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Vaezi MF, Katzka D, Zerbib F. Extraesophageal Symptoms and Diseases Attributed to GERD: Where is the Pendulum Swinging Now? Clin Gastroenterol Hepatol 2018; 16:1018-1029. [PMID: 29427733 DOI: 10.1016/j.cgh.2018.02.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/31/2018] [Accepted: 02/02/2018] [Indexed: 02/07/2023]
Abstract
The purpose of this review is to outline the recent developments in the field of extraesophageal reflux disease and provide clinically relevant recommendations. The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations: Best Practice Advice 1: The role of a gastroenterologist in patients referred for evaluation of suspected extra esophageal symptom is to assess for gastroesophageal etiologies that could contribute to the presenting symptoms. Best Practice Advice 2: Non-GI evaluations by ENT, pulmonary and/or allergy are essential and often should be performed initially in most patients as the cause of the extraesophageal symptom is commonly multifactorial or not esophageal in origin. Best Practice Advice 3: Empiric therapy with aggressive acid suppression for 6-8 weeks with special focus on response of the extraesophageal symptoms can help in assessing association between reflux and extraesophageal symptoms. Best Practice Advice 4: No single testing methodology exists to definitively identify reflux as the etiology for the suspected extra esophageal symptoms. Best Practice Advice 5: Constellation of patient presentation, diagnostic test results and response to therapy should be employed in the determination of reflux as a possible etiology in extra esophageal symptoms. Best Practice Advice 6: Testing may need to be off or on proton pump inhibitor (PPI) therapy depending on patients' presenting demographics and symptoms in assessing the likelihood of abnormal gastroesophageal reflux. A. On therapy testing may be considered in those with high probability of baseline reflux (those with previous esophagitis, Barrett's esophagus or abnormal pH). B. Off therapy testing may be considered in those with low probability of baseline reflux with the goal of identifying moderate to severe reflux at baseline. Best Practice Advice 7: Lack of response to aggressive acid suppressive therapy combined with normal pH testing off therapy or impedance-pH testing on therapy significantly reduces the likelihood that reflux is a contributing etiology in presenting extraesophageal symptoms. Best Practice Advice 8: Surgical fundoplication is discouraged in those with extra esophageal reflux symptoms unresponsive to aggressive PPI therapy. Best Practice Advice 9: Fundoplication should only be considered in those with a mechanical defect (e.g., hiatal hernia), moderate to severe reflux at baseline off PPI therapy who have continued reflux despite PPI therapy and have failed more conservative non-GI treatments.
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Affiliation(s)
- Michael F Vaezi
- Division of Gastroenterology, Hepatology, Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - David Katzka
- Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Frank Zerbib
- CHU Bordeaux, Department of Gastroenterology, Hepatology and Digestive Oncology, University of Bordeaux, Bordeaux, France
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Label-Free Detection of Salivary Pepsin Using Gold Nanoparticle/Polypyrrole Nanocoral Modified Screen-Printed Electrode. SENSORS 2018; 18:s18061685. [PMID: 29882917 PMCID: PMC6021850 DOI: 10.3390/s18061685] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/12/2018] [Accepted: 05/21/2018] [Indexed: 11/17/2022]
Abstract
Detection of salivary pepsin has been given attention as a new diagnostic tool for laryngopharyngeal reflux (LPR) disease, because saliva collection is non-invasive and relatively comfortable. In this study, we prepared polypyrrole nanocorals (PPNCs) on a screen-printed carbon electrode (SPCE) by a soft template synthesis method, using β-naphthalenesulfonic acid (NSA) (for short, PPNCs/SPCE). Gold nanoparticles (GNPs) were then decorated on PPNCs/SPCE by electrodeposition (for short, GNP/PPNCs/SPCE). To construct the immunosensor, pepsin antibody was immobilized on GNP/PPNCs/SPCE. Next, citric acid was applied to prevent non-specific binding and change the electrode surface charge before pepsin incubation. Electrochemical stepwise characterization was performed using cyclic voltammetry, and immunosensor response toward different pepsin concentrations was measured by differential pulsed voltammetry. As a result, our electrochemical immunosensor showed a sensitive detection performance toward pepsin with a linear range from 6.25 to 100 ng/mL and high specificity toward pepsin, as well as a low limit of detection of 2.2 ng/mL. Finally, we quantified the pepsin levels in saliva samples of LPR patients (n = 2), showing that the results were concordant with those of a conventional ELISA method. Therefore, we expect that this electrochemical immunosensor could be helpful for preliminarily diagnosing LPR through the detection of pepsin in saliva.
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Salivary Pepsin Test: Useful and Simple Tool for the Laryngopharyngeal Reflux Diagnosis. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.otoeng.2017.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Vaezi MF, Sifrim D. Assessing Old and New Diagnostic Tests for Gastroesophageal Reflux Disease. Gastroenterology 2018; 154:289-301. [PMID: 28774844 DOI: 10.1053/j.gastro.2017.07.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 12/13/2022]
Abstract
A detailed critique of objective measurements of gastroesophageal reflux disease (GERD) would improve management of patients suspecting of having reflux, leading to rational selection of treatment and better outcomes. Many diagnostic tests for GERD have been developed over the past decades. We analyze their development, positive- and negative-predictive values, and ability to predict response to treatment. These features are important for development of medical, surgical, and endoscopic therapies for GERD. We discuss the value of available diagnostic tests and review their role in management of patients with persistent reflux symptoms despite adequate medical or surgical treatment. This is becoming a significant health economic problem, due to the widespread use of proton pump inhibitors. GERD is believed to cause nonesophageal symptoms, such as those provoked by ear, nose, throat, or respiratory disorders. We analyze the value of GERD diagnostic tests in evaluation of these troublesome, nonesophageal symptoms.
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Affiliation(s)
- Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Daniel Sifrim
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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55
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Pepsin in saliva as a diagnostic biomarker in laryngopharyngeal reflux: a meta-analysis. Eur Arch Otorhinolaryngol 2017; 275:671-678. [DOI: 10.1007/s00405-017-4845-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 12/08/2017] [Indexed: 01/17/2023]
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56
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Cooper CA, Urso PP. Gastroesophageal Reflux in the Intensive Care Unit Patient. Crit Care Nurs Clin North Am 2017; 30:123-135. [PMID: 29413207 DOI: 10.1016/j.cnc.2017.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The incidence of gastroesophageal reflux disease (GERD) in the critically ill patient in the intensive care unit is unknown. Interventions used in critically ill patients, such as sedation, tracheal tubes, mechanical ventilation, enteral feedings, positioning, and medications, along with specific patient characteristics and comorbid conditions contribute to an increased risk for gastroesophageal reflux (GER) in this population. Critical care nurses have an integral role in helping identify critically ill patients at risk for GER or with known GERD, in preventing complications associated with these conditions.
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Affiliation(s)
- Cathy A Cooper
- Middle Tennessee State University, School of Nursing, 1301 East Main Street, Murfreesboro, TN 37132, USA.
| | - Patti P Urso
- Nursing Education, Walden University, School of Nursing, 100 Washington Avenue South, Suite 900, Minneapolis, MN 55401, USA
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Du X, Wang F, Hu Z, Wu J, Wang Z, Yan C, Zhang C, Tang J. The diagnostic value of pepsin detection in saliva for gastro-esophageal reflux disease: a preliminary study from China. BMC Gastroenterol 2017; 17:107. [PMID: 29041918 PMCID: PMC5645897 DOI: 10.1186/s12876-017-0667-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 10/12/2017] [Indexed: 02/08/2023] Open
Abstract
Background None of current diagnostic methods has been proven to be a reliable tool for gastro-esophageal reflux disease (GERD). Pepsin in saliva has been proposed as a promising diagnostic biomarker for gastro-esophageal reflux. We aimed to determine the diagnostic value of salivary pepsin detection for GERD. Methods Two hundred and fifty patients with symptoms suggestive of GERD and 35 asymptomatic healthy volunteers provided saliva on morning waking, after lunch and dinner for pepsin determination using the Peptest lateral flow device. All patients underwent 24-h multichannel intraluminal impedance pH (24-h MII-pH) monitoring and upper gastrointestinal endoscopy. Based on 24-h MII-pH and endoscopy study, patients were defined as GERD (abnormal MII-pH results and/or reflux esophagitis) and non-GERD otherwise. Results Patients with GERD had a higher prevalence of pepsin in saliva and higher pepsin concentration than patients with non-GERD and healthy controls (P < 0.001 for all). The pepsin test had a sensitivity of 73% and a specificity of 88.3% for diagnosing GERD using the optimal cut-off value of 76 ng/mL. Postprandial saliva samples collected when the symptoms occurred had a more powerful ability to identify GERD. Conclusions Salivary pepsin test had moderate diagnostic value for GERD. It may be a promising tool to replace the use of currently invasive tools with advantages of non-invasive, easy to perform and cost effective. Trial registration ChiCTR-DDD-16009506 (date of registration: October 20, 2016).
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Affiliation(s)
- Xing Du
- Department of Vascular Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, 100053, China
| | - Feng Wang
- Department of Gastroesophageal Reflux Disease, PLA Rocket Force General Hospital, Beijing, 100088, China
| | - Zhiwei Hu
- Department of Gastroesophageal Reflux Disease, PLA Rocket Force General Hospital, Beijing, 100088, China
| | - Jimin Wu
- Department of Gastroesophageal Reflux Disease, PLA Rocket Force General Hospital, Beijing, 100088, China
| | - Zhonggao Wang
- Department of Vascular Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, 100053, China. .,Department of Gastroesophageal Reflux Disease, PLA Rocket Force General Hospital, Beijing, 100088, China.
| | - Chao Yan
- Department of Vascular Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, 100053, China
| | - Chao Zhang
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, 100053, China
| | - Juan Tang
- Acupuncture and Moxibustion School of Teaching Hospital of Chengdu University of TCM, Chengdu, Sichuan, 610097, China
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Abstract
Gastroesophageal reflux disease encompasses a wide spectrum of disorders related to the reflux of gastric contents into the esophagus. Extraesophageal reflux (EER) may be suspected in patients with unexplained chronic cough, pharyngolaryngeal symptoms, and asthma. For physicians, suspected EER is challenging as there is currently no tool that can reliably make a definitive diagnosis. Endoscopic signs are not specific, pharyngeal and proximal reflux monitoring are not reliable, and if distal pH or pH-impedance monitoring can identify patients with abnormal reflux, they cannot predict the response to therapy. Controlled randomized trials have failed to reliably demonstrate any benefit of high-dose proton-pump inhibitors over placebo in patients with laryngeal symptoms, chronic cough, and asthma. Overall, the role of gastroesophageal reflux has been largely overestimated in patients with suspected EER. Especially when proton-pump inhibitors failed to improve symptoms, other diagnosis should be considered, such as functional laryngeal disorders which are probably much more prevalent in these patients than pathologic gastroesophageal reflux.
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Hashizume N, Fukahori S, Asagiri K, Ishii S, Saikusa N, Higashidate N, Yoshida M, Masui D, Sakamoto S, Tanaka Y, Yagi M, Yamashita Y. The characteristics of salivary pepsin in patients with severe motor and intellectual disabilities. Brain Dev 2017; 39:703-709. [PMID: 28495303 DOI: 10.1016/j.braindev.2017.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/08/2017] [Accepted: 04/11/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of the present study was to determine the utility of measuring the salivary pepsin level (SPL) as an objective assessment of gastroesophageal reflux disease (GERD) in severe motor and intellectual disabilities (SMID) patients. SUBJECTS AND METHODS This prospective study included 26 SMID patients who underwent simultaneous 24-h multichannel intraluminal impedance pH measurement (pH/MII) and SPL evaluation. The enrolled patients were divided into GERD (+) or GERD (-) groups according to the pH/MII findings. The age, gender and pH/MII parameters were compared between the two groups. A correlation analysis was also conducted for the SPL following early-morning fasting and post-enteral feeding and the age, gender, presence of gastrostomy and tracheostomy and pH/MII parameters. The SPL was compared between the two sampling groups. RESULTS Fifteen patients were classified as GERD (+), and 11 patients were classified as GERD (-). The mean SPL following early-morning fasting and post-enteral feeding among all patients were 104.3 (median: 38, 25th and 75th percentile: 12, 361) ng/ml and 222.2 (median: 152:0, 500) ng/ml, respectively. Regarding positivity, 76.9% and 73.1% of SPL values in early-morning fasting and post-enteral feeding SMID patients, respectively, were positive (≧16ng/ml). The SPL following early-morning fasting demonstrated a weak but significant positive correlation with age. In contrast, we noted no correlation between the pH/MII parameters and the SPL for either the early-morning fasting or post-enteral feeding patients, and no significant difference in the SPL was observed between the GERD (+) and (-) patients. CONCLUSIONS The present study showed that a high proportion of SMID patients had a relatively high SPL, regardless of the presence of GERD. The SPL in SMID patients might be affected by several distinctive factors in addition to gastroesophageal reflux.
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Affiliation(s)
- Naoki Hashizume
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan.
| | - Suguru Fukahori
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Kimio Asagiri
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Shinji Ishii
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Nobuyuki Saikusa
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Naruki Higashidate
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Motomu Yoshida
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Daisuke Masui
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Saki Sakamoto
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Yoshiaki Tanaka
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan; Division of Medical Safety Management, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Minoru Yagi
- Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Yushiro Yamashita
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Fukuoka, Japan
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Calvo-Henríquez C, Ruano-Ravina A, Vaamonde P, Martínez-Capoccioni G, Martín-Martín C. Is Pepsin a Reliable Marker of Laryngopharyngeal Reflux? A Systematic Review. Otolaryngol Head Neck Surg 2017; 157:385-391. [DOI: 10.1177/0194599817709430] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective Laryngopharyngeal reflux (LPR) is a common illness of otolaryngology visits. Over the past few years, pepsin has become a promising marker of LPR. The objective of the present research is to analyze the existing literature using pepsin as a diagnostic tool of LPR through a systematic review. Data Sources PubMed (Medline), Trip Database, Cochrane Library, EMBASE, SUMsearch, and Web of Science. Review Methods The outcome assessed was the presence of pepsin in LPR patients. We included articles in which pepsin was studied in LPR patients (clinically suspected or with confirmed diagnosis). Studies with no control group, comparison group, and/or a sample size lower than 20 patients were excluded. Results Twelve studies were included. All included studies, with the exception of 2, found statistically significant differences for pepsin in cases compared with healthy controls. Conclusion Pepsin might be a reliable marker in LPR patients, although questions remain about optimal timing, location, nature, and threshold values for pepsin testing. Future investigations are necessary to clarify the best method to use pepsin in the diagnostic process of LPR.
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Affiliation(s)
- Christian Calvo-Henríquez
- Service of Otolaryngology, Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | - Alberto Ruano-Ravina
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- CIBER de Epidemiología y Salud Pública, CIBERESP, Santiago de Compostela, Spain
| | - Pedro Vaamonde
- Service of Otolaryngology, Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
- Department of Voice and Swallowing Disorders, Service of Otolaryngology, Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Carlos Martín-Martín
- Service of Otolaryngology, Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
- Department of Otolaryngology, University of Santiago de Compostela, Santiago de Compostela, Spain
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Salivary Pepsin Test: Useful and simple tool for the laryngopharyngeal reflux diagnosis. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2017; 69:80-85. [PMID: 28522132 DOI: 10.1016/j.otorri.2017.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/09/2017] [Accepted: 03/19/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION AND OBJECTIVES Laryngopharyngeal Reflux (LPR) is a disease characterized by the presence of symptoms, signs and tissue damage caused by retrograde flow of gastric contents to the upper aerodigestive tract. It represents up to 10% of otolaryngology consultations. The aim of the study is to describe the findings obtained by applying the salivary pepsin test (PEP-test) in a sample of patients with the clinical suspicion of LPR. MATERIAL AND METHODS Our descriptive clinical study included 142 subjects with symptoms suggestive of LPR and a score above 13 on the RSI scale. The subjects underwent laryngeal endoscopy to rule out other pathologies that could justify the symptoms and the salivary pepsin test (PEP-test). The latter was carried out on fasting subjects and a second test one hour after eating, only on those with negative results. RESULTS The results obtained in the tests performed on the 142 patients included in the study were: 105 (73.94%) presented positive results in some of the salivary pepsin tests and the results of both tests were negative in 37 subjects (26.06%). CONCLUSION The salivary pepsin test is a simple, low-cost, non-invasive and easily repeatable tool which could minimize empirical treatments and invasive tests for LPR diagnosis, although further research is needed for its validation.
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Fortunato JE, D'Agostino RB, Lively MO. Pepsin in saliva as a biomarker for oropharyngeal reflux compared with 24-hour esophageal impedance/pH monitoring in pediatric patients. Neurogastroenterol Motil 2017; 29. [PMID: 27604397 DOI: 10.1111/nmo.12936] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 08/06/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pepsin in saliva is a proposed biomarker for oropharyngeal reflux. Pepsin may be prevalent in saliva from subjects with gastro-esophageal reflux and may correlate with proximal reflux by intraluminal impedance/pH monitoring (MII/pH). METHODS Patients (3 days to 17.6 years, n=90) undergoing 24-hour MII/pH monitoring and asymptomatic controls (2 months to 13.7 years, n=43) were included. Salivary pepsin was determined using a pepsin enzyme-linked immunosorbent assay. Eight saliva samples were collected from patients undergoing 24-hr MII/pH: (i) before catheter placement, (ii) before and 30 minutes after each of three meals, and (iii) upon awakening. One sample was collected from each control. KEY RESULTS In MII/pH subjects, 85.6% (77/90) had at least one pepsin-positive sample compared with 9.3% (4/43) in controls. The range of pepsin observed in individual subjects varied widely over 24 hours. The average pepsin concentration in all samples obtained within 2 hours following the most recent reflux event was 30.7±135 ng/mL, decreasing to 16.5±39.1 ng/mL in samples collected more than 2 hours later. The frequency of pepsin-positive samples correlated significantly with symptom index (rS =0.332, P=.0014), proximal (rS =0.340, P=.0010), and distal (rS =0.272, P=.0095) MII events. CONCLUSIONS & INFERENCES Concentration of salivary pepsin may not be an accurate measure of severity of reflux because of the wide range observed in individuals over 24 hours. Saliva samples must be obtained soon after a reflux event. Defining a regimen for optimal saliva collection may help to achieve the goal of using salivary pepsin as a biomarker for oropharyngeal reflux. CLINICAL TRIAL REGISTRY NCT01091805.
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Affiliation(s)
- J E Fortunato
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - R B D'Agostino
- Department of Biostatistical Sciences, Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - M O Lively
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Patel DA, Harb AH, Vaezi MF. Oropharyngeal Reflux Monitoring and Atypical Gastroesophageal Reflux Disease. Curr Gastroenterol Rep 2016; 18:12. [PMID: 26908280 DOI: 10.1007/s11894-016-0486-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The prevalence of gastroesophageal reflux disease (GERD) has been increasing since the 1990 s, with up to 27.8 % of people in North America affected by this disorder. The healthcare burden of patients who primarily have extra-esophageal manifestations of GERD (atypical GERD) is estimated to be 5 times that of patients with primarily heartburn and regurgitation due to lack of a gold standard diagnostic test, poor responsiveness to PPI therapy, and delay in recognition. Empiric twice daily PPI therapy for 1-2 months is currently considered the best diagnostic test, but due to poor responsiveness to PPIs in patients with atypical GERD in multiple randomized controlled trials, newer modes of diagnostic procedures such as oropharyngeal pH monitoring have gained significantly more traction. The utility of oropharyngeal pH monitoring systems such as Restech Dx-pH is currently limited due to lack of consensus on normal and abnormal cutoff values. Recent studies suggest its utility as a prognostic tool and its ability to predict responsiveness to medical and surgical therapy. However, routine use of oropharyngeal pH monitoring is still not widespread due to the lack of well-controlled prospective studies.
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Affiliation(s)
- Dhyanesh A Patel
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ali H Harb
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA.
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64
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Dy F, Amirault J, Mitchell PD, Rosen R. Salivary Pepsin Lacks Sensitivity as a Diagnostic Tool to Evaluate Extraesophageal Reflux Disease. J Pediatr 2016; 177:53-58. [PMID: 27453366 PMCID: PMC5037022 DOI: 10.1016/j.jpeds.2016.06.033] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 04/25/2016] [Accepted: 06/09/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To determine the sensitivity of salivary pepsin compared with multichannel intraluminal impedance with pH testing (pH-MII), endoscopy, and gastroesophageal reflux disease (GERD) questionnaires. STUDY DESIGN We prospectively recruited 50 children from Boston Children's Hospital who were undergoing pH-MII to evaluate for GERD. The patients completed 24-hour pH-MII testing, completed symptom and quality of life questionnaires, and provided a saliva specimen that was analyzed using the PepTest lateral flow test. A subset of patients also underwent bronchoscopy and esophagogastroduodenoscopy. Receiver operating characteristic curve analyses were performed to determine the sensitivity of salivary pepsin compared with each reference standard. RESULTS Twenty-one of the 50 patients (42%) were salivary pepsin-positive, with a median salivary pepsin concentration of 10 ng/mL (IQR, 10-55 ng/mL). There was no significant difference in the distributions of acid, nonacid, total reflux episodes, full column reflux, or any other reflux variable in patients who were pepsin-positive compared with those who were pepsin-negative (P > .50). There was no significant correlation between the number of reflux episodes and pepsin concentration (P > .10). There was no positive relationship between salivary pepsin positivity, any extraesophageal symptoms or quality of life scores, or inflammation on bronchoscopy or esophagogastroduodenoscopy (P > .30). CONCLUSION Salivary pepsin measurement has a low sensitivity for predicting pathological gastroesophageal reflux in children.
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Affiliation(s)
- Fei Dy
- Division of Respiratory Diseases, Boston Children’s Hospital, Boston, MA
| | - Janine Amirault
- Aerodigestive Center, Division of Gastroenterology and Nutrition, Boston Children’s Hospital, Boston, MA
| | | | - Rachel Rosen
- Aerodigestive Center, Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, MA.
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Pomari C, Mauroner L, Paiano S, Assante LR, Bertolaccini L, Ruffo G, Mainardi P, Bocus P, Geccherle A, Albanese SI, Ciaffoni S. Bronchial reacutization and gastroesophageal reflux: is there a potential clinical correlation? ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:304. [PMID: 27668224 DOI: 10.21037/atm.2016.08.40] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pepsin plays a role in gastroesophageal reflux (GER). Aims of this study were to verify if pepsin could be the cause of frequent bronchial exacerbations and to check if the persistence of chronic respiratory symptoms were correlated with pre-existing respiratory diseases. METHODS From January to May 2016, 42 patients underwent a diagnostic bronchoscopy. All patients had a history of at least one bronchial exacerbation during the previous year. Bronchial lavage fluid specimens were obtained. A semiquantitative assessment of pepsin in the samples was carried out based on the intensity of the test sample. RESULTS Pepsin was present in 37 patients (88%), but in patients with bronchial asthma and chronic obstructive pulmonary disease (COPD), the finding of pepsin in the bronchoalveolar fluid was 100%. There was a strong positive statistical correlation between pepsin detection and radiological signs of GER (ρ=0.662), and between pepsin detection and diagnosis (ρ=0.682). No correlation was found between the bacteriology and the presence of pepsin in the airways (ρ=0.006). CONCLUSIONS The presence of pepsin in the airways shows the occurrence of reflux. The persistence of respiratory symptoms by at least 2 months suggest an endoscopic bronchial examination. This straightforward test confirms the cause possible irritation of the airways and may prevent further diagnostic tests, such as an EGD or pH monitoring esophageal.
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Affiliation(s)
- Carlo Pomari
- Thoracic Endoscopy Unit, Sacro Cuore Don Calabria Hospital - Cancer Care Center, Negrar Verona, Italy
| | - Luisa Mauroner
- Laboratory Unit, Sacro Cuore Don Calabria Hospital - Cancer Care Center, Negrar Verona, Italy
| | - Simona Paiano
- Thoracic Endoscopy Unit, Sacro Cuore Don Calabria Hospital - Cancer Care Center, Negrar Verona, Italy
| | - Luca Rosario Assante
- Thoracic Endoscopy Unit, Sacro Cuore Don Calabria Hospital - Cancer Care Center, Negrar Verona, Italy
| | - Luca Bertolaccini
- Thoracic Surgery Unit, Sacro Cuore Don Calabria Hospital - Cancer Care Center, Negrar Verona, Italy
| | - Giacomo Ruffo
- Division of General Surgery, Sacro Cuore Don Calabria Hospital - Cancer Care Center, Negrar Verona, Italy
| | - Paride Mainardi
- Radiological Department, Sacro Cuore Don Calabria Hospital - Cancer Care Center, Negrar Verona, Italy
| | - Paolo Bocus
- Digestive Endoscopy Unit, Sacro Cuore Don Calabria Hospital - Cancer Care Center, Negrar Verona, Italy
| | - Andrea Geccherle
- Intestinal Bowel Disease Unit, Sacro Cuore Don Calabria Hospital - Cancer Care Center, Negrar Verona, Italy
| | - Sergio Ivan Albanese
- Otolaryngology-Head and Neck Surgery, Sacro Cuore Don Calabria Hospital - Cancer Care Center, Negrar Verona, Italy
| | - Stefano Ciaffoni
- Laboratory Unit, Sacro Cuore Don Calabria Hospital - Cancer Care Center, Negrar Verona, Italy
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Nikaki K, Woodland P, Sifrim D. Adult and paediatric GERD: diagnosis, phenotypes and avoidance of excess treatments. Nat Rev Gastroenterol Hepatol 2016; 13:529-42. [PMID: 27485786 DOI: 10.1038/nrgastro.2016.109] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Detailed investigations and objective measurements in patients with symptoms of gastro-oesophageal reflux should be performed with the intent of making the correct diagnosis, thus enabling choice of appropriate therapy. Establishing the most effective therapy is particularly important in adults who do not respond to standard treatment and in children. The use of PPIs for suspected GERD has increased substantially over the past decade, providing great relief in patients with acid-related symptoms, but also leading to adverse effects and a considerable economic burden. Adults with functional heartburn do not benefit from PPIs, while prolonged PPI use in patients with extraoesophageal symptoms remains a controversial area. Moreover, PPIs are not indicated in infants with GERD unless symptoms are proven to be acid-related. With regard to antireflux surgery, patients must be carefully selected to avoid the need for ongoing PPI treatment postoperatively. Correct diagnosis and phenotyping of patients with symptoms attributed to gastro-oesophageal reflux through detailed investigations is therefore imperative, leading to improved patient outcomes and rationalized use of available treatment options. In this Review, we outline currently available diagnostic tests and discuss approaches to limit any unnecessary medical or surgical interventions.
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Affiliation(s)
- Kornilia Nikaki
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, London E1 2AJ, UK
| | - Philip Woodland
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, London E1 2AJ, UK
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, London E1 2AJ, UK
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Johnston N, Ondrey F, Rosen R, Hurley BP, Gould J, Allen J, DelGaudio J, Altman KW. Airway reflux. Ann N Y Acad Sci 2016; 1381:5-13. [PMID: 27310222 DOI: 10.1111/nyas.13080] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
An ever-increasing number of adult and pediatric disorders have been shown to be influenced or caused by airway reflux. This has become a controversial and complicated aspect of medicine that requires a multidisciplinary approach. Evidence indicates that it is not only the acidic components of gastric refluxate that injure extraesophageal tissues but also the nonacidic components, such as pepsin and bile. There is a realization that proton pump inhibitors will not be effective when nonacidic components of refluxate are causing the problem. New in vitro and in vivo models for the study of airway reflux and new therapeutic and surgical approaches are discussed in this review article.
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Affiliation(s)
- Nikki Johnston
- Departments of Otolaryngology and Communication Sciences, and Microbiology and Molecular Genetics, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Frank Ondrey
- Department of Otolaryngology and Masonic Cancer Center, University of Minnesota School of Medicine, Duluth, Minnesota
| | - Rachel Rosen
- Department of Gastroenterology and Nutrition, Boston's Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bryan P Hurley
- Department of Pediatrics, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Jon Gould
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jacquie Allen
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - John DelGaudio
- Department of Otolaryngology, Emory University, Atlanta, Georgia
| | - Kenneth W Altman
- Department of Otolaryngology - Head & Neck Surgery, Baylor College of Medicine, Houston, Texas
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Optimal timing of saliva collection to detect pepsin in patients with laryngopharyngeal reflux. Laryngoscope 2016; 126:2770-2773. [DOI: 10.1002/lary.26018] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 02/11/2016] [Accepted: 03/10/2016] [Indexed: 02/02/2023]
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Yadlapati R, Adkins C, Jaiyeola DM, Lidder AK, Gawron AJ, Tan BK, Shabeeb N, Price CPE, Agrawal N, Ellenbogen M, Smith SS, Bove M, Pandolfino JE. Abilities of Oropharyngeal pH Tests and Salivary Pepsin Analysis to Discriminate Between Asymptomatic Volunteers and Subjects With Symptoms of Laryngeal Irritation. Clin Gastroenterol Hepatol 2016; 14:535-542.e2. [PMID: 26689899 PMCID: PMC4799733 DOI: 10.1016/j.cgh.2015.11.017] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 10/24/2015] [Accepted: 11/17/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It has been a challenge to confirm the association between laryngeal symptoms and physiological reflux disease. We examined the ability of oropharyngeal pH tests (with the Restech Dx-pH system) and salivary pepsin tests (with Peptest) to discriminate between asymptomatic volunteers (controls) and subjects with a combination of laryngeal and reflux symptoms (laryngeal ± reflux). METHODS We performed a physician-blinded prospective cohort study of 59 subjects at a single academic institution. Adult volunteers were recruited and separated into 3 groups on the basis of GerdQ and Reflux Symptom Index scores: controls (n = 20), laryngeal symptoms (n = 20), or laryngeal + reflux symptoms (n = 19). Subjects underwent laryngoscopy and oropharyngeal pH tests and submitted saliva samples for analysis of pepsin concentration. Primary outcomes included abnormal acid exposure and composite (RYAN) score for oropharyngeal pH tests and abnormal mean salivary pepsin concentration that was based on normative data. RESULTS Complete oropharyngeal pH data were available from 53 subjects and complete salivary pepsin data from 35 subjects. We did not observe any significant differences between groups in percent of time spent below pH 4.0, 5.0, 5.5, 6.0, or RYAN scores or percent of subjects with positive results from tests for salivary pepsin (53% vs 40% vs 75%; P = .50, respectively). The laryngeal + reflux group had a significantly higher estimated mean concentration of salivary pepsin (117.9 ± 147.4 ng/mL) than the control group (32.4 ± 41.9 ng/mL) or laryngeal symptom group (7.5 ± 11.2 ng/mL) (P = .01 and P = .04, respectively). CONCLUSIONS By using current normative thresholds, oropharyngeal pH testing and salivary pepsin analysis are not able to distinguish between healthy volunteers and subjects with a combination of laryngeal and reflux symptoms.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Christopher Adkins
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Diana-Marie Jaiyeola
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alcina K. Lidder
- University of Rochester School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY, USA
| | - Andrew J. Gawron
- Division of Gastroenterology, University of Utah, Salt Lake City, IL, USA
| | - Bruce K. Tan
- Division of Otolaryngology, Feinberg School of Medicine, Northwestern University, Chicago IL, USA
| | - Nadine Shabeeb
- University of Indiana School of Medicine, Indianapolis, IN, USA
| | - Caroline PE Price
- Division of Otolaryngology, Feinberg School of Medicine, Northwestern University, Chicago IL, USA
| | - Neelima Agrawal
- Division of Otolaryngology, Feinberg School of Medicine, Northwestern University, Chicago IL, USA
| | - Michael Ellenbogen
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Stephanie S. Smith
- Division of Otolaryngology, Feinberg School of Medicine, Northwestern University, Chicago IL, USA
| | - Michiel Bove
- Division of Otolaryngology, Feinberg School of Medicine, Northwestern University, Chicago IL, USA
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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de Bortoli N, Martinucci I, Bertani L, Russo S, Franchi R, Furnari M, Tolone S, Bodini G, Bolognesi V, Bellini M, Savarino V, Marchi S, Savarino EV. Esophageal testing: What we have so far. World J Gastrointest Pathophysiol 2016; 7:72-85. [PMID: 26909230 PMCID: PMC4753191 DOI: 10.4291/wjgp.v7.i1.72] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 12/02/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a common disorder of the gastrointestinal tract. In the last few decades, new technologies have evolved and have been applied to the functional study of the esophagus, allowing for the improvement of our knowledge of the pathophysiology of GERD. High-resolution manometry (HRM) permits greater understanding of the function of the esophagogastric junction and the risks associated with hiatal hernia. Moreover, HRM has been found to be more reproducible and sensitive than conventional water-perfused manometry to detect the presence of transient lower esophageal sphincter relaxation. Esophageal 24-h pH-metry with or without combined impedance is usually performed in patients with negative endoscopy and reflux symptoms who have a poor response to anti-reflux medical therapy to assess esophageal acid exposure and symptom-reflux correlations. In particular, esophageal 24-h impedance and pH monitoring can detect acid and non-acid reflux events. EndoFLIP is a recent technique poorly applied in clinical practice, although it provides a large amount of information about the esophagogastric junction. In the coming years, laryngopharyngeal symptoms could be evaluated with up and coming non-invasive or minimally invasive techniques, such as pepsin detection in saliva or pharyngeal pH-metry. Future studies are required of these techniques to evaluate their diagnostic accuracy and usefulness, although the available data are promising.
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The Role of Pepsin in LPR: Will It Change Our Diagnostic and Therapeutic Approach to the Disease? CURRENT OTORHINOLARYNGOLOGY REPORTS 2016. [DOI: 10.1007/s40136-016-0106-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Spyridoulias A, Lillie S, Vyas A, Fowler SJ. Detecting laryngopharyngeal reflux in patients with upper airways symptoms: Symptoms, signs or salivary pepsin? Respir Med 2015; 109:963-9. [DOI: 10.1016/j.rmed.2015.05.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/16/2015] [Accepted: 05/19/2015] [Indexed: 12/12/2022]
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Naik RD, Vaezi MF. Extra-esophageal gastroesophageal reflux disease and asthma: understanding this interplay. Expert Rev Gastroenterol Hepatol 2015; 9:969-82. [PMID: 26067887 DOI: 10.1586/17474124.2015.1042861] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a condition that develops when there is reflux of stomach contents, which typically manifests as heartburn and regurgitation. These esophageal symptoms are well recognized; however, there are extra-esophageal manifestations of GERD, which include asthma, chronic cough, laryngitis and sinusitis. With the rising incidence of asthma, there is increasing interest in identifying how GERD impacts asthma development and therapy. Due to the poor sensitivity of endoscopy and pH monitoring, empiric therapy with proton pump inhibitors (PPIs) is now considered the initial diagnostic step in patients suspected of having GERD-related symptoms. If unresponsive, diagnostic testing with pH monitoring off therapy and/or impedance/pH monitoring on therapy, may be reasonable in order to assess for baseline presence of reflux with the former and exclude continued acid or weakly acid reflux with the latter tests. PPI-unresponsive asthmatics, without overt regurgitation, usually have either no reflux or causes other than GERD. In this group, PPI therapy should be discontinued. In those with GERD as a contributing factor acid suppressive therapy should be continued as well as optimally treating other etiologies requiring concomitant treatment. Surgical fundoplication is rarely needed but in those with a large hiatal hernia, moderate-to-severe reflux by pH monitoring surgery might be helpful in eliminating the need for high-dose acid suppressive therapy.
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Affiliation(s)
- Rishi D Naik
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Digestive Disease Center, Vanderbilt University Medical Center, 1660 TVC, Nashville, TN 37232-5280, USA
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Formánek M, Zeleník K, Komínek P, Matoušek P. Diagnosis of extraesophageal reflux in children with chronic otitis media with effusion using Peptest. Int J Pediatr Otorhinolaryngol 2015; 79:677-9. [PMID: 25736547 DOI: 10.1016/j.ijporl.2015.02.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/06/2015] [Accepted: 02/12/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The aim of the study was to investigate whether Peptest, an immunoassay used to detect pepsin, could be used to diagnose extraesophageal reflux (EER) in children with chronic otitis media with effusion (OME). The results obtained using this fast, simple and non-expensive method were compared with the results of previous studies. METHODS Children 1-7 years old who had been diagnosed with OME and who were undergoing myringotomy with insertion of a ventilation tube were included in the prospective study. Middle ear fluid obtained during myringotomy was analyzed with Peptest to determine the presence of pepsin, and hence EER. RESULTS Bilateral and unilateral myringotomy was performed in 15/44 (34.1%) and 29/44 (65.9%) children, respectively. Pepsin in the middle ear was detected in 14/44 (31.8%) children and in 19/59 (32.2%) middle ear specimens. Serous and mucous samples were positive for pepsin in 11/32 (34.4%) and 6/27 (22.2%) cases, respectively. Pepsin in the middle ear was detected in 3/7 children (42.9%) with bronchial asthma (p=0.662). CONCLUSIONS Pepsin was detected in 1/3 of middle ear specimens of patients with OME. These patients probably suffer from more severe reflux and therefore would be potential candidates for antireflux therapy. However, this has to be confirmed in further studies.
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Affiliation(s)
- Martin Formánek
- Department of Otorhinolaryngology, University Hospital Ostrava, 17, listopadu 1790, 70852 Ostrava, Czech Republic; Faculty of Medicine University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic.
| | - Karol Zeleník
- Department of Otorhinolaryngology, University Hospital Ostrava, 17, listopadu 1790, 70852 Ostrava, Czech Republic; Faculty of Medicine University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic.
| | - Pavel Komínek
- Department of Otorhinolaryngology, University Hospital Ostrava, 17, listopadu 1790, 70852 Ostrava, Czech Republic; Faculty of Medicine University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic.
| | - Petr Matoušek
- Department of Otorhinolaryngology, University Hospital Ostrava, 17, listopadu 1790, 70852 Ostrava, Czech Republic; Faculty of Medicine University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic.
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Wilder-Smith CH, Materna A, Martig L, Lussi A. Gastro-oesophageal reflux is common in oligosymptomatic patients with dental erosion: A pH-impedance and endoscopic study. United European Gastroenterol J 2015; 3:174-81. [PMID: 25922678 DOI: 10.1177/2050640614550852] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 08/16/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Dental erosion is a complication of gastro-oesophageal reflux disease (GORD) according to the Montreal consensus statement. However, GORD has not been comprehensively characterized in patients with dental erosions and pH-impedance measures have not been reported. OBJECTIVES Characterize GORD in patients with dental erosions using 24-h multichannel intraluminal pH-impedance measurements (pH-MII) and endoscopy. METHODS This single-centre study investigated reflux in successive patients presenting to dentists with dental erosion using pH-MII and endoscopy. RESULTS Of the 374 patients, 298 (80%) reported GORD symptoms <2 per week, 72 (19%) had oesophagitis and 59 (16%) had a hiatal hernia. In the 349 with pH-MII the mean percentage time with a pH <4 (95% CI) was 11.0 (9.3-12.7), and 34.4% (31.9-36.9) for a pH <5.5, a critical threshold for dental tissue. The mean numbers of total, acidic and weakly acidic reflux episodes were 71 (63-79), 43 (38-49) and 31 (26-35), respectively. Of the reflux episodes, 19% (17-21) reached the proximal oesophagus. In 241 (69%) patients reflux was abnormal using published normal values for acid exposure time and reflux episodes. No significant associations between the severity of dental erosions and any reflux variables were found. The presence of GORD symptoms and of oesophagitis or a hiatal hernia was associated with greater reflux, but not with increased dental erosion scores. CONCLUSIONS Significant oligosymptomatic gastro-oesophageal reflux occurs in the majority of patients with dental erosion. The degree of dental erosion did not correlate with any of the accepted quantitative reflux indicators. Definition of clinically relevant reflux parameters by pH-MII for dental erosion and of treatment guidelines are outstanding. Gastroenterologists and dentists need to be aware of the widely prevalent association between dental erosion and atypical GORD.
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Affiliation(s)
- Clive H Wilder-Smith
- Brain-Gut Research Group, Gastroenterology Group Practice, Bern, Switzerland ; Department of Preventive, Restorative and Pediatric Dentistry, University of Bern, Bern, Switzerland
| | - Andrea Materna
- Brain-Gut Research Group, Gastroenterology Group Practice, Bern, Switzerland
| | - Lukas Martig
- Institute of Mathematical Statistics and Actuarial Science, University of Bern, Bern, Switzerland
| | - Adrian Lussi
- Department of Preventive, Restorative and Pediatric Dentistry, University of Bern, Bern, Switzerland
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Hayat JO, Gabieta-Somnez S, Yazaki E, Kang JY, Woodcock A, Dettmar P, Mabary J, Knowles CH, Sifrim D. Pepsin in saliva for the diagnosis of gastro-oesophageal reflux disease. Gut 2015; 64:373-80. [PMID: 24812000 DOI: 10.1136/gutjnl-2014-307049] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Current diagnostic methods for gastro-oesophageal reflux disease (GORD) have moderate sensitivity/specificity and can be invasive and expensive. Pepsin detection in saliva has been proposed as an 'office-based' method for GORD diagnosis. The aims of this study were to establish normal values of salivary pepsin in healthy asymptomatic subjects and to determine its value to discriminate patients with reflux-related symptoms (GORD, hypersensitive oesophagus (HO)) from functional heartburn (FH). DESIGN 100 asymptomatic controls and 111 patients with heartburn underwent MII-pH monitoring and simultaneous salivary pepsin determination on waking, after lunch and dinner. Cut-off value for pepsin positivity was 16 ng/mL. Patients were divided into GORD (increased acid exposure time (AET), n=58); HO (normal AET and + Symptom Association Probability (SAP), n=26) and FH (normal AET and-SAP, n=27). RESULTS 1/3 of asymptomatic subjects had pepsin in saliva at low concentration (0(0-59)ng/mL). Patients with GORD and HO had higher prevalence and pepsin concentration than controls (HO, 237(52-311)ng/mL and GORD, 121(29-252)ng/mL)(p<0.05). Patients with FH had low prevalence and concentration of pepsin in saliva (0(0-40) ng/mL). A positive test had 78.6% sensitivity and 64.9% specificity for diagnosis of GORD+HO (likelihood ratio: 2.23). However, one positive sample with >210 ng/mL pepsin suggested presence of GORD+HO with 98.2% specificity (likelihood ratio: 25.1). Only 18/84 (21.4%) of GORD+HO patients had 3 negative samples. CONCLUSION In patients with symptoms suggestive of GORD, salivary pepsin testing may complement questionnaires to assist office-based diagnosis. This may lessen the use of unnecessary antireflux therapy and the need for further invasive and expensive diagnostic methods.
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Affiliation(s)
- Jamal O Hayat
- Centre for Digestive Diseases, Barts and the London School of Medicine and Dentistry, London, UK Department of Gastroenterology, St.George's, University of London, UK
| | - Shirley Gabieta-Somnez
- Centre for Digestive Diseases, Barts and the London School of Medicine and Dentistry, London, UK
| | - Etsuro Yazaki
- Centre for Digestive Diseases, Barts and the London School of Medicine and Dentistry, London, UK
| | - Jin-Yong Kang
- Department of Gastroenterology, St.George's, University of London, UK
| | | | | | | | - Charles H Knowles
- Centre for Digestive Diseases, Barts and the London School of Medicine and Dentistry, London, UK
| | - Daniel Sifrim
- Centre for Digestive Diseases, Barts and the London School of Medicine and Dentistry, London, UK
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Ocak E, Kubat G, Yorulmaz İ. Immunoserologic pepsin detection in the saliva as a non-invasive rapid diagnostic test for laryngopharyngeal reflux. Balkan Med J 2015; 32:46-50. [PMID: 25759771 DOI: 10.5152/balkanmedj.2015.15824] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 11/27/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The most common tool for the diagnosis of laryngopharyngeal reflux (LPR) is still 24-hours esophageal pH monitoring; there is lack of non-invasive, less expensive and accurate diagnostic tools for this frequent disease. AIMS To evaluate the accuracy of immunoserologic pepsin detection in the saliva for the diagnosis of LPR. STUDY DESIGN Cross-sectional study. METHODS A two channeled 24-hour esophageal pH monitoring catheter was placed in patients with a suspicion of LPR. During the 24-hour period, each patient gave one sample of sputum for the immunoserologic pepsin detection test. Pathologic gastroesophageal reflux (GER) findings, LPR findings, pH score in the proximal and distal probes when the sputum sample was given were recorded. The sensitivity, specificity, positive and negative predictive values of the pepsin detection test were analyzed and compared to pH monitoring scores. RESULTS The study group consisted of 20 patients who met the criteria. A positive pepsin detection test was elicited from 6 patients. The sensitivity and specificity of the pepsin detection test was 33% and 100%, respectively. A positive predictive value of 100% was recorded. When the pH results of the pepsin positive patients (PPP) and the rest of the study group in the proximal probe at the sample time were compared, the PPP had an apparent acidic pH value compared to the pepsin negative patients (pH: 3.26 for the PPP, pH: 6.81 for the pepsin negative patients). CONCLUSION Pepsin detection in the saliva is a recent method and becoming increasingly popular. Because of the benefits and ease of application, a positive salivary pepsin test in a patient suspected of having LPR can be a cost effective, accurate and alternative diagnostic method. Increasing the daily number of sputum samples may increase the sensitivity of the test.
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Affiliation(s)
- Emre Ocak
- Department of Otolaryngology-Head and Neck Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gözde Kubat
- Department of Otolaryngology-Head and Neck Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - İrfan Yorulmaz
- Department of Otolaryngology-Head and Neck Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
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Asaoka D, Nagahara A, Matsumoto K, Hojo M, Watanabe S. Current perspectives on reflux laryngitis. Clin J Gastroenterol 2014; 7:471-5. [PMID: 25491904 DOI: 10.1007/s12328-014-0535-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/17/2014] [Indexed: 12/12/2022]
Abstract
Laryngopharyngeal reflux (LPR) is an extraesophageal manifestation of gastroesophageal reflux disease (GERD). With the increase of GERD patients, the importance of LPR is acknowledged widely. However, the pathophysiology of LPR is not understood completely and the diagnostic criteria for LPR remain controversial. Unfortunately, a gold standard diagnostic test for reflux laryngitis is not available. Recently, an experimental animal model for reflux laryngitis was developed to investigate the pathophysiology of reflux laryngitis. An empirical trial of lifestyle modification and proton pump inhibitor therapy is a reasonable approach for LPR symptoms. Alternatives after failure with aggressive medical treatment are limited and multichannel intraluminal impedance and pH monitoring is currently the best alternative to detect nonacid reflux. Additional prospective and evidence-based research is anticipated.
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Affiliation(s)
- Daisuke Asaoka
- Department of Gastroenterology, Juntendo University, School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan,
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Abstract
Patients with salivary gland disease present with certain objective and/or subjective signs. An accurate diagnosis for these patients requires a range of techniques that includes the organized integration of information derived from their history, clinical examination, imaging, serology, and histopathology. This article highlights the signs and symptoms of the salivary gland disorders seen in the Salivary Gland Center, and emphasizes the methodology used to achieve a definitive diagnosis and therapy.
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Affiliation(s)
- Louis Mandel
- Department of Oral and Maxillofacial Surgery, Salivary Gland Center, Columbia University College of Dental Medicine, 630 West 168th Street, New York, NY 10032, USA.
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Komatsu Y, Kelly LA, Zaidi AH, Rotoloni CL, Kosovec JE, Lloyd EJ, Waheed A, Hoppo T, Jobe BA. Hypopharyngeal pepsin and Sep70 as diagnostic markers of laryngopharyngeal reflux: preliminary study. Surg Endosc 2014; 29:1080-7. [PMID: 25159637 DOI: 10.1007/s00464-014-3789-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 07/30/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The management of laryngopharyngeal reflux (LPR) has been challenging. Hypopharyngeal multichannel intraluminal impedance (HMII) has shown to increase the sensitivity in diagnosing LPR. The objective of this study is to investigate the potential use of pepsin and Sep70 as diagnostic tools for detection of LPR in combination with HMII. MATERIALS AND METHODS Tissue samples of hypopharynx, distal esophagus, and gastric cardia were collected from patients with LPR symptoms regardless of gastroesophageal reflux (GERD) diagnosis and underwent HMII to detect LPR and high esophageal reflux (HER: reflux 2 cm distal to upper esophageal sphincter) events. Patients were classified into two groups based on the presence of abnormal proximal exposure (APE), which was defined as LPR ≥1/day and/or HER ≥5/day: (1) positive-APE and (2) negative-APE. Patients with typical GERD symptoms without LPR symptoms who did not undergo HMII were used as a "control" GERD group. Protein was isolated from tissue samples and Western blot analysis of pepsin and Sep70 was performed. Pepsinogen was used as a control to differentiate pepsin from pepsinogen. Relative quantitation was performed using Image Studio Lite Software with normalization against the internal actin of each blot. RESULTS From October 2012 to September 2013, 55 patients underwent HMII. Of 55, 20 patients underwent biopsies from hypopharynx (17 positive-APE and 3 negative-APE). Ten patients with typical GERD symptoms were identified from tissue bank as a "control" GERD group. Pepsin was detected in distal esophagus and hypopharynx in all groups without significant difference among groups. However, Sep70 in distal esophagus and hypopharynx was significantly depleted in the positive-APE group compared to the other groups (p = 0.032 and 0.002, respectively). CONCLUSION Depletion of Sep70 with the presence of pepsin in the hypopharynx may indicate cellular injury in laryngopharynx due to constant proximal reflux. However, the normative data for these markers have to be validated.
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Affiliation(s)
- Yoshihiro Komatsu
- Institute for the Treatment of Esophageal and Thoracic Disease, Allegheny Health Network, Pittsburgh, PA, USA
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81
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Johnston N, Dettmar PW, Strugala V, Allen JE, Chan WW. Laryngopharyngeal reflux and GERD. Ann N Y Acad Sci 2013; 1300:71-79. [PMID: 24117635 DOI: 10.1111/nyas.12237] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In patients with laryngopharygeal reflux (LPR), gastric contents exhibit retrograde flow into the upper aero-digestive tract, causing extraesophageal symptoms including chronic cough, hoarseness, indigestion, difficulty swallowing, globus pharyngis, and asthma. The following on laryngopharyngeal reflux includes commentaries on the use of patient-completed questionaires and anti-human pepsin antibodies and other non-invasive tests in diagnosis; the role of pepsin and acid in the etiologies of laryngeal cancers; and the application of proton pump inhibitor (PPI) therapy for the treatment of LPR.
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Affiliation(s)
- Nikki Johnston
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Peter W Dettmar
- Technostics Ltd, Castle Hill Hospital, Kingston-Upon-Hull, United Kingdom
| | - Vicki Strugala
- Technostics Ltd, Castle Hill Hospital, Kingston-Upon-Hull, United Kingdom
| | - Jacqui E Allen
- Department of Otolaryngology, North Shore Hospital, Auckland, New Zealand
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Cambridge, Massachusetts
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83
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Abstract
Gastroesophageal reflux disease (GERD) is a common disease that is defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms. In addition to the esophageal manifestations of heartburn and regurgitation, the role of GERD in causing extra-esophageal symptoms, such as laryngitis, asthma, cough, chest pain, and dental erosions, is increasingly recognized with renewed interest. Due to the poor sensitivity of endoscopy and pH monitoring, and the poor specificity of laryngoscopy, empiric therapy with proton pump inhibitors (PPI) is now considered the initial diagnostic step in patients suspected of having GERD-related symptoms. In those who are unresponsive to such therapy, other diagnostic testing such as impedance/pH monitoring may be reasonable in order to exclude continued acid or weakly acid reflux. Recent data suggest that patients with extra-esophageal symptoms who have concomitant typical symptoms, moderate-sized hiatal hernia and moderate reflux on pH testing may respond better to acid suppressive therapy. This group only accounts for 20-30 % of patients commonly referred for suspected GERD. PPI-unresponsive patients usually have causes other than GERD for their extra-esophageal signs and symptoms and continued PPI therapy in this group is not recommended.
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84
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Extra-Esophageal Manifestations of Gastroesophageal Reflux Disease: Diagnosis and Treatment. Drugs 2013; 73:1281-95. [DOI: 10.1007/s40265-013-0101-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Ates F, Vaezi MF. Approach to the patient with presumed extraoesophageal GERD. Best Pract Res Clin Gastroenterol 2013; 27:415-31. [PMID: 23998979 DOI: 10.1016/j.bpg.2013.06.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 06/27/2013] [Accepted: 06/28/2013] [Indexed: 01/31/2023]
Abstract
Reflux related cough, asthma and laryngitis are frequently encountered and are considered part of extraoesophageal syndromes. The diagnosis of extraoesophageal reflux is difficult due to the lack of gold standard diagnostic criteria. Esophagogastroduodenoscopy and esophageal pH monitoring are inadequate diagnostic tools for due to poor sensitivity and specificity. For this reason, empirical PPI therapy is recommended as an initial approach to diagnose and treat the potential underlying cause of these symptoms in patients without alarm symptoms. Diagnostic testing with esophageal pH and/or impedance monitoring and esophageal motility testing is usually reserved for those who continue to be symptomatic despite a trial of therapy with PPIs. Recent developments have increased our understanding of this difficult to treat group of patients but more research into reflux related extraoesophageal symptoms are needed to better diagnose and treat this group.
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Affiliation(s)
- Fehmi Ates
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, C2104-MCN Nashville, TN, USA
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86
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Sweis R, Kaufman E, Anggiansah A, Wong T, Dettmar P, Fried M, Schwizer W, Avvari RK, Pal A, Fox M. Post-prandial reflux suppression by a raft-forming alginate (Gaviscon Advance) compared to a simple antacid documented by magnetic resonance imaging and pH-impedance monitoring: mechanistic assessment in healthy volunteers and randomised, controlled, double-blind study in reflux patients. Aliment Pharmacol Ther 2013; 37:1093-102. [PMID: 23600790 DOI: 10.1111/apt.12318] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 03/30/2013] [Accepted: 03/30/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Alginates form a raft above the gastric contents, which may suppress gastro-oesophageal reflux; however, inconsistent effects have been reported in mechanistic and clinical studies. AIMS To visualise reflux suppression by an alginate-antacid [Gaviscon Advance (GA), Reckitt Benckiser, UK] compared with a nonraft-forming antacid using magnetic resonance imaging (MRI), and to determine the feasibility of pH-impedance monitoring for assessment of reflux suppression by alginates. METHODS Two studies were performed: (i) GA and antacid (Alucol, Wander Ltd, Switzerland) were visualised in the stomach after ingestion in 12 healthy volunteers over 30 min after a meal by MRI, with reflux events documented by manometry. (ii) A randomised controlled, double-blind cross-over trial of post-prandial reflux suppression documented by pH-impedance in 20 patients randomised to GA or antacid (Milk of Magnesia; Boots, UK) after two meals taken 24 h apart. RESULTS MRI visualized a "mass" of GA form at the oesophago-gastric junction (OGJ); simple antacid sank to the distal stomach. The number of post-prandial common cavity reflux events was less with GA than antacid [median 2 (0-5) vs. 5 (1-11); P < 0.035]. Distal reflux events and acid exposure measured by pH-impedance were similar after GA and antacid. There was a trend to reduced proximal reflux events with GA compared with antacid [10.5 (8.9) vs. 13.9 (8.3); P = 0.070]. CONCLUSIONS Gaviscon Advance forms a 'mass' close to the OGJ and significantly suppresses reflux compared with a nonraft-forming antacid. Standard pH-impedance monitoring is suitable for clinical studies of GA in gastro-oesophageal reflux disease patients where proximal reflux is the primary outcome.
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Affiliation(s)
- R Sweis
- Department of Gastroenterology, Guys and St Thomas' NHS Foundation Trust, London, UK
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Vandenplas Y. Challenges in the diagnosis of gastroesophageal reflux disease in infants and children. ACTA ACUST UNITED AC 2013; 7:289-98. [PMID: 23581607 DOI: 10.1517/17530059.2013.789857] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The diagnosis of gastroesophageal reflux disease (GERD) is challenging. The wide variation in symptoms is a major reason for the controversies. Since the expression of GERD varies from nonerosive reflux disease over Barrett's esophagus to chronic respiratory disease, it is clear that not one investigation technique will provide an answer in all situations. AREAS COVERED Relevant literature published in PubMed and CINAHL and recent guidelines were collected and reviewed. Diagnostic tests were evaluated by the following criteria: ability to confirm a diagnosis, to exclude other diagnoses with similar presentation, to detect complications, to predict disease severity. EXPERT OPINION Multiple intraluminal impedance (MII) is extensively evaluated in recent years, but other new techniques and measurements were also developed, mainly to diagnose extra-esophageal symptoms. Although evidence for a "relation" between GER and extra-esophageal symptoms is demonstrated, the "causality" between both is not proven. MII measures in a reliable reproducible way non-acid or weakly acid reflux. However, as long as medical therapeutic options are limited to anti-acid medications, MII lacks therapeutic implications, and therefore clinical impact. Since investigations for GER are invasive or cause irradiation, normal ranges cannot be established. As a consequence, the "old" techniques remain the standard diagnostic tools: barium meal for anatomy, endoscopy for esophagitis, and pH monitoring to demonstrate a time relation between (acid) GER and symptoms. MII provides more information than pH monitoring, but is more expensive and has limited therapeutic impact as long as drugs are mainly "anti-acid."
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Affiliation(s)
- Yvan Vandenplas
- Free University of Brussels, Department of Pediatrics, UZ Brussel, Brussels, Belgium.
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Abstract
This article discusses the current state of knowledge regarding the relationship between gastroesophageal reflux disease (GERD) and pulmonary and ear/nose/throat manifestations of reflux and outlines the recent developments in the diagnostic and treatment strategies for this difficult group of patients. Upper gastrointestinal endoscopy and pH monitoring are poorly sensitive for diagnosing reflux in this group of patients. Instead it is recommended that in those without warning symptoms, an empiric trial of proton-pump inhibitors be the initial approach to diagnosing and treating the potential underlying cause of these extraesophageal symptoms.
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