Combined multi-channel intraluminal impedance measurement and pHmetry in the detection of gastroesophageal reflux disease in children with cystic fibrosis

Abstract Objective To assess the prevalence of GERD exclusively by means of multichannel intraluminal impedanciometry associated with pH monitoring (MIIpH) and compare it with respiratory symptoms in children with CF. To compare MIIpH with pHmetry alone to perform GERD diagnosis. Methods An analytical cross-sectional study was conducted with children diagnosed with CF who underwent MIIpH. Clinical and laboratory markers, including respiratory and digestive symptoms, were used for comparative analyses. High-resolution chest computed tomography was performed on patients with symptoms of chronic lung disease. Severity was classified according to the Bhalla score. Results A total of 29 children < 10 yo (18 girls) were evaluated; 19 of whom with physiological GER and 10 with GERD. Of the children with GERD, seven had predominantly acid GER, two acid+non-acid GER, and one non-acid GER. Three patients had GERD diagnosed only by MIIpH. Bhalla scores ranged from seven to 17.75 with no significant relationship with GERD. The number of pulmonary exacerbations was associated with a decrease in esophageal clearance regardless of the position in pHmetry and MIIpH. Conclusions The prevalence of GERD was 34% in children with CF. There was no association between respiratory disease severity and GER types. MIIpH detected 30% more patients with GERD than pHmetry.

Multichannel intraluminal impedance-pH and psychometric properties in gastroesophageal reflux: systematic review / Impedância intraluminal multicanal associada à pHmetria e propriedades psicométricas do refluxo gastroesofágico: revisão sistemática

Abstract Objective: Systematically assess studies that have analyzed the psychometric properties of multichannel intraluminal impedance-pH for the diagnosis of gastroesophageal reflux. Systematically verify studies that have analyzed the psychometric properties of multichannel intraluminal impedance-pH regarding the diagnosis of gastroesophageal reflux disease in pediatric patients. Methods: Systematic review considering specific descriptors (children and adolescents, gastroesophageal reflux disease and multichannel intraluminal impedance-pH) and their synonyms. The systematic search was carried out in the MEDLINE/Ovid, Scopus, and Embase databases, considering the period from October 2017 to December 2018. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), which was used for study selection. The psychometric properties described in the studies were: sensitivity, specificity, accuracy, and reproducibility. Results: Sensitivity was discussed in most studies, with a result of more than 70% in four of them. Specificity was assessed only in conjunction with sensitivity, with values from 23% to 25% in two studies, and it reached 80% in a single study. Accuracy was assessed higher than 76% in one of the selected articles. The methodological quality of the studies demonstrated low risk of bias, and there was no significant concern related to applicability of the studies. Conclusions: According to the selected studies, multichannel intraluminal impedance-pH was considered a safe and effective tool, presenting higher sensitivity values than pHmetry regarding the diagnosis of gastroesophageal reflux disease.

Resumo Objetivo: Avaliar sistematicamente estudos que analisaram propriedades psicométricas da impedância intraluminal multicanal associada à pHmetria (IIM-pH) no diagnóstico de refluxo gastroesofágico. Verificar sistematicamente estudos que analisaram as propriedades psicométricas de impedância intraluminal multicanal associada à pHmetria em relação ao diagnóstico da doença do refluxo gastroesofágico em pacientes pediátricos. Métodos: Revisão sistemática que considerou descritores específicos (crianças e adolescentes, doença do refluxo gastroesofágico e impedância intraluminal multicanal associada à pHmetria) e seus sinônimos. A busca sistemática foi realizada nas bases de dados Medline/Ovid, Scopus e Embase e considerou o período de outubro de 2017 a dezembro de 2018. Esta revisão foi realizada de acordo com o checklist Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Prisma), usado para seleção de estudos. As propriedades psicométricas descritas nos estudos foram: sensibilidade, especificidade, acurácia e reprodutibilidade. Resultados: A sensibilidade foi discutida na maioria dos estudos, com um resultado de mais de 70% em quatro deles. A especificidade foi avaliada apenas em conjunto com a sensibilidade, com valores em torno de 23 a 25% em dois estudos, e alcançou 80% em um único estudo. A acurácia foi avaliada em mais de 76% em um dos artigos selecionados. A qualidade metodológica dos estudos demonstrou baixo risco de viés e nenhuma consideração significativa relacionada à aplicabilidade dos estudos. Conclusões: De acordo com os estudos selecionados, a impedância intraluminal multicanal associada à pHmetria foi considerada uma ferramenta segura e eficaz, apresentou valores de sensibilidade superiores à pHmetria no diagnóstico da doença do refluxo gastroesofágico.

Relation between chronic rhinosinusitis and gastroesophageal reflux in adults: systematic review / Relação entre rinossinusite crônica e refluxo gastroesofágico em adultos: revisão sistemática

Abstract Introduction: The relationship between gastroesophageal reflux disease (GERD) and chronic rhinosinusitis (CRS) is still a controversial issue in literature. Objective: A systematic review of the association between these two diseases in adult patients. Methods: Systematic review in PubMed and Cochrane Database with articles published between 1951 and 2015. We included all articles that specifically studied the relationship between CRS and GERD. Results: Of the 436 articles found, only 12 met the inclusion criteria. Eight cross-sectional articles suggest a relation between CRS and GERD, especially on CRS that is refractory to clinical or surgical treatment. However, the groups are small and methodologies are different. Four other longitudinal studies have assessed the effect of treatment with proton pump inhibitors (PPIs) on the improvement of symptoms of CRS, but the results were conflicting. Conclusions: There seems to be relative prevalence of reflux with intractable CRS. There is still a lack of controlled studies with a significant number of patients to confirm this hypothesis. Few studies specifically assess the impact of treatment of reflux on symptom improvement in patients with CRS.

Resumo Introdução: A relação entre a Doença do Refluxo Gastroesofágico (DRGE) e a Rinossinusite Crônica (RSC) ainda é tema de controvérsia em literatura. Objetivo: Revisão sistemática sobre a associação entre essas duas doenças em pacientes adultos. Método: Revisão sistemática no Pubmed e Cochrane Database com os artigos publicados entre 1951 e 2015. Foram incluídos todos os artigos que estudassem especificamente a relação entre RSC e DRGE. Resultados: Dos 436 artigos encontrados, apenas 12 satisfaziam os critérios de inclusão. Oito artigos transversais sugerem relação da RSC com a DRGE, especialmente sobre a RSC refratária a tratamento clínico ou cirúrgico prévio. No entanto, os grupos são pequenos e as metodologias são muito diferentes. Outros quatro estudos longitudinais avaliaram o efeito do tratamento com Inibidores de Bomba de Prótons (IBP) sobre a melhora a dos sintomas de RSC, porém os resultados foram discordantes. Conclusões: Parece haver relação de prevalência de refluxo e RSC de difícil controle. Ainda faltam estudos controlados com um número expressivo de pacientes para que se confirme essa hipótese. São escassos os estudos que avaliem especificamente o impacto do tratamento de refluxo na melhora dos sintomas em pacientes com RSC.

Reduced quality of life in patients with non-erosive gastroesophageal reflux disease

Introduction: Gastroesophageal reflux disease (GERD) is a highly prevalent condition in the Western world. It is a frequent cause of medical appointments and has a high impact on quality of life (QOL). This study aimed to assess health-related quality of life (HQ-QOL) of patients with non-erosive gastroesophageal disease (NERD) and compare their scores with the scores of patients with GERD symptoms and non-pathological acid reflux (non-NERD). Methods: We studied 42 patients with GERD symptoms­21 with positive pHmetry for acid reflux (NERD group) and 21 with negative pHmetry for acid reflux (non-NERD group). We enrolled patients matched by age and gender. Patient inclusion criteria were based on clinical and endoscopic findings and pHmetry. All other major diseases having an impact on QOL were excluded as well as patients in regular use of proton pump inhibitors, prokinetics, histamine-2 receptor antagonists and anti-depressants. All subjects were asked to fill in a validated translation of the SF-36 questionnaire. We described scores trough median and interquartile range (IQR) and assessed the significance of the comparisons through Mann-Whitney test and chi-square test or Student's t-test when appropriate. Results: We found no significant differences in the eight domains of SF-36 between the two groups. Conclusion: QOL of patients with GERD symptoms was equivalent, regardless of acid reflux at pHmetry (AU)

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.

Refluxo gastroesofágico em cães anestesiados: fisiopatologia, clínica, diagnóstico e terapêutica / Gastroesophageal reflux in anesthetized dogs: physiopathology, clinic, diagnosis and therapeutics

O refluxo gastroesofágico pode afetar várias espécies e apresenta diversas etiologias, sendo as anestesias gerais uma das principais causas de esofagite em cães, devido à redução do tônus do esfíncter esofagogástrico, ocasionada por fármacos anestésicos. São fatores responsáveis pela lesão esofágica em consequência do refluxo, o tipo do material refluído, o volume, a frequência, a duração do refluxo e a integridade da mucosa esofágica. É importante prevenir o refluxo durante a anestesia, devido ao risco de ocasionar além da esofagite pós-operatória, outras graves complicações como a formação de estenoses esofágicas ou ainda resultar em pneumonia por aspiração. Para isso, é importante estabelecer protocolos anestésicos que não modifiquem a função do esfíncter esofagogástrico, bem como determinar estratégias terapêuticas que reduzam a incidência do refluxo. Neste artigo, são revisados os aspectos anatômicos e fisiológicos da junção esofagogástrica, assim como os relacionados com o refluxo gastroesofágico em cães anestesiados.

Gastroesophageal reflux can affect various species and presents several etiologies, and general anesthesia can be considered one of the main causes of esophagitis in dogs, due to the reduction of the gastroesophageal sphincter tonus caused by anesthetic drugs. There are many factors responsible for the esophageal lesion due to reflux, including type of refluid material, reflux volume, frequency and duration, and esophageal mucosa integrity. It is important to prevent reflux during anesthesia because of the risk of causing not only post operatory esophagitis but also other serious complications such as formation of esophageal stenosis, or aspiration pneumonia . Thus, it is important to establish anesthetic protocols that do not modify the function of the gastroesophageal sphincter, as well as determine therapeutic strategies that could reduce reflux incidence. This research reviews the anatomic and physiological aspects of gastroesophageal junction as well as those aspects related with gastroesophageal reflux in anesthetized dogs.

Asociación entre síntomas digestivos y/o respiratorios y parámetros de la pHmetría intraesofágica ambulatoria de 24 horas en niños / Digestive and respiratory symptoms and parameters of 24 hours pHmetry in children with pediatric gastroesophageal reflux disease

Introducción: La enfermedad por reflujo gastroesofágico (ERGE) tiene una alta morbi-mortalidad. El estándar de oro es la pHmetría de 24 horas (pH24h). Objetivo: Determinar la asociación entre síntomas y los parámetros de la pH24h. Métodos: Es un estudio descriptivo, retrospectivo y comparativo en 35 niños menores de 14 años con ERGE que consultaron al Hospital Universitario del Valle ®Evaristo García¼ de Cali, Colombia, a quienes se les tomaron datos como nombre, edad, género, síntomas y talla. Se dividieron en tres grupos según la presentación clínica: síntomas digestivos (grupo 1), respiratorios (grupo 2) y mixtos (grupo 3). Se definió desnutrición crónica cuando el déficit de la talla para la edad era > 5% según las tablas de la NCHS. Los parámetros a la pH24h analizados fueron el índice de reflujo (IR), el número de episodios ácidos, el número de episodios ácidos >5 min, la duración del episodio más prolongado y su asociación con síntomas. El análisis estadístico se hizo con la prueba t de Student, siendo significativo una p<0.05. Resultados: Se incluyeron 35 niños (47.9±41.3 meses), 20 varones, 2 con síntomas digestivos, 17 con síntomas respiratorios, y 16 mixtos, con un déficit de la talla para la edad de 8.0±10.89%. En 20 (57.1%) la pH24h fue anormal según los parámetros de Vandenplas: 12 en el grupo 1, 1 en el grupo 2 y 7 en el grupo 3. Los parámetros a la pH24h fueron: IR 5.25±4.94%; número de episodios ácidos 77.21±78.96; número de episodios ácidos >5 min 1.30±3.67 y la duración del episodio más prolongado 9.36±20.06 min; sin diferencias significativas al ser comparados los 3 grupos (p>0.05), teniendo los niños del grupo respiratorio los parámetros más comprometidos: IR 4.75±5.17%, número de episodios ácidos 79.17±79.76, número de episodios ácidos >5 min 2.29±4.97 y duración del episodio más prolongado 15.0±27.04 min; así como su estado nutricional (p=0.003).

Introduction: Pediatric gastroesophageal reflux disease (GERD), has a high morbidity-mortality. The gold standard is the 24 hours pHmetry (pH24h). The objective is to determine the relationship between symptoms and parameters of pH24h. Methods: This is a comparative, descriptive, and retrospective study. N=35 children <14 years old suffering GERD, from the HUV in Cali, Colombia. Data: age, gender, symptoms and stature were taken. Children were divided into three groups: digestive (group 1), respiratory (group 2) and mixed (group 3). They were classified as chronic undernourished (deficit height/age >5%) according to tables from the NCHS. From pH24h were taken: reflux index (RI), number of acid episodes, number of episodes >5 min and duration of the longest episode and association with symptoms. The statistical analysis was the Student’s test t, having p<0.05 as significant. Results: 35 children were included (47.9±41.3 months), 20 males, 2 with digestive symptoms, 17 with respiratory and 16 with both symptoms, with a deficit of H/A= 8.0±10.89%. 20 (57.1%) pH24h were abnormal by Vandenplas’ criterion: 12 in group 1, 1 in group 2 and 7 in group 3. The parameters of pH24h were: IR 5.25±4.94%; number of acid episodes 77.21±78.96; number of acid episodes >5 min 1.30±3.67 and the duration of the longest episode 9.36±20.06 min. There were no significant differences between the parameters of pH24h and the study groups (p>0.05). The respiratory group showed pH24h parameters more involved: IR 4.75±5.17%, number of acid episodes 79.17±79.76, number of acid episodes >5 min 2.29±4.97 and duration of the longest episode 15.0±27.04 min; the same as their nutritional status (p=0.003).

A Study for Causative Diseases of Globus Pharyngeus Patients Who Have NoPathologic Conditions in Laryngopharynx / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Globus pharyngeus is the feeling of a lump or foreign body in the throat. Otolaryngologists are often confronted with this condition, and some authors report that it represents 3 percent of all new clinic referrals. Unfortunately, we still do not completely understand the etiologies of globus pharyngeus, but there are recently increasing evidences to link the globus symptoms with various diseases. MATERIAL AND METHODS: We selected 32 globus patients, who exhibited no pathologic condition in physical examinations, and were analysed by general work up, barium esophagogram, 24 hour-ambulatory double-probe pH monitoring, esophageal manometry test, Fuchs' series, and MMPI. RESULTS: The results were as follows, gastroesophago-laryngopharyngeal reflux disease (n=15: 46.9%), various psychotic problems (n=11: 34.4%), esophageal motility disorders (n=7: 21.9%), duodenal ulcer (n=2: 6.3%), Eagle's syndrome (n=2: 6.3%), and hiatal hernia (n=1: 3.1%). In 5 cases, we couldn't find the etiology of globus pharyngeus. CONCLUSION: Globus pharyngeus patients, who had no pathologic findings in layrnx and pharynx, might have laryngopharyngeal-gastroesophageal reflux diseases and psychologic problems.