Upright Time Research Articles

Normal 24-hour Ambulatory Esophageal pH Values in Koreans

Twenty-four-hour ambulatory esophageal pH monitoring is considered the gold standard for diagnosing gastroesophageal reflux disease. The aim of this study was to quantify normal distal esophageal acid parameters in healthy Koreans. Thirty healthy adults who were not on medication and were free from gastrointestinal symptoms were analyzed. Ambulatory esophageal acid (pH <4) exposure parameters were recorded at 5 cm above the lower esophageal sphincter. The 95th percentiles for reflux parameters assessed in the distal esophagus were as follows: percentage of total time with pH <4, 5.10%; percentage of upright time with pH <4, 7.88%; percentage of supine time with pH <4, 4.00%; number of reflux episodes, 62.7; number of reflux episodes with pH <4 for >5 minutes, 5.3; and the longest single acid-exposure episode, 21.3 minutes. Physiological gastroesophageal reflux occurs frequently in healthy Koreans. These data provide a reference range that could be utilized in studies involving Korean subjects.

EFFECT OF THIGH CUFFS ON HAEMODYNAMIC CHANGES OF THE MIDDLE CEREBRAL ARTERY AND ON ORTHOSTATIC INTOLERANCE INDUCED BY 10 DAYS HEAD-DOWN BED REST

Thigh cuffs are used by cosmonauts to limit fluid shift during space flight, but the appropriate level of cuff pressure and the duration of application to optimize their beneficial effects require further detailed investigations. In the present study, 10 days head-down tilt (HDT) bed rest was performed to assess the effects of thigh cuffs (40 mmHg, 10 h/day) on haemodynamic changes of the middle cerebral artery (MCA) and on orthostatic tolerance in six healthy male volunteers. Another six healthy male volunteers without thigh cuffs served as the control group. Haemodynamic parameters of the MCA were measured using transcranial Doppler. Orthostatic tolerance was assessed before and after HDT. After HDT, the mean upright time in the control and thigh cuff groups was 14.0 +/- 4.1 and 19.2 +/- 0.7 min, respectively. Compared with values before HDT, the percentage increase in heart rate from baseline in the upright position after HDT was significantly higher in the control group and the percentage change from baseline of mean diastolic arterial blood decreased more after HDT in this group. In the control group, systolic blood velocity (Vs) and mean blood velocity (Vm) of the right MCA decreased significantly during HDT. In the thigh cuffs group, the Vs of the right MCA decreased significantly on Days 3 and 7 of HDT and the Vm of the right MCA decreased significantly on Day 7 of HDT. The results indicate that daily use of thigh cuffs during 10 days of HDT does not completely prevent the decrease in haemodynamics of the right MCA, but is effective in preventing orthostatic intolerance.

Normal Ambulatory 24-Hour Esophageal pH Values in Koreans -A Multicenter Study-

Ambulatory 24-hr esophageal pH monitoring is considered the gold standard for diagnosing gastroesophageal reflux disease. The aim of this study was to establish normal values for gastroesophageal acid exposure in healthy Koreans. Fifty healthy volunteers (24 males and 26 females; mean age, 45 yr) without reflux symptoms and without reflux esophagitis or hiatal hernia on upper endoscopy underwent ambulatory 24-hr esophageal pH monitoring after esophageal manometry. The 95th percentiles for the reflux parameters were: the percent total time pH <4, 3.7%; the percent upright time pH <4, 5.7%; the percent supine time pH <4, 1.0%; the number of reflux episodes with pH <4, 76.5; the number of reflux episodes with pH <4 for >5 min, 1.5; the duration of the longest episode, 12.5 min; and the composite score, 14.2. Age and gender were not associated with any of the pH parameters. In conclusion, physiological gastroesophageal reflux occurs in healthy Koreans. These normal esophageal pH values will provide reference data for clinical and research studies in Korea.

Esophageal pH Testing in Patients Refractory to Proton Pump Inhibitor Therapy

Proton pump inhibitors (PPIs) are the most potent drugs available for the management of gastroesophageal reflux disease (GERD). Ambulatory 24 h pH monitoring is often recommended for patients experiencing symptoms despite PPI therapy. Recent pivotal data suggest that pH studies are predictably normal in this setting, casting doubt on the clinical utility of the current practice. To describe 24 h pH findings in patients referred by gastrointestinal specialists for the indication of GERD refractory to PPI therapy. A retrospective review was performed, examining all patients undergoing ambulatory esophageal pH monitoring at the St Boniface General Hospital Motility Laboratory, between January 2002 and June 2005. Tests performed in patients clinically suspected of having GERD who were not responding to PPI therapy formed the study group. pH data were analyzed for the total, upright and supine periods. Abnormal reflux parameters were defined by applying three criteria: DeMeester score greater than 14.72; pH less than 4.0 more than 5.5% of the total time, more than 8.3% of the time upright or more than 3% of the time in the supine position; and pH less than 4.0 for more than 1.6% of the total time. A total of 417 patients underwent pH monitoring during the time of the review. One hundred seven patients (mean age 51.7 years; 37 men and 70 women) met study criteria. Sixty-eight (63.6%) were referred by a gastroenterologist and 39 (36.4%) were referred by a gastroenterologist surgeon. Sixty-one patients were on twice-daily PPIs and 46 were on once-daily dosing. Using the most stringent pH criteria, namely criteria 2, pH readings were abnormal in 30% of patients on once-daily PPIs and in 25% of patients on twice-daily dosing. The prevalence of abnormal pH readings were even higher if criteria 1 or 3 were applied. In a patient population assessed by a specialist as having clinically suspected GERD that is not responding to PPI therapy, a substantial number of patients will have abnormal esophageal pH test results. The role of pH testing in the algorithm of GERD is evolving; however, our data suggests that an abandonment of pH testing is premature.

Assessment of 24‐h oesophageal pH monitoring should be divided to awake and asleep rather than upright and supine time periods*

Oesophageal acid exposure analysis is divided to upright and supine, based on the assumption that the supine-awake period is similar to the supine-asleep period. To determine if the principal acid-reflux characteristics of supine-awake are closer to supine-asleep or upright period. Patients with heartburn underwent an upper endoscopy and pH testing. The patients were instructed to carefully document their upright, supine-awake and supine-asleep periods. A total of 64 patients were enrolled into this study (M/F 35/29; mean age 52.4 +/- 13.3). The mean percentage total time pH <4, frequency of acid-reflux events (per h) and number of sensed reflux events was not different between upright and the supine-awake period (P = ns). In contrast, the mean percentage total time pH <4, frequency of acid-reflux events and number of sensed reflux events was significantly higher in both upright and supine-awake periods vs supine-asleep (4.3 +/- 6.9, 1.86 +/- 2.7 and 0.01 +/- 0.05, P < 0.0001, respectively). The principal characteristics of the acid-reflux events in the supine-awake period are closer to the upright period than to the supine-asleep period.

Comparison of Esophageal Acid Exposure Distribution Along the Esophagus Among the Different Gastroesophageal Reflux Disease (GERD) Groups

Patients with nonerosive reflux disease (NERD) have the lowest esophageal acid exposure profile compared with the other gastroesophageal reflux disease (GERD) groups. To compare lower esophageal acid exposure recordings 1 cm above the lower esophageal sphincter (LES) with those 6 cm above the LES as well as to determine the characteristics of esophageal acid exposure along the esophagus among the different GERD groups. Patients with classic heartburn symptoms were enrolled into the study. Patients were evaluated by a demographics questionnaire and the validated GERD Symptom Checklist. Upper endoscopy was performed to evaluate the presence of esophageal erosions and Barrett's esophagus (BE). Ambulatory pH testing was performed using a commercially available 4-sensor pH probe with sensors located 5 cm apart. The distal sensor was placed 1 cm above the LES. Sixty-four patients completed the study. Of those, 21 patients had NERD, 20 had erosive esophagitis (EE), and 23 had BE. All patient groups demonstrated greater esophageal acid exposure 1 cm above the LES than 6 cm above the LES. In NERD and EE, this phenomenon was primarily a result of a higher mean percentage of upright time with pH <4. Unlike patients with EE and BE, those with NERD had very little variation in esophageal acid exposure throughout the esophagus (total and supine). ALL GERD groups demonstrated significant greater esophageal acid exposure at the very distal portion of the esophagus, primarily as a result of short upright reflux events. Unlike erosive esophagitis and BE, NERD patients demonstrate a more homogenous acid distribution along the esophagus.

An improved operation approach for bipedal rat model construction

To explore an improved operation approach to make up the ethical deficiency of classical bipedal rat model. 20 SD rats were randomly divided into an improved group and a traditional group averagely. Improved group were operated with plexus brachialis nerve amputation, while traditional group with forelimbs amputation close to shoulder joint. Forelimb and shoulder joint movements were observed and electromyography of the peripheral muscles around shoulder joint were recorded to make certain the paralytic scope. Operation duration and axillary artery hurt probability of both the improved and traditional operation were compared to evaluate the operation risk of improved approach. Mean total upright time on 2 d, 1 w, 2 w, 4 w and 6 w post-operation and upright posture on 6 w post-operation were recorded to evaluate the human-upright-posture-simulating effect of bipedal rats operated with improved approach. Compared with classical amputation approach, improved approach exhibited simpler operation procedure, shorter operation duration and lower axillary artery hurt probability. Electromyography revealed that all forelimb muscles and most shoulder-peripheral muscles were denervated, forelimbs of the improved bipedal rats were absolutely paralyzed and shoulder joint reserved only slight abduction function. The mean total upright time of improved bipedal rats was longer than the classical ones after 2 w post-operation, while upright posture showed no difference with classical bipedal rats. The improved operation approach not only simplified operation procedures, but also achieved even better effect than classical amputation operation and exempted bipedal rat model from the ethical shadow.

Comparison of esophageal acid exposure at 1 cm and 6 cm above the squamocolumnar junction using the Bravo™ pH monitoring system

The aim of this study was to assess the quantitative differences of acid exposure at 1 cm and 6 cm above the squamocolumnar junction (SCJ) using two radiotelemetry pH capsules affixed to the esophageal mucosa. Ten normal subjects and 10 endoscopy-negative gastroesophageal reflux disease (GERD) patients without hiatus hernia (ages 20-54, 12 male) were studied for a 24-h period using the Bravo pH monitoring system. pH capsules were placed 1 cm and 6 cm above the SCJ. Interpretable data for at least 14 h was obtained in 18 of the 20 subjects (9 normal, 9 GERD). Two failures occurred secondary to early capsule dislodgement. Median esophageal acid exposure was significantly increased at 1 cm above the SCJ compared to 6 cm above the SCJ during the total, upright and postprandial time periods in both normal and GERD subjects. During a 2 h postprandial period the esophageal acid exposure was 8-fold greater in GERD subjects and 5-fold greater in normal subjects 1 cm above the SCJ compared to 6 cm above the SCJ. Confident measurement of esophageal acid exposure at a fixed position 1 cm above the SCJ is feasible with the Bravo system. Acid exposure was significantly higher 1 cm above the SCJ compared to 6 cm above the SCJ in both GERD patients and controls. These findings suggest that measurement of acid exposure 1 cm above the SCJ may improve accuracy of pH monitoring by detecting acid reflux events confined to the distal esophagus.

Function and Upright Time Following Limb Salvage, Amputation, and Rotationplasty for Pediatric Sarcoma of Bone

We wished to determine the relative physical and psychosocial merits of limb-sparing reconstruction, above-knee amputation, and rotationplasty in survivors of childhood and adolescent lower extremity bone sarcoma. In comparing minimum 5-year disease-free survivors, we found that outcome was somewhat dependent on the measuring tool administered. A superior score of statistical significance on the system of evaluation of the Musculoskeletal Tumour Society and a trend toward higher Toronto Extremity Salvage Scores were found among patients with a limb-sparing reconstruction compared with those with an above-knee amputation. Short-Form 36 results and the amount of time spent in the upright position (uptime), as assessed with a remote activity monitor, were similar between these groups. Uptime was highest in patients who had undergone rotationplasty, although statistical assessment of this group was not feasible. Psychosocial outcome was similar between all groups. This information may be useful in discussing reconstruction with patients and their families.

Treatment of Oesophageal Bile Reflux in Children

Reflux of duodenal juice into the oesophagus has a role in the pathogenesis of both oesophageal and laryngopharyngeal inflammatory and neoplastic lesions. As little is known about effective therapy, we studied the effect of proton pump inhibitor therapy on oesophageal bile reflux in children. Twenty-nine children with moderate to severe erosive oesophagitis and abnormal oesophageal bile reflux were studied before and after treatment with omeprazole 1 mg/kg per day. Outcomes included a clinical symptom score, oesophageal acid and bile reflux (simultaneous 24-hour pH and Bilitec 2000 monitoring), and mucosal healing. After 8 weeks of therapy, 17 (59%) of the patients were symptom-free, and 5 (17%) had minimal symptoms. Mucosal healing or reduction to low-grade oesophagitis was achieved in 25 children (86%; P < 0.0005). Mean percentages of total, upright, and supine time with oesophageal pH less than 4 were reduced from 17.0%, 16.8%, and 19.2% before treatment, to 2.83%, 3.17%, and 2.07%, respectively, after treatment (all P < 0.00001). Similarly, mean percentages of total, upright, and supine time with bile reflux were reduced from 16.96%, 12.67%, and 22.0%, to 2.27%, 1.91%, and 2.23%, respectively (P < 0.000001, P < 0.0001, and P < 0.000001, respectively). Omeprazole 1 mg/kg per day is an effective therapy for the majority of children with severe erosive oesophagitis due to abnormal isolated bile reflux or combined acid and bile reflux. It remains unclear how patients with treatment-resistant bile reflux should be managed.

The extent of oesophageal acid exposure overlap among the different gastro‐oesophageal reflux disease groups

Studies have demonstrated that patients with Barrett's oesophagus have the highest oesophageal acid exposure profile, followed by erosive oesophagitis and non-erosive reflux disease patients, but the exact extent of overlap remains unknown. To determine the extent of overlap in oesophageal acid exposure among the different gastro-oesophageal reflux disease groups. A total of 121 patients with gastro-oesophageal reflux disease underwent an upper endoscopy and were classified as having Barrett's oesophagus, erosive oesophagitis and non-erosive reflux disease-all (non-erosive reflux disease-positive and functional heartburn). Subsequently, patients underwent pH testing and overlap in oesophageal acid exposure among the different gastro-oesophageal reflux disease groups was determined. Of those enrolled, 24 had Barrett's oesophagus, 30 erosive oesophagitis and 28 were non-erosive reflux disease-positive. Mean oesophageal acid exposure time was 224.8 +/- 35, 134.3 +/- 21.9 and 141.3 +/- 19.8 min for Barrett's oesophagus, erosive oesophagitis and non-erosive reflux disease-positive respectively. Per cent overlap for total, upright and supine time between non-erosive reflux disease-positive and erosive oesophagitis was 47.4%, 64.7% and 81.8%, between Barrett's oesophagus and erosive oesophagitis was 47.8%, 40.7% and 24%, and between Barrett's oesophagus and non-erosive reflux disease-positive was 31.6%, 37.5% and 20.8% respectively. Our study demonstrated a high oesophageal acid exposure overlap between patients with non-erosive reflux disease-positive and erosive oesophagitis, Barrett's oesophagus and erosive oesophagitis, as well as Barrett's oesophagus and non-erosive reflux disease-positive patients.

A physiologic clinical study of achalasia: Should Dor fundoplication be added to Heller myotomy?

Myotomy for achalasia disrupts the lower esophageal sphincter, improving emptying at the expense of reflux. We hypothesized that surgical palliation of achalasia requires balancing desirable improvement in esophageal emptying with undesirable production of gastroesophageal reflux. Therefore, we objectively studied the physiologic effects of adding Dor fundoplication to Heller myotomy. From December 1996 to June 2004, 149 patients underwent Heller myotomy; 88 (59%) had additional Dor fundoplication. The adequacy of myotomy was assessed by premyotomy to postmyotomy change in lower esophageal sphincter pressures, esophageal emptying by change in timed barium esophagram, and gastroesophageal reflux by postoperative 24-hour pH monitoring. For adequacy of myotomy, postmyotomy resting lower esophageal sphincter pressure was higher with (median, 18 mm Hg) than without (median, 13 mm Hg) Dor fundoplication (P = .002), as was residual lower esophageal sphincter pressure (median, 4.6 vs 1.8 mm Hg; P = .01). For esophageal emptying, postmyotomy barium height and width were similar with or without Dor fundoplication (P > .1). For gastroesophageal reflux, percentage of upright time with a pH of less than 4 was lower with (median, 0.4%) than without (median, 2.9%) Dor fundoplication (P = .005), and percentage of supine time with a pH of less than 4 was lower with (median, 0%) than without (median, 5.8%) Dor fundoplication (P = .007). The addition of Dor fundoplication reduces the adequacy of myotomy without impairing emptying and reduces reflux. Heller myotomy and Dor fundoplication balance emptying and reflux and therefore should be the surgical treatment of choice for achalasia.

Lack of predictors of normalization of oesophageal acid exposure in Barrett's oesophagus

Barrett's oesophagus patients may continue to have abnormal oesophageal acid exposure on proton pump inhibitor therapy. The effect of factors such as Barrett's oesophagus length, hiatal hernia size and Helicobacter pylori infection on intra-oesophageal pH in Barrett's oesophagus patients has not been adequately studied. To evaluate oesophageal acid exposure in a large Barrett's oesophagus population on b.d. proton pump inhibitor therapy and determine clinical factors predicting normalization of intra-oesophageal pH on therapy. Barrett's oesophagus patients were studied using 24 h pH monitoring to evaluate intra-oesophageal acid suppression on b.d. dosing of rabeprazole. Forty-six Barrett's oesophagus patients completed the study. Median total percentage time pH < 4 was 1.05% (range: 0-29.9%) in the entire group and respective values for upright and supine percentage time pH < 4 were 1.15% and 0%. However, 34 of the Barrett's oesophagus patients (73.9%) had a normal pH study (median total percentage time pH < 4: 0.2%) and 12 patients (26.1%) had an abnormal result (median total percentage time pH < 4: 9.3%). There were no significant differences between patients with a normal and abnormal 24 h pH result with respect to age, Barrett's oesophagus length, hiatal hernia size and presence of H. pylori infection. Approximately 25% of Barrett's oesophagus patients continue to have abnormal total intra-oesophageal pH profiles despite b.d. proton pump inhibitor therapy. Factors such as age, Barrett's oesophagus length and hiatal hernia size cannot be used to predict persistent abnormal intra-oesophageal pH on proton pump inhibitor.

WIRELESS PH-METRY COMBINED WITH SURVEILLANCE ENDOSCOPY IN BARRETTʼS ESOPHAGUS

Purpose: Recent evidence indicates that normalization of esophageal acid exposure in Barrett's esophagus (BE) may reduce the risk of neoplasia. The aims of this study were (1) assess the adequacy of PPI therapy on esophageal acid exposure in patients with BE, and (2) evaluate the safety and patient tolerance of wireless pH-metry performed in conjunction with surveillance endoscopy and biopsy. Methods: We enrolled 30 patients with BE presenting for surveillance endoscopy. Subjects maintained their usual dose of PPI. The EGD and biopsies were completed according to protocol. A wireless pH capsule (Bravo pH System) was placed immediately following EGD. All pts completed an 8-question satisfaction survey using a 6-point scale for each response (6 = best). Results: The combined procedures were successful in all 30 cases. Sixteen patients (53%) were on once daily (QD) PPI and 14 (47%) were on twice daily (BID) PPI. Fourteen patients had reflux symptoms on therapy. The mean length for BE was 3.3 cm and the mean disease duration 4.8 yrs. An average of 6.4 biopsies was performed per EGD. The % time pH <4 [median (interquartile range)] was 8.4% (11.5), 6.9% (9.4), and 13.2% (18.5) for total, upright and supine time. Esophageal acid exposure was similar in patients with and without GERD symptoms. Normalization of esophageal acid exposure is reported in Table. Ratings from the post-procedural survey demonstrated: satisfaction with the procedure (5.8), ability to carry on usual activities during pH-metry (5.6), and overall assessment of the experience (4.9).TableConclusions: In pts with BE (1) PPI therapy fails to control esophageal acid exposure in 44–57% of patients, (2) the absence of GERD symptoms during PPI therapy does not predict normalization of esophageal acid exposure, and (3) wireless pH-metry is safe and well-tolerated when performed in conjunction with surveillance EGD.

P0792 TREATMENT OF DUODENOGASTROESOPHAGEAL REFLUX WITH OMEPRAZOLE

Introduction: Both acid gastroesophageal reflux (GER) and duodenogastroesophageal reflux (DGER) are important in the pathogenesis of esophagitis in children (1). The effect of omeprazole on acid GER in children is well documented (2, 3). However, its effect on DGER has not been evaluated in children yet. Therefore we studied the effect of omeprazole on both acid GER and DGER. Methods: In 14 children (5 to 16 years, mean age 9 years, 7 boys) with erosive esophagitis and pathologic DGER (defined as bilirubin absorbance > 0.14 over 1.8% of total time of monitoring) upper endoscopy and combined 24-hour esophageal pH and bilirubin monitoring were performed before and during treatment with omeprazole 1 mg/kg/day ( > 8 weeks). Results: Erosive esophagitis healed in 4 children and improved (from grades C or D to grade A) in the others. While on therapy mean percentages of total, upright and supine time with acid GER as well as with DGER were reduced significantly (all p <0.01) (Table). DGER decreased in all children and in only 2 of 14 children its quantity was stil pathologic.Table 1: Effect of omeprazole 1mg/kg/ day on acid GER and DGERConclusion: Omeprazole 1 mg/kg/day is effective in reducing both acid GER and DGER and in healing erosive esophagitis in children.

Evaluation of symptom index in identifying gastroesophageal reflux disease-related noncardiac chest pain.

Symptom index (SI), which represents the percentage of perceived gastroesophageal reflux-related symptoms that correlate with esophageal acid reflux events (pH <4), has been suggested as a measure to improve diagnosis of gastroesophageal reflux (GER)-related noncardiac chest pain (NCCP). Because no study has evaluated the value of the symptom index in NCCP patients, data to support this claim have yet to be elucidated. To evaluate the value of SI in identifying gastroesophageal reflux disease (GERD)-related NCCP patients. Patients enrolled in this study were referred by a cardiologist after a comprehensive work-up excluded a cardiac cause for their chest pain. All patients underwent upper endoscopy to determine esophageal inflammation and 24-hour esophageal pH monitoring to assess esophageal acid exposure. Patients were instructed to record all chest pain episodes during the pH test. Patients with a positive SI (> or =50%) underwent the proton pump inhibitors (PPI) test, which is a therapeutic trial using a short course of high dose PPI. A total of 94 patients with NCCP were included in this study. Forty-seven (50%) had either a positive upper endoscopy or an abnormal pH test and were considered GERD-Positive. Forty-seven patients (50%) had both tests negative and were considered GERD-Negative. Total number of reflux episodes and percent total, supine and upright time pH less than 4, were significantly higher in the GERD-Positive group as compared with the GERD-Negative group (P < 0.0001, P < 0.0001, P = 0.0045, and P < 0.0001 respectively). Only 9 (19.1%) patients in the GERD-Positive group and 5 (10.6%) patients in the GERD-Negative group had a positive SI (p = ns). Eight (89%) out of the 9 patients who had a positive SI in the GERD-Positive group and 2 (40%) out of 5 patients in the GERD-Negative group responded to the PPI test. Positive SI is relatively uncommon in NCCP patients, regardless if GERD is present or absent. Hence, symptom index provides very little improvement in diagnosing GERD-related NCCP.

Lung Transplantation Exacerbates Gastroesophageal Reflux Disease

A high prevalence of gastroesophageal reflux (GER) has been reported in lung transplant recipients and is possibly linked to the development of bronchiolitis obliterans syndrome. The etiology of posttransplant GER remains unknown but may occur due to the transplant operation or posttransplant medications, or represent preexisting GER disease. We evaluated these possibilities by studying the nature and severity of GER in a cohort of patients before and after lung transplantation. Total, upright, and supine acid contact times were recorded in lung transplant recipients who underwent 24-h pH studies before and after transplantation. Patients also underwent esophageal manometry and gastric-emptying studies. Medications for acid suppression and gastric motility were discontinued before testing. Paired comparison between pretransplant and posttransplant results was performed using a paired t test. Twenty-three patients were included in the analysis. The mean age was 51.5 years, and native diseases included emphysema (n = 11), cystic fibrosis (n = 4), pulmonary fibrosis (n = 3), and others (n = 5). Posttransplant studies occurred a median of 100 days after transplantation. After lung transplantation, the total acid contact time increased a mean of 3.7% (p = 0.03) and the supine acid contact time increased a mean of 6.4% (p = 0.019). Thirty-five percent (8 of 23 patients) had abnormal acid contact times before transplant, and 65% (15 of 23 patients) had abnormal acid contact after transplant. Changes in acid contact times were not explained by changes in esophageal or gastric motility. Only 20% (3 of 15 patients) with abnormal posttransplant pH studies were symptomatic. There is a significant increase in GER after lung transplantation, as measured objectively by 24-h pH studies, despite a lack of symptoms in most patients. Further research is needed to determine the physiologic mechanisms of posttransplant GER and its impact on long-term allograft function.

Endoscopic implantation of enteryx for treatment of GERD: 12-month results of a prospective, multicenter trial

Objectives This study aimed to assess the efficacy and safety of endoscopically implanting a nonresorbable biocompatible polymer (Enteryx) in the distal esophagus and proximal gastric cardia for the treatment of gastroesophageal reflux disease (GERD). Methods In a prospective, multicenter, international trial, 85 well-controlled GERD patients who were receiving chronic proton pump inhibitor (PPI) therapy underwent Enteryx implantation under fluoroscopic visualization, without general anesthesia. After the procedure, patients were discharged within approximately 2–4 h. Patients were judged to be treatment responders if after implantation they reduced PPI dosage by ≥50%. Follow-up evaluations were conducted at 1, 3, 6, and 12 months and included medication usage, symptoms, quality of life, endoscopy, pH monitoring, manometry, and documentation of adverse events. Results At 12 months, 80.3% (95% CI = 69.9%–88.3%) of 81 evaluable patients were treatment responders. Of the responders, 87.7% completely discontinued PPIs, and 12.3% reduced PPI dosage by ≥50%. Treatment response was more likely in patients with residual implant volume of ≥5 mL ( p = 0.027). Other patient and treatment variables were not predictive. Both GERD heartburn and regurgitation symptom scores significantly improved at 12 months compared with baseline ( p < 0.001). There were significant reductions in median supine, upright, and total percent time of esophageal exposure to pH <4. Endoscopically assessed esophagitis grades were unchanged. No serious adverse events were encountered. Transient retrosternal chest pain was experienced by 91.8% of patients. This pain was seldom severe and was typically successfully managed with prescription pain medication. Conclusions Enteryx implantation allows most patients to discontinue PPI therapy, improves their symptoms, and reduces esophageal acid exposure. The effects of implantation are long-lasting, and morbidity is transient and minimal. The procedure requires basic endoscopic skills and seems to provide a useful option in the effective clinical management of GERD.

Bile in the esophagus: a factor in the pathogenesis of reflux esophagitis in children.

Bile reflux has been postulated to be an important factor contributing to gastroesophageal reflux disease in adults. The purpose of this study was to investigate its role in children. Sixty-five children with symptoms of gastroesophageal reflux disease were classified on the basis of the endoscopic grade of reflux esophagitis: no esophagitis (n = 26), mild to moderate esophagitis (n = 26), and severe esophagitis (n = 13). Simultaneous 24-hour esophageal pH and bilirubin monitoring with Bilitec 2000 was performed. Both bile and acid reflux increased with the severity of esophagitis. The differences between all groups were significant for the percentage of total (P < 0.0005), upright (P < 0.05), and supine time (P < 0.0005) bilirubin absorbance > or = 0.14, as well as for the percentage of total and supine time pH < 4, and DeMeester score (P < 0.0005). Combined pathologic acid and bile reflux was found in 11% of children with mild esophagitis and in 70% of children with severe esophagitis, while isolated bile reflux was found in 31% and 7.5%, respectively. Combined pH and bilirubin monitoring, compared with ph-monitoring alone, increased the sensitivity from 56% to 79%, and the accuracy from 69% to 83%. Both bile and acid reflux increase stepwise with the severity of esophagitis. Combined acid and bile reflux is associated with severe esophagitis. Isolated acid or bile reflux is usually present in mild esophagitis. Simultaneous esophageal pH and bilirubin monitoring has a higher sensitivity, as well as predictive values and accuracy than ph monitoring alone.

Bile in the Esophagus: A Factor in the Pathogenesis of Reflux Esophagitis in Children

ABSTRACTObjectivesBile reflux has been postulated to be an important factor contributing to gastroesophageal reflux disease in adults. The purpose of this study was to investigate its role in children.MethodsSixty‐five children with symptoms of gastroesophageal reflux disease were classified on the basis of the endoscopic grade of reflux esophagitis: no esophagitis (n = 26), mild to moderate esophagitis (n = 26), and severe esophagitis (n = 13). Simultaneous 24‐hour esophageal pH and bilirubin monitoring with Bilitec 2000 was performed.ResultsBoth bile and acid reflux increased with the severity of esophagitis. The differences between all groups were significant for the percentage of total (P &lt; 0.0005), upright (P &lt; 0.05), and supine time (P &lt; 0.0005) bilirubin absorbance ≥ 0.14, as well as for the percentage of total and supine time pH &lt; 4, and DeMeester score (P &lt; 0.0005). Combined pathologic acid and bile reflux was found in 11% of children with mild esophagitis and in 70% of children with severe esophagitis, while isolated bile reflux was found in 31% and 7.5%, respectively. Combined pH and bilirubin monitoring, compared with ph‐monitoring alone, increased the sensitivity from 56% to 79%, and the accuracy from 69% to 83%.ConclusionsBoth bile and acid reflux increase stepwise with the severity of esophagitis.Combined acid and bile reflux is associated with severe esophagitis. Isolated acid or bile reflux is usually present in mild esophagitis.Simultaneous esophageal pH and bilirubin monitoring has a higher sensitivity, as well as predictive values and accuracy than ph monitoring alone.