Diagnostic Utility of Impedance-pH Monitoring in Refractory Non-erosive Reflux Disease

BACKGROUND/AIMS: Approximately one-third of non-erosive reflux disease (NERD) patients are refractory to proton pump inhibitors (PPI) and face a therapeutic challenge. Therefore, it is important to differentiate between pathological and non-pathological reflux utilizing multichannel intraluminal impedance-pH (MII-pH) to analyze symptom-reflux association and diagnose true NERD versus hyper-sensitive esophagus (HE) and functional heartburn (FH). Herein, we evaluated the diagnostic yield of MII-pH in refractory NERD and sub-classified it based on quantity and quality of acid/non-acid reflux and reflux-symptom association. METHODS: Sixty symptomatic NERD patients on twice daily PPI for > 2 months were prospectively evaluated by MII-pH. Distal and proximal refluxes, bolus exposure time (BET), esophageal acid exposure time, symptom index (SI) and symptom association probability (SAP) were measured. RESULTS: Thirty-two (53%) patients had BET > 1.4% (MII-pH positive-true NERD), while 28 (47%) had BET 80% of symptoms were associated with non-acid reflux. The number of distal refluxes in true NERD versus FH or HE were significantly different, but not between FH and HE. CONCLUSIONS: Approximately 60% of refractory PPI NERD patients had positive reflux-symptom association, primarily due to non-acid reflux. Nearly half of NERD patients on PPI had normal MII-pH monitoring, sub-divided further into FH and HE equally.

Hepatitis C genotype 4: genotypic diversity, epidemiological profile, and clinical relevance of subtypes in Saudi Arabia

Hepatitis C virus genotypes 4 [HCV-4] is the most prevalent genotype in Saudi Arabia, although it's various subtypes, mode and route of transmission remains unknown. The aim of this study was to analyze [i] the variability of the HCV-4 subtypes, the route and source of HCV transmission and [ii] the influence of HCV-4 subtypes on their therapeutic response. Sixty-four HCV-4 patients were analyzed retrospectively for the prevalence of various sub-genotypes and the possible mode of transmission, and it was correlated with their treatment response to pegylated interferon [PEG-IFN] alpha-2a and ribavirin therapy. Positive history of blood or blood products transfusion was noted in 22 patients [34%], hemodialysis in 10 patients [15.6%], surgery in 7 patients [11%], and unknown etiology in 25 patients [39%]. Prevalence of HCV-4 subtypes was 4a = 48.4% [31/64], 4d = 39% [25/64], 4n = 6.25% [4/64], and remaining combined [4m, 4l, 4r, 4o] 6.25% [4/64]. No significant correlation between subtypes and the source of transmission was recognized [P = 0.62]. Sustained virological response in all HCV-4 patients was 64% [41/64], while in each subtypes separately it was 4a 77.4% [24/31], 4d 52% [13/25], and combined [4n, 4m, 4l, 4r, 4o] 62.5% [5/8] [P = 0.046]. No obvious cause for the mode of HCV transmission was noted in majority of the patients. No significant correlation was observed between HCV-4 subtypes and the source of HCV infection. 4a and 4d subtypes were the most common in Saudi Arabia, and patients infected with 4a subtype responded significantly better to combination therapy than to 4d subtype

Lung Transplantation Triggered "Jackhammer Esophagus": A Case Report and Review of Literature

A 19-years-old girl was referred for lung transplant due to end stage lung disease secondary to idiopathic bilateral bronchiectasis. Her routine pre lung transplant evaluation showed normal esophageal high-resolution manometry (HRM) and 24-hours impedance pH monitoring. Four weeks after the bilateral sequential lung transplantation (LTx), she developed dysphagia, chest pain and regurgitation, complicated by aspiration pneumonia. Repeated HRM showed Jackhammer esophagus, delayed gastric emptying and abnormal 24-hour pH impedance monitoring consistent with the diagnosis of gastroesophageal reflux disease. Twelve weeks after LTx, she was symptom free, HRM and 24-hour impedance pH monitoring returned to normal. To the best of our knowledge, this rare transient esophageal hypercontractility episode occurred after LTx and recovered without any specific treatment was never reported in literature. The etiopathogenesis of Jackhammer esophagus in general and LTx induced dysmotility in particular is discussed and reviewed.

Endoscopic features of helicobate pylori induced gastritis

It's still controversial whether certain macroscopic endoscopic features can be used to diagnose Helicobacter pylori [HP] related gastritis. The literature dealing with this subject is confusing, because of the lack of precise terminology, no large control trials, major discrepancies in interpretations of macroscopic changes and poor correlation of the macroscopic appearance and histological finding of gastritis. We conducted a prospective study of 208 dyspeptic patients, who underwent upper gastrointestinal endoscopies from February 1997 to June 1997. only those patients who had either normal looking gastric mucosa or macroscopic gastritis were included in the study. Endoscopically normal looking mucosa was seen in 67 patients [65.6%], erythematous gastritis in 51 [74%], mosaic appearance in 18 [88%],erosive gastritis in 14 [85%] nodular gastritis in 17 [94%], atrophic gastritis in 12 [75%], and fundal rugae hypertrophies in 5 [80%]. We suggest that the antral nodularity, raised erosions, mosaic appearance and mixed findings, are the reliable indicators of the underlying HP induced gastritis. However, these endoscopic findings are very specific, though not sensitive, for HP gastritis