The link between airway reflux and non-acid reflux in children: a review

Abstract Objective: Airway reflux, a member of extra-esophageal reflux, has been linked to countless respiratory pathologies amongst children. The advent of novel instrumentation has enabled the discovery of non-acid reflux which was postulated as the main culprit of airway reflux. The objective of this review is to outline the association between non-acid reflux and airway reflux in children. Methods: A comprehensive review of recent literature on non-acid reflux and airway reflux in children was conducted. Studies ranged from January 2010 till November 2021 were searched over a period of a month: December 2021. Results: A total of eleven studies were identified. All studies included in this review revealed a strong link between non-acid reflux and airway reflux in children. 6 of the included studies are prospective studies, 3 retrospective studies, 1 cross-section study, and type of study was not mentioned in 1 study. The most common reported respiratory manifestation of non-acid reflux in children was chronic cough (7 studies). Predominant non-acid reflux was noted in 4 studies. The total number of children in each study ranges from 21 to 150 patients. MII-pH study was carried out in all studies included as a diagnostic tool for reflux investigation. Conclusion: Non-acid reflux is the culprit behind airway reflux as well as other myriads of extra-esophageal manifestations in children. Multicentre international studies with a standardized protocol could improve scientific knowledge in managing non-acid reflux in airway reflux amongst children.

Influence of Ineffective Swallows on Esophageal Motility and Gastroesophageal Reflux / 胃肠病学

Background : Studies showed that esophageal body dysmotility is associated with gastroesophageal reflux disease (GERD), however, their interactions are still unclear. Aims: To explore the influence of proportion of ineffective swallows on esophageal motility and gastroesophageal reflux in esophageal high-resolution manometry (HRM). Methods: Patients who completed esophageal HRM and 24 h esophageal impedanee-pH monitoring and were identified as normal esophageal motility or mild dysmotility from March 2018 to December 2019 at the First Affiliated Hospital of Nanjing Medical University were recruited retrospectively. According to the times of ineffective swallows in 10 warm water swallows in HRM, these patients were allocated into four groups; Group A (0 times), Group B (1-4 times), Group C (5-7 times), Group D (8-10 times). The parameters of esophageal HRM and 24 h esophageal impedance-pH monitoring were analyzed, and the value of ineffective swallows for assistant diagnosis of pathological acid reflux was assessed. Results: A total of 142 patients were included. There were no significant differences in abnormal manometric parameters between the four groups (all P > 0. 05). In Group D, the number of weak and non-peristalsis were increased, while the mean and maximum value of distal contractile integral (DCI) were decreased as compared with those in Group A and Group B (all P 70 % might be most significant, and to a certain extent, can predicts pathological acid reflux.

Clinical Characteristics of Gastroesophageal Reflux Disease Patients With Laryngopharyngeal Symptoms / 胃肠病学

Background: The laryngopharyngeal symptoms of gastroesophageal reflux disease (GERD) include hoarseness, foreign body sensation, chronic cough, dysphagia, etc. Its pathogenic mechanisms and reflux characteristics may be different from those of GERD patients simply with typical esophageal symptoms. Aims: To explore the clinical characteristics of GERD patients complicated with laryngopharyngeal symptoms. Methods: Fifty-nine patients having a gastroesophageal reflux disease questionnaire (GerdQ) score ≥8 and abnormal reflux identified by 24 h esophageal impedance-pH monitoring were selected from the outpatients at the First Affiliated Hospital of Nanjing Medical University from January 2019 to December 2021. Twenty-nine cases simply with typical esophageal symptoms were allocated into typical symptom group, and 30 cases complicated with laryngopharyngeal symptoms were allocated into laryngopharyngeal reflux (LPR) group. The general information, results of gastroscopy, 24 h esophageal impedance - pH monitoring and esophageal manometry, as well as the efficacy of proton pump inhibitor (PPI) were collected and compared between the two groups. Results: The proportion of esophagitis in GERD patients in typical symptom group was significantly increased than that in LPR group (P<0.05), while the values of mean nocturnal baseline impedance at 7-3 cm above lower esophageal sphincter (LES) were significantly lower (all P<0.05). Compared with typical symptom group, increased frequency of weak acid reflux, prolonged mean acid clearance time, higher LES relaxation rate, lower velocity of peristaltic waves at 11-7 cm above LES, and poor efficacy of PPI treatment were observed in LPR group (all P<0.05). The severity of heartburn was positively correlated with the percentage of total acid exposure time and DeMeester score (all P<0.05); while the severity of foreign body sensation was positively correlated with the frequency of weak acid reflux and mean time of acid clearance (all P<0.05). Conclusions: The esophageal mucosal injury was mild in GERD patients complicated with laryngopharyngeal symptoms. Laryngopharyngeal symptoms are more likely to be associated with the decreased acid clearance capacity due to esophageal body dysmotility. Strengthened acid suppression therapy should be recommended.

Alteraciones bucales asociadas a la enfermedad por reflujo gastroesofágico / Oral alterations associated to gastroesophageal reflux disease

RESUMEN Introducción: La enfermedad por reflujo gastroesofágico es un trastorno funcional, multifactorial, del tracto gastrointestinal superior. Las alteraciones bucales han sido consideradas como parte de sus manifestaciones extraesofágicas. Objetivo: Determinar las alteraciones bucales encontradas en pacientes con enfermedad por reflujo gastroesofágico. Métodos: Se realizó un estudio observacional descriptivo en 37 pacientes con diagnóstico de enfermedad por reflujo gastroesofágico. Las variables analizadas fueron: edad, sexo, presencia de alteración, signos y síntomas, y localización. Se confeccionó base de datos con registros, se calcularon las frecuencias absolutas y porcentajes. Resultados: El 48,6 por ciento de los pacientes presentó alguna alteración bucal, como sensación de ardor o urente (40,5 por ciento) y eritema (35,1 por ciento). Entre las regiones afectadas se encontraron paladar blando/úvula (72,2 por ciento) y lengua (61,1 por ciento). Conclusiones: Casi la mitad de los pacientes afectados por reflujo gastroesofágico presentó alguna manifestación bucal. Las más frecuentemente encontradas fueron: la sensación de ardor o urente, eritema, sensación de boca seca y ulceraciones. Las localizaciones más frecuentes fueron paladar blando/úvula y lengua(AU)

ABSTRACT Introduction: Gastroesophageal reflux disease is a functional multifactorial disorder of the upper gastrointestinal tract. Oral alterations are considered to be extraesophageal manifestations of this disease. Objective: Determine the oral alterations found in patients with gastroesophageal reflux disease. Methods: An observational descriptive study was conducted of 37 patients diagnosed with gastroesophageal reflux disease. The variables analyzed were age, sex, presence of alteration, signs and symptoms, and location. A database was developed with the information recorded, and absolute frequencies and percentages were estimated. Results: Of the patients studied, 48.6 percent had some sort of oral alteration, such as a burning sensation (40.5 percent) and erythema (35.1 percent). The regions affected included the soft palate / uvula (72.2 percent) and the tongue (61.1 percent). Conclusions: Almost half of the patients affected by gastroesophageal reflux had some sort of oral manifestation, the most common of which were a burning sensation, erythema, a dry mouth sensation and ulcerations. The most common locations were the soft palate / uvula and the tongue(AU)

Postprandial proximal gastric acid pocket and its association with gastroesophageal acid reflux in patients with short-segment Barrett's esophagus / 浙江大学学报（英文版）（B辑：生物医学和生物技术）

OBJECTIVE@#To determine the characteristics of postprandial proximal gastric acid pockets (PPGAPs) and their association with gastroesophageal acid reflux in patients with Barrett's esophagus (BE).@*METHODS@#Fifteen patients with BE (defined by columnar lined esophagus of ≥1 cm) and 15 healthy individuals that were matched for age, gender, and body mass index, were recruited. The fasting intragastric pH and the appearance time, length, lowest pH, and mean pH of the PPGAP were determined using a single pH electrode pull-through experiment. For BE patients, a gastroesophageal reflux disease questionnaire (GerdQ) was completed and esophageal 24-h pH monitoring was carried out.@*RESULTS@#The PPGAP was significantly longer (5 (3, 5) cm vs. 2 (1, 2) cm) and the lowest pH (1.1 (0.8, 1.5) vs. 1.6 (1.4, 1.9)) was significantly lower in patients with short-segment BE than in healthy individuals. The PPGAP started to appear proximally from the gastroesophageal pH step-up point to the esophageal lumen. The acidity of the PPGAP was higher in the distal segment than in the proximal segment. In short-segment BE patients, there were significant correlations between the acidity and the appearance time and length of the PPGAP. The length and acidity of the PPGAP were positively associated with gastroesophageal acid reflux episodes. The acidity of the PPGAP was associated with the DeMeester scores, the GerdQ scores, and the fasting intragastric pH.@*CONCLUSIONS@#In patients with short-segment BE, a PPGAP is commonly seen. Its length and acidity of PPGAP are associated with gastroesophageal acid reflux, the DeMeester score, and the GerdQ score in patients with short-segment BE.

Postprandial proximal gastric acid pocket and its association with gastroesophageal acid reflux in patients with short-segment Barrett’s esophagus / 浙江大学学报（英文版）（B辑：生物医学和生物技术）

Objective: To determine the characteristics of postprandial proximal gastric acid pockets (PPGAPs) and their association with gastroesophageal acid reflux in patients with Barrett’s esophagus (BE). Methods: Fifteen patients with BE (defined by columnar lined esophagus of ≥1 cm) and 15 healthy individuals that were matched for age, gender, and body mass index, were recruited. The fasting intragastric pH and the appearance time, length, lowest pH, and mean pH of the PPGAP were determined using a single pH electrode pull-through experiment. For BE patients, a gastroesophageal reflux disease questionnaire (GerdQ) was completed and esophageal 24-h pH monitoring was carried out. Results: The PPGAP was significantly longer (5 (3, 5) cm vs. 2 (1, 2) cm) and the lowest pH (1.1 (0.8, 1.5) vs. 1.6 (1.4, 1.9)) was significantly lower in patients with short-segment BE than in healthy individuals. The PPGAP started to appear proximally from the gastroesophageal pH step-up point to the esophageal lumen. The acidity of the PPGAP was higher in the distal segment than in the proximal segment. In short-segment BE patients, there were significant correlations between the acidity and the appearance time and length of the PPGAP. The length and acidity of the PPGAP were positively associated with gastroesophageal acid reflux episodes. The acidity of the PPGAP was associated with the DeMeester scores, the GerdQ scores, and the fasting intragastric pH. Conclusions: In patients with short-segment BE, a PPGAP is commonly seen. Its length and acidity of PPGAP are associated with gastroesophageal acid reflux, the DeMeester score, and the GerdQ score in patients with short-segment BE.

Differences in Distribution of Gastroesophageal Acid Reflux and Bile Reflux During Preprandial and Postprandial Period / 胃肠病学

Background: Besides acid reflux, bile reflux also plays an important role in the mucosal injury and Barrett metaplasia in gastroesophageal reflux disease (GERD). Until now, there are rarely literatures reporting whether bile reflux and acid reflux occur simultaneously, and whether they have the same pathogenic mechanism. Aims: To analyze the differences in distribution of gastroesophageal acid reflux and bile reflux during preprandial and postprandial period. Methods: A retrospective analysis was performed on individuals with typical gastroesophageal reflux symptoms and suspicious of GERD. According to the results of esophageal 24-hour pH-Bilitec 2000 monitoring, the subjects were divided into physiological acid reflux group, pathological acid reflux group and pathological bile reflux group. The preprandial and postprandial profiles of acid and bile reflux were compared. Results: Both physiological and pathological acid reflux were much more frequent during postprandial than preprandial period. In patients with pathological acid reflux, the frequency of postprandial acid reflux was two-fold over the preprandial acid reflux (P<0.05), and the postprandial longest acid reflux time was significantly shorter than preprandial (P<0.05). In patients with pathological bile reflux, the frequency of preprandial bile reflux, the preprandial longest bile reflux time, and time percentage of bile reflux were significantly increased than those of postprandial (P<0.05). Conclusions: Gastroesophageal acid reflux is prone to occur during postprandial period while bile reflux during preprandial period. There may be different mechanisms related with acid reflux and bile reflux.

Effect of Postprandial Proximal Gastric Acid Pocket in Gastroesophageal Reflux Disease / 胃肠病学

Background:Postprandial proximal gastric acid pocket (PPGAP)is an unbuffered layer of high acidity in the proximal stomach postprandially. It is considered to play an important role in gastroesophageal reflux disease (GERD). Aims:To investigate the effect of PPGAP in GERD. Methods:Sixty outpatients with GERD,including 20 non-erosive reflux disease (NERD),20 mild reflux esophagitis (RE)and 20 moderate-to-severe RE from Mar. 2014 to Dec. 2016 at the Second Affiliated Hospital of Xi'an Jiaotong University were enrolled. Twenty healthy volunteers were served as controls. All the subjects underwent a high-resolution esophageal manometry in fasting state to identify the location of the lower border of the lower esophageal sphincter (LBLES). Then a station pull-through pH monitoring was performed from 5 cm below the LBLES (stomach)to the esophagus in increments of 1 cm in fasting state and repeated after a standardized meal to detect the PPGAP. Results:PPGAP was identified in all the subjects. There were no significant differences in appearing time of PPGAP among healthy volunteers and different subtypes of GERD (P ＞0.05 ). Compared with the healthy volunteers,the disappearing time of PPGAP was significantly later and the lasting time was significantly longer in patients with NERD,mild RE and moderate-to-severe RE (P＜0.05);meanwhile,the length of PPGAP was enlarged and the nadir pH and mean pH were decreased in NERD,mild RE and moderate-to-severe RE (P＜0.05). When comparison was made between different subtypes of GERD,no significant differences were observed in above-mentioned parameters (P＞0.05). Conclusions:PPGAP is present generally in normal individuals and GERD patients,and is lasting longer, more acidic and enlarged in length in GERD patients than in normal individuals. PPGAP may be the reservoir from which acid reflux events originate and contributes to the development of GERD.

Correlation between esophageal motility abnormalities and characteristics of esophageal reflux in patients with different subtypes of refractory gastroesophageal reflux disease / 中华消化杂志

Objective To investigate the correlation between esophageal motility abnormalities and the characteristics of gastroesophageal reflux in patients with different subtypes of refractory gastroesophageal reflux disease (rGERD).Methods From September 2015 to May 2016,a total of 100 rGERD patients were collected,all of whom received gastroendoscopy examination,high resolution manometry (HRM) and 24 h impedance-pH monitoring.According to the results of gastroendoscopy examination,the patients were divided into refractory non-erosive reflux disease (NERD) group and refractory reflux esophagitis (RE) group.Abnormal esophageal motility and pathological gastroesophageal reflux of each group were analyzed.Chi-square test,t test and sum-rank test were performed for comparison,the correlation factors were analyzed by multivariate unconditional Logistic regression.Results Among the 100 patients with rGERD,there were 83 cases in refractory NERD group and 17 in refractory RE group.The episodes of weak acid and gas-liquid mixed reflux of refractory NERD group were both significantly higher than those of refractory RE group (80.2±56.9 vs 44.8± 13.7,56.0± 25.6 vs 25.2±16.1);and the differences were statistically significant (t=3.202 and 2.229,both P＜ 0.05).The DeMeester score,acid reflux episodes and the percentage of reflux time of refractory NERD group were all significantly lower than those of refractory RE group (24.2±8.5 vs 56.8±3.0,21.4± 11.8 vs 35.9 ± 32.6,(7.1 ± 1.6) ％ vs (16.2 ± 8.8) ％),and the differences were statistically significant (t=-2.820,-2.230 and-2.604;all P＜0.05).However,the average resting pressure of lower esophageal sphincter was higher than that of refractory RE group ((7.9±5.6) mmHg (1 mmHg=0.133 kPa) vs (4.5±2.2) mmHg),and the difference was statistically significant (t=2.443,P＜0.05).Patients with esophageal motility disorders of refractory NERD group and refractory RE group were 58 cases (69.9 ％) and 12 cases (12/17),respectively,and the difference was not significant (P＞0.05).Compared with refractory RE group,the ratio of intermittent contraction was higher (1/17 vs 26.5％,22/83) and the peristaltic contraction disorder was lower in refractory NERD group (11/17 vs 43.4％,36/83);and the differences were statistically significant (x2 =3.389 and 2.587,both P ＜ 0.05).The results of multivariate non-conditional Logistic regression analysis showed that intermittent contraction and gas reflux were risk factors of the incidence of pathological weak acid reflux (odd ratio (OR) =3.139 and 1.254,both P＜0.05),while body mass index and gas-liquid mixed reflux were the risk factors of the occurrence of pathological acid reflux (OR =1.302 and 1.026,both P＜ 0.05),whereas the distal contractile integral was a protective factor (OR=0.998,P＜0.05).Conclusion Esophageal dysmotility is common in patients with rGERD,and the dysmotility disorders are different in patients with different subtypes,which may be related to the different reflux characteristics.

Treatment of Reflux Esophagitis from Cold / 浙江中医药大学学报

[Objective]This paper mainly introduced the etiology, pathogenesis and treatment of reflux esophagitis due to cold, and tried to help doctors of TCM explore the new thinking for clinical treatment.[Methods]Based on the relevant account of past dynasties literature of traditional Chinese medicine, clinically,we conclude that reflux esophagitis can result from pathogenic cold, inner cold and transmission between Zang and Fu organs.Moreover,we explain the corresponding treatment.In order to better describe this therapy, a clinical case was reported. [Results]Adverse rising of gastric qi is a basic TCM pathogenesis in reflux esophagitis.Syndromes due to cold can be divided into cold pathogen attacking stomach,Yang deficiency of the spleen and stomach, deficiency of kidney-YANG and liver cold.So the corresponding prescriptions are given respectively.[Conclusion]This has solid theoretical basis and important clnical significance to treat the disease from cold.Cold can come from outside, but also from the inside.For this kind of patients,we have to identify the excess cold and asthenia cold and the related zang-fu organs,then choose a flexible medication, and get a good curative effect.

Treatment of Reflux Esophagitis from Cold / 浙江中医药大学学报

[Objective]This paper mainly introduced the etiology, pathogenesis and treatment of reflux esophagitis due to cold, and tried to help doctors of TCM explore the new thinking for clinical treatment.[Methods]Based on the relevant account of past dynasties literature of traditional Chinese medicine, clinically,we conclude that reflux esophagitis can result from pathogenic cold, inner cold and transmission between Zang and Fu organs.Moreover,we explain the corresponding treatment.In order to better describe this therapy, a clinical case was reported. [Results]Adverse rising of gastric qi is a basic TCM pathogenesis in reflux esophagitis.Syndromes due to cold can be divided into cold pathogen attacking stomach,Yang deficiency of the spleen and stomach, deficiency of kidney-YANG and liver cold.So the corresponding prescriptions are given respectively.[Conclusion]This has solid theoretical basis and important clnical significance to treat the disease from cold.Cold can come from outside, but also from the inside.For this kind of patients,we have to identify the excess cold and asthenia cold and the related zang-fu organs,then choose a flexible medication, and get a good curative effect.

Decreased Esophageal Sensitivity to Acid in Morbidly Obese Patients: A Cause for Concern?

BACKGROUND/AIMS: To evaluate esophageal sensitivity to acid between morbidly obese (MO) patients and non-MO controls with abnormal esophageal acid exposure. METHODS: We conducted a cross-sectional study of 58 patients: 30 MO (cases) and 28 non-MO (controls). Esophageal symptoms and esophageal sensitivity to 0.1 M hydrochloric acid solution (Bernstein test) were compared between MO and non-MO patients with a prior diagnosis of abnormal esophageal acid exposure. RESULTS: MO patients were less symptomatic than non-MO controls (14% vs 96%; odds ratio [OR], 0.006; 95% confidence interval [CI], 0.001 to 0.075; p=0.000). MO patients were more likely to present with decreased esophageal sensitivity to the instillation of acid than non-MO controls (57% vs 14%; OR, 8; 95% CI, 1.79 to 35.74; p=0.009). Subgroup analysis revealed no differences in esophageal sensitivity in MO patients with and without abnormal esophageal acid exposure (43% vs 31%; p=0.707). CONCLUSIONS: Silent gastroesophageal reflux disease (GERD) is common among MO individuals, likely due to decreased esophageal sensitivity to acid. The absence of typical GERD symptoms in these patients may delay discovery of precancerous conditions, such as Barrett’s esophagus. We believe that these patients may require a more aggressive diagnostic work-up to rule out the presence of silent GERD.

Persistent gastro-oesophageal reflux symptoms despite proton pump inhibitor therapy

About one-third of patients with suspected gastro-oesophageal reflux disease (GERD) do not respond symptomatically to proton pump inhibitors (PPIs). Many of these patients do not suffer from GERD, but may have underlying functional heartburn or atypical chest pain. Other causes of failure to respond to PPIs include inadequate acid suppression, non-acid reflux, oesophageal hypersensitivity, oesophageal dysmotility and psychological comorbidities. Functional oesophageal tests can exclude cardiac and structural causes, as well as help to confi rm or exclude GERD. The use of PPIs should only be continued in the presence of acid reflux or oesophageal hypersensitivity for acid reflux-related events that is proven on functional oesophageal tests.

Effects of Acupuncture Therapy with Finger on Back-shu Point on Acid Reflux and Lower Esophageal Sphincter Pressure of GERD Patients / 中国中医药信息杂志

Objective To observe the effects of acupuncture therapy with finger on back-shu point on acid reflux and lower esophageal sphincter pressure (LESP) of the patients with gastroesophageal reflux disease (GERD). Methods Totally 120 patients of GERD were randomly divided into treatment group and control group through random number table method, 60 cases in each group. Patients in the treatment group were treated with the acupuncture therapy with finger on back-shu point, and patients in control group were treated with lansoprazole tablets and dispersible mosapride citrate for two weeks. Total percentage of acid reflux time, the long time acid reflux episodes, and the longest acid reflux time of two groups were observed six months after the treatment. At the same time, the LESP variation of two groups was followed up six months after the treatment. Results The total percentage of acid reflux time, the long time acid reflux episodes, and the longest acid reflux time decreased significantly in all patients after treatment (P0.05). After treatment, LESP of two groups was significantly improved (P0.05). Conclusion The acupuncture therapy with finger on back-shu point can reduce acid reflux, and achieve the goal of treatment of GERD by improving the lower esophageal sphincter pressure. The duration of improving LESP is longer.

Impedâncio-pHmetria prolongada: observações preliminares / Extended impedance-pHmetry: preliminary observation

Racional: a Doença do Refluxo Gastroesofágico (DRGE) é uma doença de alta prevalência em todo o mundo, apresentando elevada taxa de morbidade. O diagnóstico da DRGE tem evoluído muito nos últimos anos e a pHmetria esofagiana prolongada atualmente é considerada o padrão-ouro para este diagnóstico. Entretanto, este método é limitado, uma vez que avalia apenas a presença do refluxo ácido, não detectando o refluxo de outros tipos. Com a ampla utilização das drogas antissecretoras, surgiu um grupo diferente de pacientes, aqueles que persistem com sintomas típicos e/ou atípicos da DRGE, apesar do tratamento adequado. Em tais casos, questiona-se a importância de outros fatores na gênese dos sintomas, como o refluxo não-ácido ou fracamente ácido. Nos últimos anos, a impedâncio-pHmetria 24h (IMP-PH) foi introduzida para diagnosticar estes casos. Entretanto, a real contribuição do método ainda é muito controversa, uma vez que os resultados dos estudos realizados são conflitantes e o número de pacientes incluídos nestes estudos pequenos. Objetivo: avaliar a experiência prévia da Unidade de Esôfago, Serviço de Gastroenterologia, da Universidade Federal do Rio de Janeiro, no uso da IMP-PH. Métodos: Este é um estudo de corte, transversal, que avaliou pacientes encaminhados à Unidade de Esôfago, da Universidade Federal do Rio de Janeiro para serem submetidos á IMP-PH. Todos os pacientes estudados persistiam com sintomas da DRGE (típicos ou atípicos) e já haviam sido submetidos previamente à endoscopia digestiva alta, esofagomanometria (EMN) e à pHmetria esofagiana de 24h, sem esclarecimento da causa dos seus sintomas. Um gravador portátil foi empregado (Sleuth 200-0145, Sandhill Scientific), com um cateter de 2,1 milímetros de diâmetro, um sensor de pH e seis pares de eletrodos de impedância. Com o paciente em jejum, a sonda foi introduzida através de uma das narinas e o sensor de pH posicionado 5 cm acima do esfíncter esofagiano inferior (EEI) previamente determinado pela EMN. As medidas de impedância foram feitas 3, 5, 7, 9, 15 e 17 centímetros acima do EEI. Os pacientes foram instruídos a não restringir suas atividades, para excluir alimentos ácidos e bebidas carbonatadas, e a anotar as horas de decúbito, a ingestão de alimentos e os sintomas. Eles também foram instruídos a pressionar botões específicos, se eles apresentassem sintomas como dor torácica, tosse e/ou azia. Após 22-24h, o paciente retornava ao laboratório, o equipamento era retirado e, em seguida, o exame processado pelo software Bioview. Além disso, era informado o uso (IBP em dose dupla) ou não de medicação antissecretora. No caso de um exame feito sem medicação, os inibidores da bomba de prótons (IBP) foram interrompidos 7-10 dias antes do exame. Com relação à impedância, considerou-se inicio do episódio de refluxo quando havia uma queda retrógrada na impedância de pelo menos 50% em relação ao seu valor basal e término do refluxo quando este valor voltava ao seu nível basal anterior. Na ausência de drogas antissecretoras, considerou-se refluxo anormal quando o número de episódios de refluxo registrados pela impedância foi superior a 73 e para o monitoramento do pH quando a percentagem de tempo total pH <4 foi acima de 4,5%. Naqueles pacientes em uso de IBP em dose dupla, considerou-se refluxo anormal quando o número de episódios de refluxo foi superior a 48 e o percentual de tempo total de pH < 4 foi superior a 1,6%. Para avaliar a relação refluxo / sintoma, empregou-se o Índice de Sintomas (IS), sendo considerado positivo quando igual ou superior a 50%. Resultados: Foram incluídos 30 pacientes, 14 homens (47%) e 16 mulheres (53%), com média de idade de 56 anos (36-79). Tosse crônica foi a principal queixa - 14 pacientes (47%) - seguidos de azia apesar do uso do IBP em oito (27%), dor torácica em 5 (17%) regurgitação em 1 (3%), rouquidão em 1 (3%) e soluços em 1 (3%). Dos 30 pacientes estudados, o teste foi realizado em uso do IBP em 17 e sem IBP em 13. A IMP-PH mostrou que 15 pacientes (50%) apresentavam refluxo anormal, sendo anormal ácido em 7 (23%) e anormal não-ácido em 8 (27%). Dos 15 pacientes em que o teste foi anormal, 7 (47%) apresentaram refluxo anormal ácido, e destes apenas um (14%) apresentou IS positivo, 4 (57%) apresentaram IS negativo e 2 (29%) não apresentaram sintomas. Nos 8 pacientes (53%) com refluxo anormal não-ácido, 4 (50%) apresentaram IS positivo, 3 (38%) apresentaram IS negativo (12%) e 1 (12%) foi assintomático. Conclusão: a IMP-PH é um novo método capaz de avaliar o refluxo anormal de qualquer natureza química e sua relação com sintomas típicos e atípicos da DRGE, especialmente nos pacientes em uso do IBP. Além disso, permite avaliar os pacientes onde a pH 24h apresenta limitações (refluxo não-ácido), representando o progresso para o diagnóstico da DRGE. Entretanto, o significado real do refluxo não-ácido, ainda está por ser determinado.

Background: the gastroesophageal reflux disease (GERD) is a highly prevalent disease worldwide, with high morbidity. The diagnosis of GERD has evolved greatly in recent years and esophageal pHmetry 24h (pH24H) is currently considered the gold standard for diagnosis. However, this method is limited, since evaluates only acid reflux, not detect another types of reflux. With the widespread use of anti-secretory drugs, came a different group of patients, those who persist with typical or atypical GERD symptoms, despite adequate treatment. In such cases, arise the importance of other factors in the genesis of symptoms as non-acid or weakly acid reflux. In recent years, the impedance-pHmetry 24h (IMP-PH) was introduced to diagnose these cases. However, the real contribution of the method is controversial, since the results of the studies are conflicting and the number of patients enrolled in these studies small. Objective: assess previous experience of Esophagus Unit, Gastroenterology Service, Federal University of Rio de Janeiro, using IMP-PH. Method: This is a cross-sectional study, that evaluated patients referred to the Esophagus Unit of Federal University of Rio de Janeiro, to be submitted to IMP-PH. All patients had GERD persisting symptoms (typical or atypical) and had previously undergone upper endoscopy, esophageal manometry (EMN) and pH24h, without clarification of the cause of your symptoms. A portable recorder was used (200-0145 Sleuth, Sandhill Scientific), with a catheter of 2.1 mm in diameter, a pH sensor and six pairs of impedance electrodes. With the fasting patient, the probe was introduced through one nostril and the pH sensor positioned 5 cm above the lower esophageal sphincter (LES) previously determined by EMN. The impedance measurements were made 3,5,7,9,15 and 17 cm above the LES. Patients were instructed not to restrict their activities, exclude acidic foods and carbonated beverages, and record the hours of recumbency, food intake and symptoms. They were also instructed to press specific buttons, if they had symptoms such as chest pain, cough and or heartburn. After 22-24h, the patient returned to the laboratory, recorder was removed and then processed by the software Bioview. Furthermore, was reported use (IBP double dose) or absence of antisecretory drugs. In the case of a test done without medication, proton pump inhibitors (PPI) were stopped 7-10 days before the test. With respect to impedance, it is considered the start of reflux episode when there was a retrograde fall in impedance at least 50% compared to baseline level and end of reflux when the value returned to previous baseline level. In the absence of anti-secretory drugs, it was considered abnormal reflux when the number of reflux episodes recorded by impedance was greater than 73 and pH monitoring when the percentage of total time pH <4 was above 4.5%. In those patients using double-dose PPI, abnormal reflux was considered when the number of reflux episodes was greater than 48 and the percentage of total time pH <4 was greater than 1.6%. To evaluate the relationship reflux / symptom, we used the Symptom Index (IS), was considered positive when above 50%. Results: We included 30 patients, 14 men (47%) and 16 women (53%), mean age 56 years (36-79). Chronic cough was the main complaint - 14 patients (47%) - followed by heartburn despite the use of PPI in eight (27%), chest pain in 5 (17%) regurgitation in 1 (3%), hoarseness in 1 (3 %) and hiccups 1 (3%). Of the 30 patients tested, the test was performed using PPI in 17 and without PPI in 13. The IMP-PH showed abnormal reflux in 15 patients (50%), these 7 (23%) was abnormal acid and 8 (27%) abnormal non-acid. Of the 15 patients in whom the test was abnormal, 7 (47%) had abnormal acid reflux, and of these only one (14%) presented positive IS, 4 (57%) negative IS and 2 (29%) were asymptomatic. In 8 patients (53%) with abnormal reflux non-acid, 4 (50%) were positive IS, 3 (38%) negative IS (12%) and 1 (12%) was asymptomatic. Conclusion: the IMP-PH is a new method to evaluate the abnormal reflux of any chemical nature and its relationship with typical or atypical GERD symptoms, especially in patients using PPI. In addition, evaluate patients where pH24h has limitations (non-acid reflux), representing progress in the diagnosis of GERD. However, the real meaning of non-acid reflux, is yet to be determined.

Ameliorative effects of Panax quinquefolium on experimentally induced reflux oesophagitis in rats.

Background & objectives: Reflux oesophagitis (RE), is one of the most prevalent chronic gastrointestinal disorders commonly referred to as gastroesophageal reflux disease (GERD) and requires long term therapy. The present study was designed to investigate the protective effects of Panax quinquefolium (PQ), administered with variable doses, on experimentally induced reflux oesophagitis (RE) in rats. Methods: Forty two female Sprague-Dawley (180-220 g) rats were randomly divided to receive standardized root powder of PQ (50-200mg/kg, po), standard anti-reflux (omeprazole, 5 mg/kg, ip) and anti-oxidant (α-tocopherol, 16 mg/kg, po). After 45 min drug pretreatment, RE was produced in rats by simultaneous ligation of the pyloric end and forestomach. Several parameters, including macroscopic lesion index, glutathione system, lipid peroxidation (LPO) and tissue myeloperoxidase (MPO) activity were measured. Alterations in ICAM-1, CINC-2 and MCP-1 gene expression were examined through reverse transcriptase polymerase chain reaction (RT-PCR). Results: PQ significantly attenuated the severity of the macroscopic signs of RE-induced tissue damage, replenished the depleted GSH level and reduced the RE-associated LPO levels dose dependently. In contrast, omeprazole though effectively improved the mucosal damage, it failed to bring significant attenuation of RE-associated changes in LPO, GSH level and MPO activity. α-Tocopherol significantly ameliorated RE-induced tissue injury and improved LPO level and GSH/GSSG ratio but failed to counteract RE-induced MPO activity. PQ at dose of 100 mg/kg significantly downregulated ICAM-1 and CINC-2 expression whereas it showed no effect over MCP-1 expression. Interpretation & conclusions: The present data indicate that PQ protects against RE-induced oesophageal damage via a mechanism that inhibits the influx of inflammatory cell to oesophagus and a consequence excessive oxidative load, opening the avenue to its promising protective role in patients with gastroesophageal reflux disease (GERD).

Association of helicobacter pylori infection with reflux esophagitis and Barrett esophgus / 中国综合临床

Objective To study the influence of anti-Helicobacter pylori therapy on reflux esophagitis (RE) and Barrett's esophagus (BE). Methods Two hundred and sixty-two patients including 177 patients with RE and 85 patients with BE were divided into 2 groups: Group A,139 patients without Hp infection;Group B,123 patients with Hp infection, which was further divided into 2 groups (group B1 and group B2) randomly. The pa-tients in group A and B1 were treated with Losec 20 mg bid, domperidone 10 mg tid and colloidal bismuth pectin 100 mg tid for 8 weeks, group B2 were treated with 2 kinds of antibiotics which were chosen from 3 types of antibiot-ics including amoxicillin 500 mg bid, Clarithromycin 500 mg bid or tinidazole 500 mg bid for 2 weeks additional to the same treatment as group A and B1. Endoscopy, pathologic examination, 24 h esophagus pH value and bilirubin were measured before and after treatment. Results The overall rates of improvement on symptoms in the 3 groups were 95.0% (group A: 97.8% (136/139), group B1: 96.8% (60/62), group B2: 98.4% (60/61)), which was significantly different from that before treatment (P < 0.05). However, the overall effect rates were not significantly different among the 3 groups (P > 0.05). The overall effect rate based on endoscopy examination in the RE patients 92.9% (78/84),91.8% (45/49) and 88.6% (39/44) in group A,B1 and B2,respectively,and the differences were statistically significant among the 3 groups (P <0.05). The overall effect rates in the BE patients were about 35.0%,which showed non-significant effect compared to that before treatment (P >0.05). 24 hrs esophagus PH value and bilirubin were significantly improved in the 3 groups (P < 0.05), whereas the difference among the 3 groups were not significant (P > 0.05). Conclusions RE and BE patients with HP infection could be treated with anti-Helicobacter pylori therapy. However, systematic therapy of anti gastric acid, prokinetics and mucosa protector must be performed simultaneously. This might be effective in preventing the development of RE and BE in short term. The long term effect is still uncertain and large scale, long term clinical studies are needed.

Usefulness of Multichannel Intraluminal Impedance-pH Metry in Children with Suspected Gastroesophageal Reflux Disease / 대한소화기학회지

BACKGROUND/AIMS: pH monitoring of the esophagus has been considered as the gold standard for the measurement of acid reflux. However, it has several limitations related to its inability to detect nonacid reflux. We conducted this study to characterize the proportion of acid and non-acid reflux events in children using pH-multichannel intraluminal impedance (MII) monitoring and to determine the correlation of the symptom index with non-acid and acid reflux events. METHOS: Seventy-five children, aged from 9 days to 12 years, underwent 24 hour pH-MII monitoring at Asan Medical Center from March 2006 to June 2007. We investigated the underlying disease and main problems related to gastroesophageal reflux (GER) of the patients, the number of acid and nonacid reflux, symptom index, symptom sensitivity index in pH monitoring only and pH-MII monitoring. RESULTS: While 2,247 reflux events were detected by MII, and only 967 reflux events were detected by pH probe alone. The percentage of acid reflux was 43% (967) and that of non-acid was 57% (1,280). The non-acid reflux increased at postprandial time (p<0.001). The symptom index increased when measured by pH-MII (31.1%) compared with those by pH probe alone (8.2%) (p=0.003). CONCLUSIONS: This study suggests that significant number of GER include non-acid reflux which cannot be detected by pH probe alone, therefore combining pH with MII monitoring is a valuable diagnostic tool for diagnosing GER in children.

The association between extraesophageal manifestation of reflux esophagitis and acid reflux / 中国实用内科杂志

Objective To investigate the association between extraesophageal syndromes of RE and acid reflux.Methods We investigated RE patients in Beijing hospital in the same time period.These patients were diagnosed with reflux esophagitis on endoscopy.In extraesophageal reflux disorders group(32 patients)and the control group(35 patients),extraesophageal reflux disorders symptoms and the control symptoms were evaluated by questionnaire.All patients underwent 24 h esophageal pH monitoring and symptom score evaluation.All patients were treated with esomeprazole.Results The symptoms score in patients whose pH monitoring was positive were significantly decreased after treatments.In extraesophageal reflux disorders group,the effective rate was 86.4%.In control group,the effective rate was 91.7%.Conclusion Extraesophageal syndromes of RE are significantly associated with acid reflux.

Characteristics of Transient Lower Esophageal Sphincter Relaxation in Healthy Korean Adults / 대한소화관운동학회지

BACKGROUND/AIMS: Transient lower esophageal sphincter relaxation (tLESR) is the main cause of gastroesophageal reflux (GER) in both healthy subjects and patients with GER disease. Unfortunately, we have no data on tLESR and its relationship with GER in Korea. Therefore, this study was performed to evaluate the characteristics of tLESR in Korean subjects and the mechanisms of GER after Korean meals. METHODS: Eight healthy volunteers (8 men, 23 to 25 yrs) received a Korean meal (laver-rolled rice, fried egg, sweet rice juice, 640 Kcal). A mylohyoid electromyogram, LES pressure using a Dent sleeve and esophageal pH were simultaneously recorded for 1 hour while fasting and 3 hours after the meal. We compared the manometric profile of swallow-induced LES relaxation (sLESR) with the manometric profile of tLESR and evaluated the frequency of tLESR and reflux episodes, and their relationship. RESULTS: Compared with sLESR, tLESR showed longer time onset to completion, slower relaxation rate, longer duration of relaxation, and a lower nadir pressure. Incidence of tLESR increased after the meal, which was mostly accompanied by GER. Also, the frequency of GER increased after the meal, which mostly occurred during tLESR. CONCLUSIONS: Our results suggest that tLESR is a main cause of GER in healthy Korean adults, which is a similar result to studies of Westerners.