Frequency of functional esophageal disorders in patients with refractory reflux symptoms in Lima, Peru

Gastroesophageal reflux disease (GERD) is a clinical condition in which gastric reflux causes symptoms or damage to the esophageal mucosa. It is managed with proton pump inhibitors, however, up to 45% of patients with suspected GERD are refractory to treatment. It is necessary to establish a true GERD diagnosis by means of a digestive endoscopy, which does not show lesions in approximately 70% of patients. In this scenario, it is necessary to perform an esophageal pH-impedance measurement, a procedure that allows to determine whether exposure to gastric acid is pathological. Of this group, patients with pathological acid exposure are diagnosed as true non-erosive reflux disease (NERD). If, in addition to not presenting esophageal lesions, they have a physiological exposure to gastric acid, they suffer from esophageal hypersensitivity or functional heartburn, which are functional disorders. These require a different approach from that of GERD or NERD, as the symptoms are not due to pathological exposure to gastric acid. The aim was to calculate the frequency of esophageal hypersensitivity and functional heartburn in patients with suspected NERD. This was a cross-sectional study. Data was collected by reviewing pH-impedance and manometry reports, 166 patients were selected. The frequency for functional disorders was 86.15%, being 46.9% for functional heartburn and 39.2% for esophageal hypersensitivity. The frequency of functional disorders was higher than that reported in previous studies. In conclusion, age, psychological conditions, dietary, cultural, ethnic or lifestyle factors inherent to our environment might play important roles in the development of functional disorders.

La enfermedad por reflujo gastroesofágico (ERGE) es una condición clínica en la que el reflujo gástrico provoca síntomas o daños en la mucosa esofágica. Se maneja con inhibidores de la bomba de protones; sin embargo, hasta el 45% de los pacientes con sospecha de ERGE son refractarios al tratamiento. Por lo cual, es necesario establecer un verdadero diagnóstico de ERGE mediante una endoscopia digestiva, que no muestra lesiones en aproximadamente el 70% de los pacientes. En este escenario, es necesario realizar una medición de pH-impedancia esofágica, procedimiento que permite determinar si la exposición al ácido gástrico es patológica. De este grupo, los pacientes con exposición patológica al ácido son diagnosticados como verdadera enfermedad por reflujo no erosiva (ERNE). Si además de no presentar lesiones esofágicas, tienen una exposición fisiológica al ácido gástrico, padecen hipersensibilidad esofágica o pirosis funcional, que son trastornos funcionales. Estos requieren un enfoque diferente al ERGE o ERNE, ya que los síntomas no se deben a una exposición patológica al ácido gástrico. El objetivo fue calcular la frecuencia de hipersensibilidad esofágica y pirosis funcional en pacientes con sospecha de ERNE. Este fue un estudio transversal. Los datos se recopilaron mediante la revisión de informes de pH-impedancia y manometría, se seleccionaron 166 pacientes. La frecuencia de trastornos funcionales fue de 86,15%, siendo 46,9% de pirosis funcional y 39,2% de hipersensibilidad esofágica. La frecuencia de trastornos funcionales fue superior a la reportada en estudios previos. En conclusión, la edad, las condiciones psicológicas, los factores dietéticos, culturales, étnicos o de estilo de vida inherentes a nuestro entorno podrían jugar un papel importante en el desarrollo de trastornos funcionales.

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.

Diagnostic Value of Mean Nocturnal Baseline Impedance for Gastroesophageal Reflux Disease by 24 - Hour Multichannel Intraluminal Impedance-pH Monitoring / 胃肠病学

The value of 24 - hour multichannel intraluminal impedance - pH (24 h MII - pH) monitoring is still unknown in most patients with gastroesophageal reflux disease (GERD), and the value of mean nocturnal baseline impedance (MNBI) in the diagnosis of GERD remains controversial. Aims: To analyze the characteristics of esophageal MNBI in GERD patients, and to investigate the diagnostic value of MNBI for GERD. Methods: The clinical data of 111 patients suspected of GERD and monitored for 24 h MII-pH from May 2019 to December 2021 at the Second Affiliated Hospital of Baotou Medical College were retrospectively analyzed. According to DeMeester standard, patients were divided into non - GERD group and GERD group. Reflux parameters and MNBI of each channel between the two groups were compared. The correlation between distal and proximal esophageal MNBI and reflux parameters were analyzed. ROC curve was used to evaluate the sensitivity and specificity of MNBI for GERD. Results: Compared with non-GERD patients, the acid exposure time (AET), DeMeester score, total reflux times, acid reflux times and non-acid reflux times in GERD group were increased, the differences were statistically significant (P<0.01). MNBI at 3 cm, 5 cm and 7 cm above the dentate line and distal MNBI in the GERD group were decreased, the differences were statistically significant (P<0.01). Spearman correlation analysis showed that distal MNBI was negatively correlated with AET, DeMeester score, acid reflux times and weak acid reflux times (P<0.05). There were significant negative correlations between proximal MNBI and AET, DeMeester score and weak acid reflux times (P<0.05). ROC curve analysis showed that AUC of distal MNBI for the diagnosis of GERD was 0.72 (95% CI: 0.66-0.81, P<0.01), when the cut-off value was 1 191.42 Ω, the sensitivity and specificity of distal MNBI for diagnosis of GERD were 82.9% and 53.9%, respectively. Conclusions: Distal esophageal MNBI has good diagnostic significance for GERD patients, and can be used as a new impedance index for the auxiliary diagnosis of GERD.

Application and development of pH monitoring technology in gastroesophageal reflux disease / 中华实用儿科临床杂志

Gastroesophageal reflux disease (GERD) is a common digestive system disease with various symptoms or complications.Currently, pH monitoring is the most powerful technology to diagnose GERD, generally including the 24-hour dynamic esophageal pH monitoring, Bilitec bile reflux monitoring, 24-hour multichannel intraluminal impedance-pH monitoring, wireless capsule pH monitoring and oropharyngeal pH monitoring.This study aims to review the development and clinical application of pH monitoring technology in GERD.

Recomendaciones para el diagnóstico y tratamiento de reflujo gastroesofágico en pediatría / Recommendations for the diagnosis and treatment of gastroesophageal reflux in childhood

El reflujo gastroesofágico es una situación frecuente en el primer año de vida. En ausencia de signos y síntomas de alarma, se lo considera fisiológico. No requiere estudios y puede ser abordado por el pediatra con medidas no farmacológicas. La enfermedad por reflujo (definidaporsíntomasmolestosocomplicaciones) debe ser manejada por el gastroenterólogo. Los exámenes complementarios tienen indicaciones precisas y el tratamiento incluye medidas no farmacológicas, farmacológicas y quirúrgicas (si fuera necesario). Nuestro objetivo es describir los diferentes métodos diagnósticos, sus indicaciones y limitaciones, así como los recursos terapéuticos disponibles, incluidas las indicaciones y los efectos adversos

Gastro esophageal reflux is a frequent condition in infants. In the absence of warning symptoms and signs, it is considered physiologic. No exam is required and a non-pharmacologic approach can be instituted by pediatricians. Gastro esophageal reflux disease is characterized by troublesome symptoms or complications and should be managed by a pediatric gastroenterologist. Diagnostic tests have accurate indications and treatment includes pharmacologic and non-pharmacologic measures as well as surgery. Our objective is to describe the different diagnostic methods, their indications and limitations as well as the therapeutic resources available, including indications and adverse effects.

Importance of esophageal pH monitoring and manometry in indicating surgical treatment of gastroesophageal reflux disease

SUMMARY OBJECTIVE: To demonstrate the need of performing esophageal pH monitoring and manometry in patients with clinical suspicion of Gastroesophageal reflux disease, as more accurate and practical complementary exams in the indication of surgical treatment. METHODS: A systematic review was carried out in the PubMed/Medline database, based on the recommendations of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol, selecting studies in humans, published in Portuguese, Spanish, and English, from January 1, 2009 to August 5, 2020. The following descriptors were used: "reflux gastroesophageal" AND "surgery" AND "surgical treatment" AND "esophageal manometry" OR "pH monitoring". After that, retrospective or prospective observational studies with a sample of less than 100 individuals, or with limited access, reports or case series, review articles, letters, comments, or book chapters were excluded. To facilitate the application of the exclusion criteria, the Rayyan management base was used. RESULTS: Out of the 676 studies found, 19 valid and eligible studies were selected to make inferences. CONCLUSIONS: Based on the best evidence, currently, considering national particularities, performing a 24-hour esophageal pH monitoring and esophageal manometry for all patients undergoing anti-reflux surgery.

Reflux symptom index, reflux finding score, esophageal motility and their correlation with laryngopharyngeal reflux in patients with vocal cord polyps / 中国基层医药

Objective:To investigate reflux symptom index (RSI), reflux finding score (RFS), esophageal motility and to correlate them with laryngopharyngeal reflux in patients with vocal cord polyps, providing guidance for clinical study.Methods:A total of 100 patients with vocal cord polyps who received treatment from January 2018 to January 2020 in Jiangshan People's Hospital were included in the observation group. A total of 100 healthy controls who concurrently received physical examination were included in the control group. RSI and RFS were used to preliminarily evaluate laryngopharyngeal reflux. The characteristics of esophageal motility and the pressure of upper and lower sphincter were monitored. The correlation between RSI, RFS, esophageal motility and laryngopharyngeal reflux was analyzed.Results:In the observation group, 35.00% of patients had RSI > 13 points, and 30.00% of patients had RFS > 7 points. The RSI and RFS in the observation group were significantly higher than those in the control group [RSI: (24.17 ± 1.14) points vs. (7.28 ± 12) points; RFS: (17.59 ± 1.52) points vs. (4.28 ± 0.21) points, t = 147.344, 86.742, both P < 0.05)]. The time to upper sphincter relaxation recovery and the duration of upper sphincter relaxation in the observation group were significantly shorter than those in the control group ( t = 5.373, 4.660, both P < 0.05). The intra pellet pressure in the observation group was significantly greater than that in the control group ( t = 2.186, P < 0.05). The length of the lower sphincter in the observation group was significantly shorter than that in the control group ( t = 4.977, P < 0.05). Correlation analysis showed that RSI was positively correlated with foreign body sensation in the throat, continuous throat clearing, nasal reflux or phlegm ( r = 0.640, 0.649, 0.507, all P < 0.05). RFS was positively correlated with disappearance of laryngeal chamber, posterior commissure hyperplasia and vocal cord edema ( r = 0.742, 0.516, 0.547, all P < 0.05). Conclusion:RSI and RFS of patients with vocal cord polyps are positively correlated with laryngopharyngeal reflux. Some patients with vocal cord polyps have dysfunction and abnormal structure of upper and lower esophageal sphincter as well as laryngopharyngeal reflux. Therefore, reflux symptom index, reflux finding score and esophageal motility can be used together to diagnose laryngopharyngeal reflux and increase the diagnosis accuracy

Wireless ph monitoring and conventional esophageal ph monitoring: comparative study of discomfort, limitations in daily activities and complications / Phmetria sem cateter e phmetria esofágica convencional: estudo comparativo do desconforto, limitações das atividades diárias e complicações

ABSTRACT Background: The catheter of the esophageal pH monitoring is associated with nasal and throat discomfort, and different behave in patients. The capsule of the wireless pH monitoring may cause chest pain and complications. Aim: To compare the wireless and conventional pH monitoring concerning the degree of discomfort and limitations in daily activities, complications, ability to diagnose pathological reflux, and costs. Methods: Twenty-five patients with symptoms of gastroesophageal reflux were prospectively submitted, in a simultaneous initial period, to 24-hour catheter esophageal pH monitoring and 48-hour wireless system. After removing each system, patients underwent a specific clinical questionnaire. Results: Fifteen patients (60%) pointed a higher discomfort in the introduction of the capsule (p=0.327). Discomfort and limitations in daily activities were lower on 2nd day (p<0.05); however, continued to be expressive (32% to 44%). Chest pain occurred in 13 (52%) patients. The diagnostic gain of pathological reflux was 12% with the wireless system (p=0.355). Conclusions: 1) There is no significant difference between the discomfort mentioned in the introduction of the capsule and the catheter; 2) during reflux monitoring, the wireless system provides significant less discomfort and limitations in daily activities; 3) there is no significant difference between the two methods in the ability to diagnose pathological reflux; 4) wireless pH monitoring has higher cost.

RESUMO Racional: O cateter da pHmetria esofágica associa-se ao desconforto nasal e na garganta, e comportamento diferente nos pacientes. A cápsula da pHmetria sem cateter pode causar dor torácica e complicações. Objetivo: Comparar as pHmetrias sem cateter e a convencional, em relação ao desconforto e limitações das atividades diárias, complicações, capacidade de diagnosticar refluxo patológico, e custos. Métodos: Vinte e cinco pacientes com sintomas de refluxo gastroesofágico foram prospectivamente submetidos, em um período inicial simultâneo, à pHmetria esofágica com cateter durante 24 h e à pHmetria sem cateter durante 48 h. Após a retirada de cada método, pacientes responderam o questionário clínico específico. Resultados: Quinze pacientes (60%) relataram maior desconforto na introdução da cápsula (p=0,327). Desconforto e limitações das atividades diárias foram menores no 2º dia (p< 0,05); entretanto, continuaram sendo expressivos (32% a 44%). Dor torácica ocorreu em 13 (52%) pacientes. O ganho diagnóstico no refluxo patológico foi de 12% com o sistema sem cateter (p=0,355). Conclusões: 1) Não há diferença significativa entre o desconforto relatado na introdução da cápsula e do cateter; 2) durante a monitorização do refluxo, o sistema sem cateter proporciona significativo menor desconforto e limitações das atividades diárias; 3) não há diferença significativa entre os dois métodos na capacidade de diagnosticar o refluxo patológico; 4) pHmetria sem cateter tem custo maior.

Correlation analysis between Dx-pH monitoring and proton pump inhibitor test in the diagnosis of laryngopharyngeal reflux disease / 中华耳鼻咽喉头颈外科杂志

Objective@#The consistency of 24-hour oropharyngeal Dx-pH monitoring and proton pump inhibitor(PPI) test in the diagnosis of laryngopharyngeal reflux disease (LPRD) was investigated.@*Methods@#Sixty patients with laryngopharyngeal reflux (LPR) related symptoms who had never received PPI treatment were assessed by reflux symptom index (RSI) and reflux finding score (RFS) between October 2017 and October 2018, including 28 males and 38 females, aged from 16 to 72 years, with a medium age of 38 years. Prior to treatment, all patients were evaluated with 24 hours oropharyngeal Dx-pH monitoring(Restech). After empiric therapy with PPI twice-daily for 8 weeks, the efficacy was evaluated according to posttreatment RSI score.The data was analysed with Kruskal-Wallis test, Student Newman Keuls test and consistency check.@*Results@#(1)Among all 60 patients,13 patients (21.7%) had pathologic Ryan score and all resulted responsive to PPI;27 patients (45.0%) with a negative Ryan score were unresponsive to PPI; 20 patients (33.3%) despite a negative Ryan score resulted responsive to PPI therapy. Considering responsiveness to PPI therapy as the gold standard for the diagnosis of LPRD, the sensitivity, specificity, positive predictive value and negative predictive value of Ryan score were 39.4%, 100%, 100% and 57.4% respectively. The Kappa value was 0.369 (P<0.01). (2)Among 34 patients (56.7%) with positive Dx-pH results (24-hour oropharyngeal acid reflux events≥ 3 times), 29 patients were positive and 5 patients were negative in PPI test. Among 26 patients with negative Dx-pH results (24-hour oropharyngeal acid reflux events<3 times), 4 patients were positive and 22 patients were negative in PPI test. Considering responsiveness to PPI therapy as the gold standard for the diagnosis of LPRD, the sensitivity, specificity, positive predictive value and negative predictive value of 24-hour oropharyngeal acid reflux events were 87.9%, 81.5%, 85.3% and 84.6% respectively. The Kappa value was 0.696(P<0.01).@*Conclusions@#There is a positive correlation between 24-hour oropharyngeal Dx-pH monitoring positive results (24-hour oropharyngeal acid reflux events≥3 times) and PPI test in the diagnosis of LPRD. The 24-hour oropharyngeal Dx-pH monitoring can be a promising tool for the diagnosis of suspected LPRD patients, and more sensitive and accurate Dx-pH diagnostic index will be required in the clinic.

Análise da presença de formol e avaliação do ph de alisantes capilares / Analysis of presence of formol and ph assessment in hair straighteners

O processo de alisamento capilar é uma prática comum realizada nos salões de beleza. O procedimento exige a utilização de substâncias com capacidade de rompimento das cadeias dissulfídricas da fibra capilar com posterior modelamento para o efeito desejado, sendo o formol um dos compostos mais utilizados para esta finalidade, porém indevidamente. De acordo com a legislação vigente, o formol só pode ser utilizado em produtos cosméticos com a função de conservante em uma concentração máxima de 0,2%. Devido a seu uso incorreto em produtos capilares o presente trabalho teve como objetivo realizar uma análise semi-quantitativa da presença de formol em amostras de alisantes capilares, bem como verificar o pH destes produtos. Foram obtidas 22 amostras de alisantes capilares doadas por salões de beleza da região de Umuarama - PR. A determinação da presença de formol foi realizada através da reação de Shiff e comparação com escala colorimétrica de concentrações padronizadas de formaldeído variando de 0,005% a 10%. A verificação do pH foi realizada através da preparação de soluções aquosas de 10% do alisante e posterior aferição em pHmetro digital. Das amostras analisadas, verificou-se 22,72% encontraram-se em conformidade, apresentando quantidade de formaldeído adequada com a legislação (até 0,2%) ou ausência do composto, enquanto que 77,28% apresentaram valores acima do permitido. Já o pH adequado foi constatado em apenas 13,64% amostras. O uso incorreto ou exagerado do formol pode acarretar danos à saúde, como cefaléia, dispnéia, queimadura, edema pulmonar e até câncer. Uma maior fiscalização deve ser realizada nos estabelecimentos que realizam procedimentos de alisamento capilar, bem como nas indústrias produtoras e ainda em importadoras, para uma melhor garantia do cumprimento da legislação tanto para a preservação da saúde dos profissionais quando dos usuários.

The hair-straightening process is a common practice in most beauty salons. The procedure requires the use of substances capable of disrupting the disulfide chains of the hair fiber with subsequent modeling for the desired effect, with formaldehyde being one of the most commonly but improperly used compounds for this purpose. According to the current legislation, formaldehyde can only be used in cosmetic products as a preservative function in a maximum concentration of 0.2%. Due to its incorrect use in capillary products, this work has the purpose of developing a semi-quantitative analysis of the presence of formaldehyde in samples of hair straighteners, as well as verifying the pH of those products. Twenty-two samples of hair straighteners were donated by beauty salons from the region of Umuarama-PR. The determination of the presence of formaldehyde was performed using the Shiff reaction and compared using the colorimetric scale for standard formaldehyde concentrations varying from 0.005% to 10%. The pH verification was carried out by the preparation of 10% aqueous solutions of the straightener and subsequent measurement in a digital pH meter. From the analyzed samples, 22.72% were found to be in compliance, presenting the amount of formaldehyde within the legislation (up to 0.2%) or absence of the compound, while 77.28% presenting values above the legal limitations. Additionally, adequate pH was verified in only 13.64% of the samples. Incorrect or exaggerated use of formaldehyde can lead to health issues, such as headache, dyspnea, burns, pulmonary edema and even cancer. Greater surveillance should be carried out in establishments that perform hair straightening procedures as well as in the producing and importing industries in order to guarantee better compliance with the legislation both for the preservation of the health of professionals and users alike.

Study on esophageal motility and anti-reflux barrier function in patients with heartburn symptom and negative endoscopic findings based on Rome Ⅳ criteria / 中华消化杂志

Objective To evaluate esophageal motility and anti-reflux barrier function in patients with different phenotypes of heartburn and negative endoscopic findings based on the Rome Ⅳ criteria.Methods From March 2011 to November 2018,136 patients with heartburn and negative endoscopic findings were retrospectively analyzed.The patients underwent high-resolution manometry (HRM),24-hour pH monitoring and proton pump inhibitor (PPI) test and according to the Rome Ⅳ criteria and new diagnostic procedures,they were divided into non-erosive reflux disease (NERD) group,reflux hypersensitivity (RH) group,functional heartburn (FH) group and unclassified group.During the same period,20 healthy volunteers were selected as healthy control group.The changes of esophageal motility and HRM were analyzed among different groups.Statistical analysis was performed using one-way analysis of variance,Kruskal-Wallis H test and chi-square test.Results According to Rome Ⅳ criteria,35 patients were enrolled into the NERD group,43 patients were enrolled into the RH group,48 patients were included in the FH group,and 10 patients were enrolled into unclassified group.There were no significant differences between the NERD group,the RH group,the FH group,the unclassified group and healthy control group in the length of the lower esophageal sphincter (LES),end lower esophageal sphincter resting pressure (LESP),mean LESP,4-second-integrated relaxation pressure (4 s-IRP),distal latency (DL),upper esophageal sphincter residual pressure (UES-RP),upper esophageal sphincter relaxation time to nadir,upper esophageal sphincter (UES) recovery time and esophagogastric junction contractile integral (EGJ-CI,all P ＞0.05).The distal contractile integral (DCI) of NERD group and unclassified group were both lower than that of healthy control group (919.7 mmHg · s · cm (411.7,1 417.9) mmHg· s · cm (1 mmHg =0.133 kPa),535.6 mmHg · s · cm (321.4,1 513.4) mmHg · s · cm vs.1 322.1 mmHg · s · cm (841.6,1 918.5) mmHg · s · cm),and the differences were statistically significant (Z =-2.62 and-2.20,P =0.01 and 0.03).The upper esophageal sphincter pressure (UESP) of the unclassified group was lower than that of the healthy control group (57.0 mmHg (31.3,77.8) mmHg vs.70.4 mmHg (49.4,97.8) mmHg),and the difference was statistically significant (Z =-2.64,P =0.02).There was significant difference in esophagogastric junction (EGJ) subtypes between the NERD group,the RH group,the FH group and the unclassified group (x2 =10.85,P =0.02);the proportion of type Ⅲ patients was highest in unclassified group,followed by NERD group,which were both higher than those of RH group and FH group.There was no significant difference in the proportion of esophageal motility subtypes between NERD group,RH group,FH group and unclassified group (P ＞ 0.05).Conclusions Patients with different phenotypes of heartburn and negative endoscopy finding should be classified by efficient diagnostic procedure according to the Rome Ⅳ criteria combined with HRM,24-hour pH monitoring and PPI test.The unclassified patients need further evaluation,especially for those with effective PPI test and negative pH monitoring.However,the evaluation of anti-reflux barrier function by the HRM parameters in patients with heartburn and negative endoscopic findings has certain limitations.

Results of 24-hour esophageal impedance-pH monitoring in 141 patients with gastroesophageal reflux disease / 中华消化杂志

Objective To analyze the relationship between body type,age,gender,esophageal motility function,lower esophageal sphincter pressure (LESP) and clinical classification and type of reflux contents of patients with gastroesophageal reflux disease (GERD).Methods From September 2015 to July 2016,at Beijing Tongren Hospital of China Capital Medical University,the results of 24-hour esophageal impedance-pH monitoring of 141 patients with GERD were retrospectively analyzed.The differences of reflux contents were compared in patients with GERD among different body type,age,gender,esophageal motility function,LESP and clinical classification.Mann-Whitney test was performed for comparison between groups.Results Acid reflux was more common in obese patients (body mass index more than 23.9 kg/m2) compared with patients with normal body type (body mass index from 18.5 to 23.9 kg/m2) (18.5,7.0 to 45.3 vs.10.0,2.0 to 32.0),and the difference was statistically significant (Z =-2.320,P =0.020).Patients under 65 years old had more numbers of weak acid reflux,non-acid reflux and gas reflux than patients over 65 years old (58.5,32.8 to95.0 vs.40.0,24.0to71.0;19.5,6.0to47.5 vs.8.0,3.0 to19.0;46.0,23.8to79.3 vs.35.0,11.0 to 56.0),and the differences were statistically significant (Z =-2.690,-3.286 and-2.091,all P＜0.05).Male patients had more gas and mixed reflux compared with female patients (53.5,24.0 to 122.8 vs.36.0,19.0 to 67.0;34.0,20.8 to 50.0 vs.27.0,14.0 to 43.0),and the differences were statistically significant (Z =-2.424 and-1.961,both P ＜ 0.05).There was no statistically significant difference in reflux contents between patients with normal esophageal motility and patients with esophageal motility disorder (weak or interrupted peristalsis) (all P ＞ 0.05).Patients with reflux esophagitis(RE) and/or Barrett's esophagus (BE) had more weak acid reflux,non-acid reflux and gas reflux compared with patients with non-erosive reflux disease (NERD) (61.0,31.3 to 102.5 vs.44.0,24.5 to 66.5;18.0,8.0 to 36.5 vs.8.0,2.0 to 22.0;49.5,27.5 to 86.5 vs.26.0,11.0 to 47.0),and the differences were statistically significant (Z =-2.585,-2.942 and-3.278,all P ＜ 0.05).Patients with lower esophageal sphincter (LES) relaxation were more likely to have weak acid reflux than patients with normal LES function (57.0,32.3 to 87.0 vs.40.0,21.0 to 73.0),the difference was statistically significant (Z =-2.065,P =0.039).Conclusion Body type,age,gender,LESP and clinical classification are related to type of reflux contents in GERD patients,while esophageal peristalsis is irrelevant.

A Review of Making the Modern Diagnosis of Gastrointestinal Reflux Disease: the Lyon Consensus / 대한소화기학회지

Gastroesophageal reflux disease (GERD) is diagnosed according to the medical history or in response to proton pump inhibitor therapy. However, the need for further testing is always appropriate. The decisive evidence for the current diagnosis of GERD is severe erosive esophagitis of Los Angeles grade C or D, long-segment Barrett's mucosa or peptic strictures seen on endoscopy or an acid exposure time >6% on ambulatory pH or pH impedance monitoring. If ambulatory reflux monitoring correlates between reflux and the symptoms, then the diagnosis and treatment are certain. If it is difficult to clearly diagnose this malady as seen upon endoscopy and ph/pH impedance monitoring, then this review recommends the biopsy findings, motor evaluation and novel impedance metrics. Novel impedance metrics include the baseline impedance and the post reflux swallow-induced peristaltic wave index. Therefore, making a future GERD diagnosis should focus on defining the patient's phenotype. The phenotype is determined by the level of reflux exposure, clearance efficacy, anatomy of the esophageal gastric junction, and the psychological state of the patient. The purpose of this review is to clarify the diagnostic guideline for GERD according to several test methods.

Establishment and research of a New Zealand rabbit model of laryngopharyngeal reflux / 中华耳鼻咽喉头颈外科杂志

Objective@#To establish a New Zealand rabbit animal model of laryngopharyngeal reflux disease (LPRD) using esophageal balloon together with metal internal stent dilation and to investigate the changes of mucosa.@*Methods@#20 New Zealand rabbits were randomly divided into experimental group and control group, with 10 in each group. Balloon dilatation and metal internal stent dilation were carried out in experimental group to reproduce the animal model of LPRD.The middle of balloon was placed at the lower esophageal sphincter (LES) while the stent was placed at the upper esophageal sphincter (UES). The guide wire was placed in the control group, but the balloon was not expanded and the stent was not placed. The general condition, pH value of hypopharynx, laryngeal histopathology and changes of pepsin content of New Zealand rabbits were observed regularly. The difference between experimental group and control group was compared.@*Results@#The 24-hour Dx-pH monitoring results showed that the number of reflux episodes(20.0[9.5, 35.0], 13.0[6.5, 22.0]), and the percent time below pH 5.5 (1.36%[0.60%, 4.57%], 1.36%[0.43%, 2.77%]) in the experimental group at the 2nd and 4th week were significantly different from those in the control group (0[0,3.0], 1.0[0.5, 3.8]; 0[0, 0.01%], 0[0, 0], respectively, all P<0.01), suggesting that the experimental group New Zealand rabbits developed LPRD. Compared with the control group under microscope, lymphocytes infiltration and submucosal gland hyperplasia increased in the mucosa of the throat of the experimental group. The results of pepsin immunohistochemical staining between the two groups were statistically significant (P=0.014).@*Conclusion@#The use of balloon dilatation of the LES combined with metal stent dilatation of the UES can successfully establish a laryngopharyngeal reflux model, and lesions in the throat tissue can be observed.

Study on esophageal motility and anti-reflux barrier function in patients with heartburn symptom and negative endoscopic findings based on Rome Ⅳ criteria / 中华消化杂志

Objective@#To evaluate esophageal motility and anti-reflux barrier function in patients with different phenotypes of heartburn and negative endoscopic findings based on the Rome Ⅳ criteria.@*Methods@#From March 2011 to November 2018, 136 patients with heartburn and negative endoscopic findings were retrospectively analyzed. The patients underwent high-resolution manometry (HRM), 24-hour pH monitoring and proton pump inhibitor (PPI) test and according to the Rome Ⅳ criteria and new diagnostic procedures, they were divided into non-erosive reflux disease (NERD) group, reflux hypersensitivity (RH) group, functional heartburn (FH) group and unclassified group. During the same period, 20 healthy volunteers were selected as healthy control group. The changes of esophageal motility and HRM were analyzed among different groups. Statistical analysis was performed using one-way analysis of variance, Kruskal-Wallis H test and chi-square test.@*Results@#According to Rome Ⅳ criteria, 35 patients were enrolled into the NERD group, 43 patients were enrolled into the RH group, 48 patients were included in the FH group, and 10 patients were enrolled into unclassified group. There were no significant differences between the NERD group, the RH group, the FH group, the unclassified group and healthy control group in the length of the lower esophageal sphincter (LES), end lower esophageal sphincter resting pressure (LESP), mean LESP, 4-second-integrated relaxation pressure (4 s-IRP), distal latency (DL) , upper esophageal sphincter residual pressure (UES-RP), upper esophageal sphincter relaxation time to nadir, upper esophageal sphincter (UES) recovery time and esophagogastric junction contractile integral (EGJ-CI, all P>0.05). The distal contractile integral (DCI) of NERD group and unclassified group were both lower than that of healthy control group (919.7 mmHg·s·cm (411.7, 1 417.9) mmHg·s·cm (1 mmHg=0.133 kPa), 535.6 mmHg·s·cm (321.4, 1 513.4) mmHg·s·cm vs. 1 322.1 mmHg·s·cm (841.6, 1 918.5) mmHg·s·cm), and the differences were statistically significant (Z=-2.62 and -2.20, P=0.01 and 0.03). The upper esophageal sphincter pressure (UESP) of the unclassified group was lower than that of the healthy control group(57.0 mmHg (31.3, 77.8) mmHg vs. 70.4 mmHg (49.4, 97.8) mmHg), and the difference was statistically significant (Z=-2.64, P=0.02). There was significant difference in esophagogastric junction (EGJ) subtypes between the NERD group, the RH group, the FH group and the unclassified group (χ2=10.85, P=0.02); the proportion of type Ⅲ patients was highest in unclassified group, followed by NERD group, which were both higher than those of RH group and FH group. There was no significant difference in the proportion of esophageal motility subtypes between NERD group, RH group, FH group and unclassified group (P>0.05).@*Conclusions@#Patients with different phenotypes of heartburn and negative endoscopy finding should be classified by efficient diagnostic procedure according to the Rome Ⅳ criteria combined with HRM, 24-hour pH monitoring and PPI test. The unclassified patients need further evaluation, especially for those with effective PPI test and negative pH monitoring. However, the evaluation of anti-reflux barrier function by the HRM parameters in patients with heartburn and negative endoscopic findings has certain limitations.

Feasibility analysis of pepsin strip test in diagnosis of laryngopharyngeal reflux disease / 中华耳鼻咽喉头颈外科杂志

Objective@#To evaluate the feasibility of pepsin strip test in the diagnosis of laryngopharyngeal reflux.@*Methods@#From August 2017 to September 2018,80 patients in Department of Otorhniolaryngology Head and Neck Surgery,Chinese People′s Liberation Army General Hospital-Six Medical Centre, underwent pepsin strip test and 24-hour multichannel intraluminal impedance(MII)-pH monitoring. The results of the two methods were analyzed for consistency,and 24-hour MII-pH monitoring was used as a statistical reference for the sensitivity and specificity of pepsin strip test in the diagnosis of laryngopharyngeal reflux. Data were analyzed by SPSS 19.0 software.@*Results@#There were 57 patients with positive pepsin test strip and 23 patients with negative pepsin test strip. The score of reflux symptoms and signs, and the positive rate of laryngopharyngeal reflux events in patients with positive pepsin strip test were significantly higher than those in patients with negative pepsin test strip. If there was one or more throat reflux events (including acid reflux,weak acid reflux and alkali reflux) as the positive results of 24-hour MII-pH monitoring,the consistency between the results of pepsin strip and 24-hour MII-pH was moderate (Kappa=0.614). The sensitivity and specificity of pepsin strip were 86.9% (53/61) and 78.9% (15/19) respectively.@*Conclusions@#Pepsin strip detection has the advantages of non-invasive,cheap and easy to operate.As an objective method for early diagnosis of laryngopharyngeal reflux, pepsin strip detectionis feasible,but can not be the final diagnosis for laryngopharyngeal reflux disease.

Monitorização prolongada do refluxo gastroesofágico por impedancio-pHmetria esofágica: uma revisão sobre o tema ponderada com nossa experiência de 1. 200 casos com o método / Prolonged gastroesophageal reflux monitoring by impedance-phmetry: a review of the subject pondered with our experience with 1, 200 cases

ABSTRACT BACKGROUND: Prolonged monitoring increased our knowledge on gastroesophageal reflux (GER), and the disease became known as gastroesophageal reflux disease (GERD). Prolonged reflux monitoring permits the diagnosis of GERD when endoscopic findings are not enough to characterize it. OBJECTIVE: The objective of this paper is to review the current knowledge on impedance-pH monitoring, taking into account the published literature and the authors experience with 1,200 exams. METHODS: The different types of prolonged reflux monitoring, namely: conventional pHmetry, catheter-free pHmetry and impedance-pHmetry will be briefly described. The new possibilities of evaluation with impedance-pHmetry are emphasized, namely: the study of symptomatic patients in use of proton pump inhibitors (PPIs); evaluation of patients with symptoms suggestive of GERD although with normal endoscopy and normal pHmetry, diagnostic elucidation of patients with atypical symptoms or supra-esophageal symptoms, mainly chronic cough, study of patients complaining of belch, differentiating gastric and supra-gastric belching, and the proper work-up before anti-reflux surgery. RESULTS: When impedance was associated to pH monitoring, an impressive technological evolution became apparent, when compared to pH monitoring alone. The main advantages of impedance-pHmetry are: the ability to detect all types of reflux: acid, non-acid, liquid, gaseous. In addition, other important measurements can be made: the ability of the esophagus in transporting the bolus, the measurement of basal mucosal impedance and the evaluation of primary peristalsis post reflux. CONCLUSION: Impedance-pHmetry is a promising method, with great advantages over conventional pHmetry. The choice between these two types of monitoring should be very judicious. The authors suggest the importance of careful evaluation of each reflux episode by the physician responsible for the examination, necessary for the correct interpretation of the tracings.

RESUMO CONTEXTO: A monitorização prolongada ampliou o conhecimento sobre o refluxo gastroesofágico; a afecção decorrente do mesmo, passou a ser designada por doença do refluxo gastroesofágico (DRGE). O estudo prolongado do refluxo viabiliza o diagnóstico da DRGE nos casos sem alterações endoscópicas suficientes para caracterização da afecção. OBJETIVO: O objetivo do presente trabalho é apresentar uma revisão sobre a monitorização do refluxo por impedâncio-pHmetria, ponderando-se os dados de literatura com a experiência dos autores com o método em 1.200 exames realizados. MÉTODOS: São apresentados detalhes dos diferentes tipos de monitorização prolongada do refluxo; ou seja, a pHmetria convencional, a pHmetria sem cateter e a impedâncio-pHmetria. Salientam-se as novas possibilidades de avaliação que a impedâncio-pHmetria propicia e suas principais indicações: estudo de pacientes que permanecem sintomáticos durante o tratamento do refluxo com antissecretores; análise de pacientes com sintomas sugestivos de DRGE que não apresentem esofagite ao exame endoscópico e que tenham pHmetria normal; esclarecimento diagnóstico de pacientes com sintomas atípicos e supraesofágicos - em especial na tosse crônica; estudo da eructação diferenciando-as em dois grupos: gástricas e supragástricas e no auxílio na indicação do tratamento cirúrgico do refluxo. RESULTADOS: A monitorização associando duas modalidades de avaliação: a impedancio-pHmetria representa evolução tecnológica expressiva em relação à modalidade baseada apenas na análise do pH (pHmetria). As principais vantagens da impedâncio-pHmetria são: possibilidade de avaliação de todas modalidades de refluxo; ou seja, ácido, não-ácido, líquido e gasoso e também a possibilidade de estudo de outras variáveis importantes; ou seja: capacidade de transporte do bolus, impedância basal do esôfago e peristalse pós refluxo. CONCLUSÃO: A impedancio-pHmetria é um método promissor, com grandes vantagens sobre a pHmetria convencional. A escolha do tipo de monitorização a ser utilizada, deve ser criteriosa. Os autores destacam a importância da análise cuidadosa de cada episódio de refluxo, pelo médico responsável pela execução do exame, para correta interpretação e valorização dos dados obtidos.

Deglutição em pacientes com laringite / Swallowing in patients with laryngitis

ABSTRACT BACKGROUND: Dysphagia is described as a complaint in 32% of patients with laryngitis. OBJECTIVE: The objective of this investigation was to evaluate oral and pharyngeal transit of patients with laryngitis, with the hypothesis that alteration in oral-pharyngeal bolus transit may be involved with dysphagia. METHODS: Videofluoroscopic evaluation of the swallowing of liquid, paste and solid boluses was performed in 21 patients with laryngitis, 10 of them with dysphagia, and 21 normal volunteers of the same age and sex. Two swallows of 5 mL liquid bolus, two swallows of 5 mL paste bolus and two swallows of a solid bolus were evaluated in a random sequence. The liquid bolus was 100% liquid barium sulfate and the paste bolus was prepared with 50 mL of liquid barium and 4 g of food thickener (starch and maltodextrin). The solid bolus was a soft 2.2 g cookie coated with liquid barium. Durations of oral preparation, oral transit, pharyngeal transit, pharyngeal clearance, upper esophageal sphincter opening, hyoid movement and oral-pharyngeal transit were measured. All patients performed 24-hour distal esophageal pH evaluation previous to videofluoroscopy. RESULTS: The evaluation of 24-hour distal esophageal pH showed abnormal gastroesophageal acid reflux in 10 patients. Patients showed longer oral preparation for paste bolus and a faster oral transit time for solid bolus than normal volunteers. Patients with laryngitis and dysphagia had longer preparation for paste and solid boluses, and a faster oral transit time with liquid, paste and solid boluses. CONCLUSION: A longer oral preparation for paste and solid boluses and a faster transit through the mouth are associated with dysphagia in patients with laryngitis.

RESUMO CONTEXTO: Disfagia é uma queixa presente em 32% dos pacientes com laringite. OBJETIVO: O objetivo desta investigação foi avaliar o trânsito oral e faríngeo de pacientes com laringite, com a hipótese de que a alteração no trânsito do bolo pela boca e faringe pode estar envolvida com a queixa de disfagia. MÉTODOS: A avaliação videofluoroscópica da deglutição de bolos líquido, pastoso e sólido foi realizada em 21 pacientes com laringite, 10 deles com disfagia e 21 voluntários normais da mesma idade e sexo. Duas deglutições de 5 mL de bolo líquido, duas deglutições de bolo pastoso e duas deglutições de bolo sólido foram avaliadas em sequência casual definida por sorteio. Bolo líquido foi sulfato de bário 100%, e o bolo pastoso foi preparado com 50 mL de bário líquido e 4 g de espessante alimentar (amido e maltodextrina). O bolo sólido foi 2,2 g de uma bolacha macia embebida em bário líquido. A duração da preparação oral, trânsito oral, trânsito faríngeo, depuração da faringe, abertura do esfíncter superior do esôfago, movimento do hióide e do trânsito oral-faríngeo foram medidas. Precedendo a videofluoroscopia todos pacientes realizaram exame de pHmetria de 24 horas. RESULTADOS: O registro do pH intraesofágico distal revelou resultado anormal em 10 pacientes. Pacientes com laringite apresentaram maior duração da preparação oral para bolo pastoso e um tempo de trânsito oral mais rápido para bolo sólido. Os pacientes com laringite e disfagia tiveram uma preparação oral mais longa para bolo pastoso e sólido e tempo de trânsito oral menor com bolos líquido, pastoso e sólido. CONCLUSÃO: Preparação oral mais longa para bolos pastoso e sólido e trânsito mais rápido através da boca são situações associadas com a presença de disfagia em pacientes com laringite.

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.

Comparison of Characteristics According to Reflux Type in Patients With Laryngopharyngeal Reflux

OBJECTIVES: To analyze laryngopharyngeal reflux (LPR) as an acidic, nonacidic, or mixed type according to 24-hour multi-channel intraluminal impedance (MII) pH monitoring and the clinical characteristics of each type. METHODS: Ninety patients were prospectively enrolled in this study. All patients underwent 24-hour MII pH monitoring as a diagnostic tool. Eighty-three patients were diagnosed with LPR. The patients were classified into three groups according to the pH of the hypopharyngeal probe: the acid reflux group, nonacid reflux group, and mixed reflux group. Subjective symptoms and objective findings were evaluated based on patients' responses to the Short Form 12 Survey (SF-12), LPR health-related quality of life (LPR-HRQOL), reflux symptom index, and reflux finding score. RESULTS: The results of each group were compared. As a result, 34 patients were classified into the nonacid reflux group and 49 into the mixed reflux group. There were no patients classified as having acid reflux alone. There was no significant difference between the two groups when comparing the reflux symptom index, reflux finding score, LPR-HRQOL, or the mental component score of the SF-12. However, the physical component score of the SF-12 was higher in the nonacid reflux group (P=0.018). The DeMeester composite score (P=0.015) and total number of LPR events (P=0.001) were lower in the nonacid reflux group than in the mixed reflux group. CONCLUSION: In conclusion, no LPR patient had only acid reflux. The nonacid reflux LPR patients showed similar clinical characteristics and findings compared to the mixed reflux group, but exhibited significantly fewer LPR episodes.