux at PHM. We found no significant correlation between abnormal reflux and the presence of symptoms.

Association between gastroesophageal reflux disease and vocal fold polyps.

The aim of this study is to explore the relationship between gastroesophageal reflux disease (GERD) and vocal fold polyps (VFPs).This is a Case-Control study and was performed with the help of The Second Affiliated Hospital of Chongqing Medical University.Twenty-seven patients with VFP and 20 controls without VFP were recruited between May and October 2018. All the subjects underwent a saliva pepsin test, completed the GerdQ questionnaire and 24-hour multichannel intraluminal impedance with pH (24-h MII-pH) monitoring. Twenty-five resected VFP specimens were examined with immunohistochemical (IHC) and double immunofluorescence (IF) staining.The incidence of GERD in the VFP group was significantly higher than that in the control group (P = .003). Patients with VFP had significantly higher GerdQ scores, pepsin concentrations, and pepsin-positive rates (P < .05). Moreover, the number of proximal and upright reflux events was significantly higher in the VFP group (P < .05). The pepsin concentration in saliva showed a significant positive correlation with the pepsin levels in tissues (r2 = 0.50, P = .011). Pepsin and TGF-β1-positive cells were colocalized with CD45RO-positive cells. IHC staining showed that the majority of VFP patients had a positive expression of pepsin (20/25, 80%) and pepsin-positive cells were found in both the squamous epithelium and mesenchymal tissues. IHC staining of TGF-β1 in VFP revealed findings similar to those of pepsin staining.GERD is an important risk factor for VFP. Pepsin may promote the aggregation of immune cells, increase the local cytokines, and promote inflammatory reaction, suggesting a potential new pathogenesis for VFP. The saliva pepsin test is a reliable method for GERD diagnosis.

The correlation between gastric bubble size and laryngopharyngeal reflux pattern in patients with laryngopharyngeal reflux disease

Objective: To investigate the correlation between gastric bubble size and laryngopharyngeal reflux pattern in patients with laryngopharyngeal reflux disease(LPRD). Methods: A total of 52 LPRD patients who underwent Dx-pH monitoring and anteroposterior chest radiography at the same time from February 2016 to November 2018 were retrospectively studied. Patients were devided into three position-related groups according to the Ryan score of upright and supine: isolated upright reflux(IUR), isolated supine reflux(ISR) and bipositional reflux(BR) groups. In addition, 13 healthy volunteers with negative pH monitoring were selected as the control group. Gastric bubble size and pH monitoring data among the four groups were compared. SPSS 24.0 was used for statistical analysis. Results: In all the 52 patients, 35 cases (67.3%) were classified as IUR, 9 cases (17.3%) as ISR, and 8 cases (15.4%) as BR. The height of gastric bubbles in the four groups were: IUR (26±14) mm, ISR (9±8) mm, BR (20±13) mm, control (17±15) mm, and statistical difference was found among the four groups(P=0.004). Post Hoc Multiple Comparisons found that IUR group had statistical difference between ISR group and control group (P=0.001, P=0.034 respectively). There was no statistical difference of gastric bubble width and area among the four groups(P=0.340, P=0.186 respectively). The ROC curve of the gastric bubble height with isolated upright and supine reflux patterns was obtained, and the optimal cutoff value of the gastric bubble height was 11 mm. Accordingly, we divided the patiens into two groups with high and low gastric bubble. LPRD reflux pattern distribution was significantly different between the two groups(P<0.001). The comparison of reflux parameters in pH monitoring also showed that the supine reflux parameters in the lower group were significantly higher than those in the higher group, and the upright reflux parameters in the higher group were significantly higher than those in the lower group(P<0.001). Conclusions: The height of gastric bubble is significantly correlated with the reflux patterns in LPRD patients. The gastric bubble of patients with IUR is significantly higher than that of patients with ISR. Taking 11 mm as the cutoff value, patients with higher gastric bubble are more prone to upright laryngopharyngeal reflux, while those with lower gastric bubble are more prone to supine laryngopharyngeal reflux.

450 Esophageal Motility Disorders and GERD in Patients With Pulmonary Nontuberculous Mycobacterial Infection: A Growing Medical Problem

INTRODUCTION: The prevalence of pulmonary infections by nontuberculous mycobacteria (NTM) is increasing worldwide. The etiology of this increase is unclear. There is evidence that gastroesophageal reflux disease (GERD) is associated with NTM infections and can increase the severity of pulmonary disease. Data regarding esophageal motility in this population is sparse. We aimed to characterize esophageal motility disturbances and GERD in patients with bronchiectatic NTM and explore its associations with pulmonary pathology and lung function. METHODS: We conducted a retrospective review of all patients with a confirmed diagnosis of bronchiectatic NTM at a single center who underwent high resolution esophageal manometry (HRM) between November 2014 and March 2018. Chicago Classification 3.0 was used to characterize HRM findings. Combined multichannel intraluminal impedance-pH (pH-MII) was utilized to assess reflux burden. Statistical relationships between proportions and percentages were evaluated by Fisher’s exact test. Linear regression was utilized to assess associations with pulmonary function testing. RESULTS: A total of 32 patients underwent HRM, of which 27 underwent pH-MII. The mean age of all was 70 (SD 10), mean body mass index was 23.4 (SD 6.1), 78% were female, and 44% had a smoking history. The mean lower esophageal sphincter (LES) resting and residual pressures (mmHg) were 36.12 (SD 17.12) and 11 (SD 8.37), respectively. HRM motility disorders included 38% ineffective esophageal motility, 38% normal esophageal motility, 19% esophagogastric outflow obstruction, and 6% jackhammer esophagus. Significant evidence of GERD on pH testing was seen in 12 patients (44%). pH testing showed similar upright and supine reflux burdens of 7.6% and 7.4% respectively. On endoscopy, 2 patients (6.25%) had Barrett’s esophagus. No statistically-significant correlations were found between BMI, gender, mycobacterial organism, imaging characteristics, pulmonary function, HRM diagnosis or presence of significant reflux. CONCLUSION: Esophageal motility is frequently abnormal among patients with NTM. NTM patients also have a high prevalence of GERD, including supine GERD, and Barrett’s esophagus, which is far greater than the general population. Consideration should be given to screening for BE among patients with NTM related bronchiectasis. Larger studies are warranted to further characterize esophageal physiology in these patients and the potential impact on pulmonary pathology.

Characteristics of upright versus supine reflux pattern in patients with laryngopharyngeal reflux

IntroductionMany laryngeal-related problems have been attributed to laryngopharyngeal reflux including dysphonia, frequent throat clearing, chronic cough, and globus sensation. However, there is still controversy regarding diagnosis and clinical presentation of this disorder. ObjectiveThe main objective of this study is to describe laryngopharyngeal reflux characteristics of different reflux position patterns in laryngopharyngeal reflux patients diagnosed with oropharyngeal pH monitoring. MethodsA retrospective chart review was conducted for 161 laryngopharyngeal reflux patients diagnosed with 24h oro-pharyngeal pH monitoring. Study subjects were categorized into upright and supine laryngopharyngeal reflux groups based on the pH results. The two groups were compared regarding the clinical presentation and pH characteristics. ResultsSignificant higher rates of upright laryngopharyngeal reflux position than supine laryngopharyngeal reflux position (P<0.0001) were reported among the study group. Reflux symptoms index results were significantly higher in the upright larybgopharyngeal reflux group compared to the supine laryngopharyngeal reflux group. 24h oropharyngeal pH measurements composite Ryan score was significantly higher in the upright group compared to the supine group (P<0.0001). No significant difference was found between the upright and supine laryngopharyngeal reflux groups regarding the frequency of clinical presentation or voice handicap index ratings. ConclusionLaryngopharyngeal reflux was found to be more prevalent occurring in the upright position among the study group. Reflux-related characteristics including pH parameters were more evident in the upright laryngopharyngeal reflux position.

The Development and Validation of an Endoscopic Grading System for Hiatal Hernia: The Houston Hiatal Criteria

Introduction: A hiatal hernia (HH) is frequently found during esophagogastroduodenoscopy (EGD). Length of the HH is routinely measured as the distance between the gastroesophageal junction (GEJ) and the diaphragmatic pinch. Although gastroenterologists routinely perform examination of the gastric fundus in retroflexion, the diaphragmatic diameter and Hill grade of the gastroesophageal flap valve are not routinely reported during EGD. Methods: A multidisciplinary GERD group at our institution developed the Houston Hiatal criteria, standardized criteria for endoscopic assessment and reporting of HH. These criteria include length (L), diaphragmatic diameter (D) and Hill grade (H). We retrospectively applied these criteria to a prospectively maintained database of patients undergoing 96-hour wireless pH evaluation, and compared the results between groups of patients with and without HH. Results: In our cohort of 257 consecutive patients (94 male, mean age 52.6 years (19-84 years)), 46 patients met the Houston Hiatal criteria for HH, defined as L > 1 cm, D > 1 cm and H ≥ 2. Patients with HH based on these criteria were twice as likely to have endoscopic evidence of esophagitis compared to patients without HH (40% vs 19%, p < 0.01). We also found a positive correlation between higher DeMeester scores and increasing Houston Hiatal criteria scores of HH on 96-hour wireless pH studies (p < 0.01). Patients with HH also had higher mean DeMeester scores (32.38 ± 28 vs 21.54 ± 22, p < 0.01). 96-hour pH study results were more frequently abnormal in patients with HH compared to patients without HH: Total time spent in reflux (91% patients with HH vs 78% patients without HH, p <0.01), upright reflux (96% vs 81%, p < 0.01), supine reflux (89% vs 62%, p < 0.01), and postprandial reflux (98% vs 81%, p < 0.01). Conclusion: The Houston Hiatal criteria for HH allowed accurate endoscopic assessment, description, and grading of HH. Patients with HH based on these criteria were more likely to have esophagitis and objective findings of GERD on 96-hour pH study.328 Figure 1. Houston Hiatal Hernia statistic report

PS01.054: GASTROESOPHAGEAL REFLUX DISEASE PHENOTYPES IN THE MODERN ERA: CLINICAL, ENDOSCOPIC, MANOMETRIC AND PH TESTING PROPERTIES

Abstract Background Reflux phenotypes have classically been divided into supine, upright, and bipositional predominant reflux. Recent data on clinical, endoscopic, and manometric features in these patient groups are scant and most prior reports occurred prior to the advent of high resolution impedance manometry and prolonged wireless pH monitoring. We aimed to evaluate the distribution, demographic, manometric, and endoscopic characteristics of the reflux phenotypes in this modern era of testing. Methods Patients who had esophageal physiology testing at a single tertiary care center over a one year period were retrospectively reviewed for demographic, clinical, endoscopic, manometric and pH impedance data. We included consecutive patients who had undergone pH-impedance or wireless pH testing with an EGD within 6 months. Results 139 patients were included and 91 (65.5%) patients were women was mean age of 51.9 + /- 15.2 years and mean BMI of 29.1 + /- 6.4. The most common reflux pattern was bipositional (46% of patients), followed by supine (25%). Baseline characteristics, endoscopic and manometric data across groups are included in Table 1. Barrett's esophagus was most common in the non-acid group. Endoscopically, esophagitis was most common in the supine and bipositional groups. Manometric findings were similar across groups. Conclusion The epidemiology of GERD patients appears to be changing as evidenced by a higher mean BMI than in the largest prior study from 1999. Despite demographic changes in GERD and more widespread use of advanced esophageal physiology testing, the manometric and endoscopic characteristics of GERD phenotypes remains fairly similar. Disclosure All authors have declared no conflicts of interest.

Mo1025 - Increased Upright Reflux on Wireless Capsule pH-Metry does not Predict Delayed Gastric Emptying

Mo1025 - Increased Upright Reflux on Wireless Capsule pH-Metry does not Predict Delayed Gastric Emptying

Secrets for successful laparoscopic antireflux surgery: predictors

Gastroesophageal reflux disease (GERD) is a common malady. It is a protean disease with many manifestations. Most patients seek medical attention due to symptoms. When a surgical remedy is contemplated, it is incumbent upon the surgeon to identify those patients in whom antireflux surgery (ARS) will lead to elimination of pathologic reflux and symptomatic improvement. There are many patient-related factors and technical factors which can predict success or failure of ARS. These predictors can be divided into proper diagnosis of GERD-like symptoms, GERD-related patient factors, non-GERD related patient factors, and operation-related factors. Proper diagnosis includes insuring that the GERD-like symptoms are in fact related to pathologic reflux and not some other disease or psychological process. GERD-related patient factors include differentiating between typical and atypical symptoms, as well as upright and supine reflux. This also includes assessing for reflux related complications, such as ulcers, strictures and neoplasia. Non-GERD-related patient factors include other gastrointestinal disorders such as irritable bowel syndrome (IBS), gastroparesis and peptic ulcer disease. Psychological disorders, such as anxiety and depression, can also affect the outcomes of ARS. Lastly, technical aspects, such as the type and geometry of the fundoplication, hiatal closure, division of the short gastric vessels and addition of a pyloroplasty can affect success. Attention to these details will place the surgeon in the best position to insure a favorable outcome of an antireflux operation.

The expression and significance of pepsin in laryngeal carcinoma

To evaluate the relationship between pepsin induced by laryngopharyngeal reflux and laryngeal carcinoma. Patients with vocal cord leukoplakia(n=18) and laryngeal carcinoma(n=21) encountered in Nanfang Hospital between December 2012 and April 2014 were included and sixteen healthy volunteers were recruited as control. Laryngeal biopsy specimens were taken from the patients with laryngeal carcinoma, or vocal cord leukoplakia and control subjects for the immunohistochemical study of pepsin. The correlation between pepsin expression and reflux events of 24 hour multichannel intraluminal impedance-pH monitoring (MII-pH) was analyzed. The patients with laryngeal carcinoma showed the highest expression of pepsin, followed by the patients with vocal cord leukoplakia and control subjects, with significant difference among the three groups (in strong positive expression, the constituent ratio of each group are 0/16、1/18 and 4/21, P<0.01). The presence of pepsin was associated with upright and total laryngopharyngeal acid reflux (P<0.05), including acid reflux episodes, the percentage of times that the pH was below four, the percentages of acid reflux time and average acid removal time. There was a significant correlation between the pepsin level and the esophageal acid reflux parameters (P<0.05) except supine the percentage of time that the pH was below four. Pepsin expression in laryngeal tissue increases in patients with vocal cord leukoplakia and laryngeal carcinoma, contributing to the development of laryngopharyngeal carcinogenesis.

OC-065 Motility and Oesophageal Clearance in Barrett’s Oesophagus

Introduction It is not clear if Barrett’s is a consequence of excessive reflux only or reduced clearance of refluxed materials. This study compares oesophageal reflux over 24 hours and High Resolution Manometry (HRM) response to solids in Barrett’s with non-Barrett’s reflux (NBR). Methods Reports for 19 consecutive patients (M58:F14) with ≥2 cm Barrett’s during 2015 were compared with 25 patients with NBR (M10:F16) and 13 patient controls with normal physiology/endoscopy (M3:F10). All had at least one typical symptom of heartburn, regurgitation or chest pain. All had HRM with the intention of completing 10x5cc water and 5x1cc bread. Contractile vigour was measured with the Distal Contractile Integral (amplitude x length x contraction time); DCI > 450 mmHg.cm.s and breaks in peristalsis of Results Lower oesophageal sphincter pressure was lower in Barrett’s (8 vs. 14 mmHg; p = 0.009). Compared to NBR, patients with Barrett’s (2–10 cm) had significantly reduced DCI for both 5 ml water (318 vs. 650 mmHg.cm.s; p = 0.007) and solid (1096 vs. 2002 mmHg.cm.s; p = 0.009). On the other hand, the likelihood of measuring a DCI of >450 was significantly reduced in Barrett’s only with solids (69% vs. 100%; p only for solids (44% vs. 65%; p = 0.029). All reflux parameters were similar between the two groups: total (p = 0.116), upright (p = 0.233) and supine reflux (p = 0.110), symptom index (p = 0.16), symptom association probability (p = 0.106) and total number of reflux events (p = 0.063). On the other hand, bolus clearance time (BCT) was significantly prolonged for Barrett’s (13 vs. 10 s; p = 0.009) solely due to prolonged supine BCT (14 vs. 10 s; p Comparing those with prior endoscopic Barrett’s therapy (n = 6) with treatment naive (n = 13), there was no difference in any motility or pH monitoring parameter apart from BET which was greater in those who received therapy (5.87% vs. 1.99%; p = 0.046). Conclusion Solids were superior to water swallows in demonstrating ineffective contractility in Barrett’s. This was associated with reduced nocturnal oesophageal clearance and increased exposure to refluxate during the day/night. These findings contribute to the theory of impaired contractility and reduced clearance despite acid-reducing medication in Barrett’s. Disclosure of Interest R. Sweis Conflict with: Organised Symposium funded by Given img/Diagmed, A. Raeburn: None Declared, E. Athanasakos: None Declared, N. Zarate-Lopez: None Declared, L. Lovat: None Declared, R. Haidry: None Declared, M. Banks: None Declared, A. Emmanuel: None Declared

The relationship between idiopathic pulmonary fibrosis and gastroesophageal reflux disease

To study the prevalence and characteristics of gastroesophageal reflux disease (GERD) in patients with idiopathic pulmonary fibrosis (IPF). A total of 48 patients with diffuse parenchymal lung disease (DPLD) including 25 IPF and 23 other DPLD were enrolled from Department of Respiratory Disease in the First Affiliated Hospital of China Medical University. All patients were subjected to 24-hour esophageal pH monitoring. Pulmonary function test and HRCT of lung were performed at the same time. The prevalence of GERD in IPF patients was 64.0%, which was significantly higher than that in other DPLD patients. DeMeester scores were significantly higher in IPF patients than those in non-IPF group [(22.8 ± 21.5) score vs (15.7 ± 14.0) score respectively P < 0.05]. Numbers of reflux longer than 5 minutes [(3.8 ± 4.1) time vs (2.1 ± 2.1) time respectively) and reflux index (1.8 ± 1.7 vs 1.3 ± 1.2) in IPF group were higher than those in non-IPF group, yet without statistical significance. Patients with IPF had significantly higher values of following parameters than those in non-IPF patients including percentage of total reflux time (pH < 4.0) (9.2 ± 5.1)%, percentage of upright reflux time (8.5 ± 5.2)%, percentage of supine reflux time (10.8 ± 10.7)%, numbers of reflux (54.2 ± 22.7) time, numbers of regurgitation longer than 5 minutes (6.3 ± 4.2) time, the longest reflux time (14.5 ± 15.3) min, reflux index 2.5 ± 1.7 and DeMeester scores (34.9 ± 20.3) time (P < 0.05). DeMeester score was positively correlated with gastroesophageal reflux diseases questionnaire (GerdQ) score (r = 0.667, P < 0.01). The prevalence of typical GERD sympotoms in the IPF-GERD patients was higher (heartburn 7/16, regurgitation 6/16) than that in IPF patients without GERD (heartburn 2/9, regurgitation 1/9). Patients with IPF have a high prevalence of GERD, but usually without typical GERD symptoms. In the hospitals 24-hour esophageal pH monitoring not available, GerdQ can be used to identify GERD in IPF patients.

Pre-lung transplant measures of reflux on impedance are superior to pH testing alone in predicting early allograft injury.

To evaluate pre-lung transplant acid reflux on pH-testing vs corresponding bolus reflux on multichannel intraluminal impedance (MII) to predict early allograft injury. This was a retrospective cohort study of lung transplant recipients who underwent pre-transplant combined MII-pH-testing at a tertiary care center from January 2007 to November 2012. Patients with pre-transplant fundoplication were excluded. Time-to-event analysis was performed using a Cox proportional hazards model to assess associations between measures of reflux on MII-pH testing and early allograft injury. Area under the receiver operating characteristic (ROC) curve (c-statistic) of the Cox model was calculated to assess the predictive value of each reflux parameter for early allograft injury. Six pH-testing parameters and their corresponding MII measures were specified a priori. The pH parameters were upright, recumbent, and overall acid reflux exposure; elevated acid reflux exposure; total acid reflux episodes; and acid clearance time. The corresponding MII measures were upright, recumbent, and overall bolus reflux exposure; elevated bolus reflux exposure; total bolus reflux episodes; and bolus clearance time. Thirty-two subjects (47% men, mean age: 55 years old) met the inclusion criteria of the study. Idiopathic pulmonary fibrosis (46.9%) represented the most common pulmonary diagnosis leading to transplantation. Baseline demographics, pre-transplant cardiopulmonary function, number of lungs transplanted (unilateral vs bilateral), and post-transplant proton pump inhibitor use were similar between reflux severity groups. The area under the ROC curve, or c-statistic, of each acid reflux parameter on pre-transplant pH-testing was lower than its bolus reflux counterpart on MII in the prediction of early allograft injury. In addition, the development of early allograft injury was significantly associated with three pre-transplant MII measures of bolus reflux: overall reflux exposure (HR = 1.18, 95%CI: 1.01-1.36, P = 0.03), recumbent reflux exposure (HR = 1.25, 95%CI: 1.04-1.50, P = 0.01) and bolus clearance (HR = 1.09, 95%CI: 1.01-1.17, P = 0.02), but not with any pH-testing parameter measuring acid reflux alone. Pre-transplant MII measures of bolus reflux perform better than their pH-testing counterparts in predicting early allograft injury post-lung transplantation.

Gastroesophageal Reflux in a Cohort of Morbidly Obese Patients Before and After Sleeve Gastrectomy

Introduction: Laparoscopic sleeve gastrectomy (LSG) offers excellent sustainable weight loss for morbidly obese patients. Previous studies have demonstrated an increase in gastroesophageal reflux (GER) following LSG. The aim of this study was to compare acid reflux parameters in a cohort of obese patients before and after surgery. Methods: We prospectively enrolled adult obese patients greater than 18 years old undergoing preoperative evaluation for LSG. Patients underwent PPIs pre-operative 24 hour combined ambulatory pH and impedance testing off of PPI. Studies were repeated at least 6 months after LSG. Reflux data collected included Johnson-DeMeester (JD) score, to include percent total time pH<4, percent supine time pH<4, percent upright pH <4, number of reflux episodes <5 minutes, longest reflux episode, and impedance testing results. Results: We enrolled 18 consecutive adult patients presenting for preoperative evaluation for LSG with a mean age of 51.5 (SD); 7 were white (78%), and 2 were male (22%). Sixteen patients successfully underwent LSG, of which 9 patients completed their post-operative testing. After LSG, there was a statistical increase in mean acid reflux episodes from 24.36 to 51.57 (p=0.03) and mean distal esophageal impedance episodes from 47.67 to 69.78 (p=0.04), but no change in proximal impedance (p=0.16). Although there was an almost 2-fold increase in mean JD score from 16.68 to 31.23 (p=0.09), this was not statistically significant. Likewise, there was no statistically significant change in total percent time (p=0.23), percent upright reflux (p=0.44), percent supine reflux (p=0.08), number of reflux episodes >5 minutes (p=0.21), or longest reflux episode (p=0.37). Conclusion: In this small ongoing study, LSG significantly increased the number of acid and impedance reflux episodes. A trend towards an increase in JD score was observed.

Research on the association of the laryngeal carcinoma and laryngopharyngeal reflux

The objective of this study is to investigate the association between laryngeal carcinoma and laryngopharyngeal reflux. This was a case-control study with 31 laryngeal cancer patients who had undergone 24-hour ambulatory double pH monitoring and 76 in the control group which were divided into negative group (36 patients) and positive group (40 patients) by the score of RSI (reflux symptom index) and RFI (reflux findings index) scale. The results of reflux and parameters of 24-hour ambulatory double pH monitoring among the three groups were statistically analysed. The smoking rate of 80.6% (25/31) in laryngeal carcinoma group was significantly higher than that of (36.1%, P < 0.0167) in the negative group while it did not vary in laryngeal carcinoma group and the positive group (65.0%, P > 0.0167). The drinking rate of 71.0% (22/31) in laryngeal carcinoma group was higher than that of (36.1%, P < 0.0167) in the negative group whereas there was no significant difference between laryngeal carcinoma group and positive group (50.0%, P > 0.0167). The positive rate of laryngopharyngeal reflux in laryngeal carcinoma group, the positive group, the negative group were 74.2% (23/31), 16.7% (6/36) and 52.5% (21/40) respectively, which was significantly different (P < 0.05). The positive rate of gastroesophageal reflux in the three groups above were 71.0% (22/31), 52.8% (19/36) and 75.0% (30/40), which had no significant difference (P > 0.05). The positive rate of laryngopharyngeal reflux differed in laryngeal carcinoma group and the negative group (P < 0.0167) while did not differ in laryngeal carcinoma group and the positive group (P > 0.0167). In the results of 24-hour ambulatory double pH monitoring, there was significant difference in the total and upright reflux number, the total reflux time, the percent times for the pH falling below 4, total reflux number which lasted more than 5 minutes and DeMeester Scores. The positive rate of laryngopharyngeal reflux in laryngeal carcinoma group was very high while the drinking and smoking rate were also high. Therefore whether the laryngopharyngeal reflux is a risk factor of the laryngeal carcinoma, it needs further research.

Tu1401 The Mechanism of Action of Radiofrequency Energy Delivery (Rfed) to the Gastroesophageal Junction (GEJ) May Be Ideal for Upright Refluxers: a Retrospective Cohort Study

Tu1401 The Mechanism of Action of Radiofrequency Energy Delivery (Rfed) to the Gastroesophageal Junction (GEJ) May Be Ideal for Upright Refluxers: a Retrospective Cohort Study