251
|
Pandolfino JE, Richter JE, Ours T, Guardino JM, Chapman J, Kahrilas PJ. Ambulatory esophageal pH monitoring using a wireless system. Am J Gastroenterol 2003; 98:740-9. [PMID: 12738450 DOI: 10.1111/j.1572-0241.2003.07398.x] [Citation(s) in RCA: 327] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Limitations of catheter-based esophageal pH monitoring are discomfort, inconvenience, and interference with normal activity. An alternative to conventional pH monitoring is the wireless Medtronic Bravo pH System. The aim of this study was to evaluate the safety, performance, and tolerability of this system. METHODS A total of 44 healthy subjects and 41 patients with gastroesophageal reflux disease (GERD) were studied for a 2-day period. The pH telemetry capsule was positioned transorally 6 cm above the squamocolumnar junction using endoscopic measurement. The signal transmitted from the capsule was received and recorded by a small, pager-sized receiver, and pH data were subsequently uploaded to a computer for analysis. RESULTS Successful 24-h pH studies were completed in 82 subjects (96%). During the 24-h study period the median percentage of the time that pH was <4 was 2.3% (95th percentile, 5.9%) in controls and 6.5% (range, 0.8-27.6) in GERD patients. In 76 subjects (89%), 36-48 h recordings were obtained. For the extended period the median percentage of the time that pH was <40 was 2.0% (95% percentile, 5.3%) in controls and 6.6% (range, 1.0-26.7) in GERD patients. Capsules required endoscopic removal in three subjects (4%). Optimal sensitivity in distinguishing controls from reflux patients was achieved when analyzed from the perspective of the worst of the 2 days. CONCLUSIONS The wireless Bravo pH System successfully recorded esophageal acid exposure in 96% of the patients during a 24-h period and in 89% of subjects for >36 h. The 95th percentile for the 2-day recordings in control subjects was 5.3%, slightly higher than observed with conventional systems.
Collapse
Affiliation(s)
- John E Pandolfino
- Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611-3008, USA
| | | | | | | | | | | |
Collapse
|
252
|
Zentilin P, Iiritano E, Vignale C, Bilardi C, Mele MR, Spaggiari P, Gambaro C, Dulbecco P, Tessieri L, Reglioni S, Mansi C, Mastracci L, Vigneri S, Fiocca R, Savarino V. Helicobacter pylori infection is not involved in the pathogenesis of either erosive or non-erosive gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2003; 17:1057-64. [PMID: 12694088 DOI: 10.1046/j.1365-2036.2003.01547.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The majority of reflux patients have non-erosive reflux disease. AIM To evaluate the influence of Helicobacter pylori on oesophageal acid exposure in patients with both non-erosive and erosive reflux disease and in a group of controls. The pattern and distribution of chronic gastritis were also assessed. METHODS One hundred and twelve consecutive patients with symptoms of gastro-oesophageal reflux disease agreed to undergo both upper gastrointestinal endoscopy and 24-h oesophageal pH-metry. Patients were grouped as H. pylori-positive or H. pylori-negative on the basis of both CLO-test and histology, and as cases with or without oesophagitis on the basis of endoscopy. The controls consisted of 19 subjects without reflux symptoms and with normal endoscopy and oesophageal pH-metry. RESULTS H. pylori was positive in 35 patients (31%) and in six controls (31%); oesophagitis was found in 44 patients (39%) and non-erosive reflux disease in 68 (61%). The prevalence of chronic gastritis in the antrum and corpus was higher in H. pylori-positive than in H. pylori-negative patients (P < 0.001), but was more frequently mild (P < 0.001) than moderate or severe. The percentage total time the oesophageal pH < 4.0 was higher in patients than in controls (P < 0.008-0.001), but there was no difference between H. pylori-positive and H. pylori-negative patients (12.3% vs. 12%, P = 0.43) or H. pylori-positive and H. pylori-negative controls (1.07% vs. 1.47%, P = 0.19). CONCLUSIONS H. pylori infection had the same prevalence in reflux patients and in controls. It did not affect oesophageal acid exposure, as there was no difference between H. pylori-positive and H. pylori-negative individuals. The high prevalence of mild body gastritis in H. pylori-positive patients suggests that H. pylori eradication is unlikely to lead to gastric functional recovery, which might precipitate or worsen symptoms and lesions in patients with gastro-oesophageal reflux disease.
Collapse
Affiliation(s)
- P Zentilin
- Dipartimento di Medicina Interna, Università di Genova, Genova, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
253
|
|
254
|
Aksglaede K, Funch-Jensen P, Thommesen P. Intra-esophageal pH probe movement during eating and talking. A videoradiographic study. Acta Radiol 2003. [PMID: 12694094 DOI: 10.1034/j.1600-0455.2003.00033.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To registrate the oscillations of the pH probe in the esophagus during phonation and swallowing in the erect and supine positions. MATERIAL AND METHOD Sixty-seven patients with suspicion of gastroesophageal reflux disease underwent manometry, 24-h pH monitoring, and videoradiography. In 43 patients the effect of dry, wet, and solid swallows in the erect and supine positions was determined, making a total of 258 swallows. In another 24 patients the effect of pH probe movement during phonation was studied. RESULTS During every swallow the probe moved in the proximal direction from 0.5 to 2.0 cm, returned to baseline, and in 48 swallows an additional descendent movement of up to 2.0 cm was seen, the last mentioned more pronounced during solid swallows. In the erect position, no significant difference was observed for the different swallowing types, whereas in the supine position, movements were significantly more pronounced during solid food swallows. During phonation the pH probe only ascended and returned to the baseline, with no descending part. CONCLUSION The pH probe movements are dependent on body position, bolus size, bolus composition, and talking. The ascending movements can only partially compensate for the esophageal shortening during swallow because of the time difference, and could perhaps explain the variation in results and reproducibility of 24-h pH monitoring.
Collapse
Affiliation(s)
- K Aksglaede
- Motility Laboratory, Aarhus University Hospital, Aarhus, Denmark.
| | | | | |
Collapse
|
255
|
Aksglaede K, Funch-Jensen P, Thommesen P. Which is the better method for location of the gastro-esophageal junction: radiography or manometry? Acta Radiol 2003. [PMID: 12694092 DOI: 10.1034/j.1600-0455.2003.00031.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE To evaluate whether location of the gastro-esophageal junction (GEJ) could be determined with the same accuracy on radiography as by manometry with special reference to pH probe positioning. MATERIAL AND METHODS Ninety patients with suspected esophageal motility disorders underwent simultaneous manometry and video-radiography. The lower esophageal sphincter pressure (LESP) and location was determined, and pressure recordings were made in the body of the esophagus. The GEJ and any structural changes were diagnosed on radiography during single-barium swallows and continuous barium drinking. Simultaneous radiographic and manometric investigations were performed with the pressure-catheter placed 5 cm proximal to the superior border of the GEJ located by manometry, and the distance to the radiographically determined superior border could be measured directly on the videotapes using a radiopaque metric ruler placed under the patient. RESULTS On radiography, the GEJ proved to be situated < 2 cm distally as compared to its location determined by manometry in 95.6% of the patients, and the maximal difference was 2.5 cm. The LESP or structural changes had no significant influence on the results. CONCLUSION The variation of location of GEJ on radiography as compared with manometric findings was sufficiently small to accept both methods as valid in the positioning of the pH probe properly.
Collapse
Affiliation(s)
- K Aksglaede
- Motility Laboratory, Aarhus University Hospital, Aarhus, Denmark.
| | | | | |
Collapse
|
256
|
Zentilin P, Dulbecco P, Bilardi C, Gambaro C, Iiritano E, Biagini R, Mela GS, Tessieri L, Mele MR, Mansi C, Pandolfo N, Vigneri S, Savarino V. Circadian pattern of intragastric acidity in patients with non-erosive reflux disease (NERD). Aliment Pharmacol Ther 2003; 17:353-9. [PMID: 12562447 DOI: 10.1046/j.1365-2036.2003.01422.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
BACKGROUND Most patients with gastro-oesophageal reflux disease have non-erosive reflux disease. Proton pump inhibitors are less effective than expected in these patients, but no previous study has measured their 24-h gastric pH values. AIMS To evaluate whether there are differences in 24-h intragastric acidity between reflux patients with and without oesophagitis and controls. The influence of Helicobacter pylori on the gastric pH of reflux patients was also assessed. METHODS Sixty-three consecutive patients with gastro-oesophageal reflux disease symptoms who agreed to undergo endoscopy and 24-h pH-metry were recruited. Twenty-five (39%) had erosive oesophagitis and 38 (61%) did not. H. pylori was diagnosed by CLO test, histology and 13C-urea breath test. Gastric pH was also measured in 30 controls without digestive symptoms. RESULTS H. pylori was found in seven of the 25 (28%) patients with oesophagitis and 14 of the 38 (37%) patients with non-erosive reflux disease. Oesophageal pH-metry was abnormal in 21 of the 25 (84%) patients with oesophagitis and in 32 of the 38 (84%) patients with non-erosive reflux disease. The median gastric pH did not differ between patients with and without oesophagitis or between them and controls during the 24 h (P = 0.8) and other time intervals (P = 0.2-0.4). The gastric pH did not differ between infected and non-infected patients with oesophagitis (P = 0.2-0.4) or non-erosive reflux disease (P = 0.3-0.8). CONCLUSIONS The circadian pattern of intragastric acidity does not differ between patients with non-erosive reflux disease and oesophagitis. Moreover, the study confirms that H. pylori infection does not affect the gastric pH in either group of reflux patients.
Collapse
Affiliation(s)
- P Zentilin
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Genova, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
257
|
Smit CF, Mathus-Vliegen LMH, Devriese PP, van Leeuwen JAMJ, Semin A. Monitoring of laryngopharyngeal reflux: influence of meals and beverages. Ann Otol Rhinol Laryngol 2003; 112:109-12. [PMID: 12597282 DOI: 10.1177/000348940311200202] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ambulatory 24-hour double-probe pH monitoring seems to be the best test to measure reflux. Artifacts caused by intake of acid foods and beverages have to be excluded, necessitating a time-consuming manual review of the 24-hour data. Dietary restrictions used to bypass these artifacts would interfere with the normal daily life situation. Therefore, the influence of food and beverages ingested during the monitoring period was studied. Data from 252 patients who underwent double-probe pH monitoring were analyzed, first by visual inspection of the 24-hour tracing and second by leaving out the intake periods. As to the registration of gastroesophageal reflux, the inclusion or omission of meals and beverages hardly influenced the data. However, the registration of laryngopharyngeal reflux was severely biased by intake of food and beverages and other artifacts. Leaving out meals and beverages did not correct for all artifacts. Therefore, we recommend review of each laryngopharyngeal pH drop.
Collapse
Affiliation(s)
- Conrad F Smit
- Department of Otorhinolaryngology-Head and Neck Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | | | | |
Collapse
|
258
|
Fox VL, Nurko S, Teitelbaum JE, Badizadegan K, Furuta GT. High-resolution EUS in children with eosinophilic "allergic" esophagitis. Gastrointest Endosc 2003; 57:30-6. [PMID: 12518127 DOI: 10.1067/mge.2003.33] [Citation(s) in RCA: 203] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The pathophysiology of dysphagia associated with eosinophilic esophagitis is unknown. This study investigated possible anatomic alterations in children with eosinophilic esophagitis in comparison with healthy children by using high-resolution EUS to precisely measure individual tissue layers of the esophagus. METHODS Children with eosinophilic esophagitis (n = 11) and control children (n = 8) without esophagitis were prospectively evaluated by high-resolution EUS with a 20-MHz catheter US probe during an endoscopic examination. Real-time measurements of the distal esophagus were obtained including the thickness of the total wall, combined mucosa and submucosa, muscularis propria, and circular muscle. RESULTS Statistically significant differences were found between patients with eosinophilic esophagitis and control patients for mean values for thickness of the total wall (respectively, 2.8 vs. 2.1 mm; p = 0.004), combined mucosa and submucosa (respectively, 1.6 vs. 1.1 mm; p = 0.001), and muscularis propria (respectively, 1.2 vs. 1.0 mm; p = 0.043). Mean values for circular muscle did not differ between patient groups. CONCLUSION High-resolution EUS reveals significant expansion of the esophageal wall and individual tissue layers including the combined mucosa and submucosa, and muscularis propria in children with eosinophilic esophagitis compared with healthy control patients.
Collapse
Affiliation(s)
- Victor L Fox
- Division of Gastroenterology and Nutrition, Department of Pediatrics, Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | |
Collapse
|
259
|
Assimakopoulos D, Patrikakos G. The role of gastroesophageal reflux in the pathogenesis of laryngeal carcinoma. Am J Otolaryngol 2002; 23:351-7. [PMID: 12430127 DOI: 10.1053/ajot.2002.128038] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Gastroesophageal reflux (GER) has been strongly associated with carcinogenesis of the lower esophagus and development of several otolaryngologic disorders. Epidemiologic studies support concept that the malignant transformation of laryngeal mucosal surfaces is due to GER-initiated chronic laryngeal inflammation. However, large clinical studies with matched control groups and further experimental investigations are necessary to ascertain the relationship between reflux and laryngeal carcinoma. This review stresses that early diagnosis of GER disease, based on clinical suspicion, ambulatory 24-hour double-probe pH monitoring, and endoscopic examination, as well as effective treatment of reflux, are considered the keys for relief of symptomatology and preventing the chronic irritation of the laryngeal mucosa that may contribute to the development of laryngeal carcinoma.
Collapse
Affiliation(s)
- Dimitrios Assimakopoulos
- Department of Otorhinolaryngology, University of Ioannina Medical School, Ioannina 45110, Greece
| | | |
Collapse
|
260
|
Tack J, Janssens J. Functional Heartburn. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2002; 5:251-258. [PMID: 12095472 DOI: 10.1007/s11938-002-0047-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Functional heartburn is defined as the presence of a retrosternal burning sensation in the absence of pathologic gastroesophageal reflux. The underlying pathophysiology seems to be heterogeneous. In a subset of patients, esophageal hypersensitivity to physiologic esophageal acid exposure is involved, and this is likely to respond to intensive antireflux treatment. Antireflux surgery was not studied systematically in these patients and should be considered only in exceptional cases. In the remaining patients, non-acid reflux, esophageal mechanosensitivity, and psychological factors may be involved. Treatment options in these patients are limited owing to a lack of studies. Emerging therapies include selective serotonin reuptake inhibitors and relaxation therapy.
Collapse
Affiliation(s)
- Jan Tack
- Department of Internal Medicine, Division of Gastroenterology, University Hospital, Gasthuisberg, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | | |
Collapse
|
261
|
Cekin AH, Boyacioglu S, Gursoy M, Bilezikci B, Gur G, Akin ED, Ozdemir N, Yilmaz U. Gastroesophageal reflux disease in chronic renal failure patients with upper GI symptoms: multivariate analysis of pathogenetic factors. Am J Gastroenterol 2002; 97:1352-6. [PMID: 12094849 DOI: 10.1111/j.1572-0241.2002.05772.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The association between gastroesophageal reflux disease and end-stage renal disease remains unclear. We aimed to assess the prevalence of gastroesophageal reflux disease and also to identify possible pathogenetic factors in the development of reflux in symptomatic end-stage renal disease patients. METHODS The study involved 42 end-stage renal disease patients with upper GI symptoms (group I) and 46 age- and sex-matched controls who did not have renal disease but had the same symptoms (group II). Endoscopy, endoscopic biopsies, and 24-h esophageal pH studies were used to diagnose gastroesophageal reflux disease. Subjects were also investigated for Helicobacter pylori gastritis and GI amyloidosis. RESULTS The prevalences of gastroesophageal reflux disease in the two groups were similar (81% vs 84.8%, p = 0.423). The prevalence of H. pylori infection was significantly lower in group I than in group II (38.1% vs 67.4%, p = 0.01). There were II cases of GI amyloidosis in group I. Multivariate logistic regression analysis in group I showed that GI amyloidosis (OR = 7.28, 95% CI = 1.13-46.93), chronic ambulatory peritoneal dialysis treatment (OR = 5.54, 95% CI = 1.01-30.43), and absence of H. pylori infection (OR = 3.75, 95% CI = 1.01-13.9) were significantly associated with reflux esophagitis. CONCLUSIONS Upper GI symptoms are important in predicting gastroesophageal reflux disease in end-stage renal disease patients. Chronic ambulatory peritoneal dialysis, GI amyloidosis, and absence of H. pylori infection seem to be risk factors for the development of gastroesophageal reflux disease in end-stage renal disease patients.
Collapse
Affiliation(s)
- Ayhan Hilmi Cekin
- Department of Gastroenterology, Baskent University School of Medicine, Ankara, Turkey
| | | | | | | | | | | | | | | |
Collapse
|
262
|
Teitelbaum JE, Fox VL, Twarog FJ, Nurko S, Antonioli D, Gleich G, Badizadegan K, Furuta GT. Eosinophilic esophagitis in children: immunopathological analysis and response to fluticasone propionate. Gastroenterology 2002; 122:1216-25. [PMID: 11984507 DOI: 10.1053/gast.2002.32998] [Citation(s) in RCA: 347] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis (EE) shares symptoms with gastroesophageal reflux disease but has distinctive pathologic features and unknown immunopathology. Treatments with antigen restriction or systemic immunosuppression pose problems with compliance and side effects. Topically applied steroids offer an attractive alternative treatment. The aims of this study were to determine the immunopathologic features of EE and the effectiveness of antigen-specific diet restriction (DR) and topical immunosuppression. METHODS A prospective trial was conducted examining the impact of DR and swallowed fluticasone propionate (FP) on pediatric patients with EE. Clinicopathologic features, including immunohistochemical analysis of the esophageal mucosa, were measured before and after treatment. RESULTS Immunohistochemical analysis of 11 prospectively identified children showed a significantly greater number of mucosal CD3 and CD8 lymphocytes, as well as CD1a antigen-presenting cells compared with normal controls. DR did not induce clinical improvement in any patients, whereas all children who completed treatment with FP had resolution of symptoms. Posttreatment analysis of proximal and distal esophageal mucosa showed a significant reduction in the number of eosinophils, as well as CD3(+) and CD8(+) lymphocytes compared with pretreatment sections. CONCLUSIONS EE is characterized by immunologically active esophageal mucosa. FP, not DR, effectively relieves symptoms. FP significantly reduces mucosal inflammation associated with EE.
Collapse
Affiliation(s)
- Jonathan E Teitelbaum
- Pediatric Gastroenterology and Nutrition, Department of Pathology, and Division of Allergy and Immunology, Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | |
Collapse
|
263
|
De Diego Damiá A, Plaza Moral V, Garrigues Gil V, Izquierdo Alonso JL, López Viña A, Mullol Miret J, Pereira Vega A. [Chronic cough]. Arch Bronconeumol 2002; 38:236-45. [PMID: 12028932 DOI: 10.1016/s0300-2896(02)75201-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
264
|
Ylitalo R, Ramel S. Extraesophageal reflux in patients with contact granuloma: a prospective controlled study. Ann Otol Rhinol Laryngol 2002; 111:441-6. [PMID: 12018329 DOI: 10.1177/000348940211100509] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The aim of this study was to compare the incidences of extraesophageal reflux in patients with contact granuloma and healthy controls. A 24-hour ambulatory pH monitoring technique was used to measure reflux parameters in the pharynx and distal esophagus. Pharyngeal acid reflux events occurred in 17 of 26 granuloma patients (1 to 20 episodes per patient) and 5 of 19 controls (1 to 8 episodes per subject). The reflux episodes were typically short and occurred predominantly in an upright position. A comparison between the groups showed a significant difference in the number of pharyngeal reflux episodes (p = .009) and in the total time of pH below 4 (p = .006). On the other hand, we found no significant differences in any esophageal reflux parameters, except for the percentage of distal esophageal reflux episodes that reached the pharynx (p = .006). In this study, pharyngeal acid exposure was significantly more prevalent in patients with contact granuloma than in healthy controls.
Collapse
Affiliation(s)
- Riitta Ylitalo
- Department of Logopedics and Phoniatrics, Huddinge University Hospital, Stockholm, Sweden
| | | |
Collapse
|
265
|
Zentilin P, Conio M, Mele MR, Mansi C, Pandolfo N, Dulbecco P, Gambaro C, Tessieri L, Iiritano E, Bilardi C, Biagini R, Vigneri S, Savarino V. Comparison of the main oesophageal pathophysiological characteristics between short- and long-segment Barrett's oesophagus. Aliment Pharmacol Ther 2002; 16:893-8. [PMID: 11966497 DOI: 10.1046/j.1365-2036.2002.01237.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIM To assess the oesophageal manometric characteristics and 24-h pH profiles of patients with both short-segment and long-segment Barrett's oesophagus and compare them with those of patients with reflux oesophagitis and controls. METHODS Seventy-nine patients who had undergone upper digestive endoscopy were recruited: 16 had short-segment Barrett's oesophagus, 13 had long-segment Barrett's oesophagus, 25 had grade III oesophagitis according to the Savary-Miller classification and 25 were used as controls. The diagnosis of Barrett's oesophagus was based on the histological detection of specialized intestinal metaplasia, which extended < 3 cm into the oesophagus in patients with short-segment disease and > 3 cm in patients with long-segment disease. All subjects underwent oesophageal manometry and basal 24-h oesophageal pH monitoring. RESULTS The lower oesophageal sphincter pressure was significantly lower in patients with reflux oesophagitis and short-segment and long-segment Barrett's oesophagus than in controls (P=0.0004-0.0001), but there was no difference among the three reflux groups. The peristaltic wave amplitude of patients with long-segment Barrett's oesophagus was significantly lower than that of controls (P=0.002) and patients with short-segment Barrett's oesophagus (P=0.02), but was no different from that of patients with reflux oesophagitis. The percentage of non-propagated wet swallows was significantly higher in patients with reflux oesophagitis and short-segment and long-segment Barrett's oesophagus when compared with that of controls (P=0.0004-0.0001). The total percentage of time the oesophagus was exposed to pH < 4.0 was significantly higher in patients with reflux oesophagitis and short-segment and long-segment Barrett's oesophagus (P=0.0001) than in controls, and was higher in patients with long-segment disease than in those with short-segment disease (P=0.01). CONCLUSIONS Long-segment Barrett's oesophagus is characterized by a greater impairment of peristaltic wave amplitude and a higher oesophageal acid exposure than is short-segment Barrett's oesophagus. However, both forms are linked to increased acid reflux.
Collapse
Affiliation(s)
- P Zentilin
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Genova, Genova, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
266
|
Wu JCY, Chan FKL, Ching JYL, Leung WK, Lee YT, Sung JJY. Empirical treatment based on "typical" reflux symptoms is inappropriate in a population with a high prevalence of Helicobacter pylori infection. Gastrointest Endosc 2002; 55:461-5. [PMID: 11923754 DOI: 10.1067/mge.2002.122617] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Empirical therapy or early endoscopy have been recommended as acceptable management options for GERD. The objective of this study was to determine whether diagnosis and empirical treatment based on reflux symptoms alone are appropriate as initial management for patients with gastroesophageal reflux. METHOD Consecutive patients presenting with weekly reflux symptoms were evaluated with a structured questionnaire followed by endoscopy. Patients with dyspepsia as the predominant symptom, "alarm" symptoms (weight loss, dysphagia, or bleeding), history of peptic ulcer or gastric surgery, or recent nonsteroidal anti-inflammatory drugs intake were excluded. RESULTS Four hundred sixty patients were studied: 82 (18%) were found to have peptic ulcer disease and 78 (95%) were infected with Helicobacter pylori. Concomitant erosive esophagitis was found in 26 (32%) of these patients with peptic ulcer disease. In the remaining 378 patients, 218 (58%) had erosive esophagitis and 1 had esophageal cancer. Among the 159 patients with no endoscopic lesion, 148 (93%) had relief of symptoms when treated with a proton pump inhibitor. Multivariate analysis showed that male gender (OR: 1.8, p = 0.03), age greater than 60 years (OR: 2.2, p = 0.01) and H pylori infection (OR: 3.6, p = 0.008) were significantly associated with a diagnosis of peptic ulcer disease. Coexisting dyspeptic symptom was not a predictor (p = 0.13) for peptic ulcer disease. CONCLUSIONS In populations with a high prevalence of H pylori infection, a significant proportion of patients with GERD have concomitant peptic ulcer disease. Empirical treatment based on "typical" GERD symptoms alone may not be appropriate.
Collapse
Affiliation(s)
- Justin C Y Wu
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | | | | | | | | | | |
Collapse
|
267
|
Abstract
Symptomatic gastroesophageal reflux disease (GERD) is a common problem that affects a substantial proportion of the American population. It is estimated that the symptoms of GERD may afflict 40% to 45% of Americans each month. The diagnosis of GERD can be difficult, as its symptoms vary from typical symptoms like heartburn to atypical symptoms such as hoarseness, coughing, and chest pain. Most patients present with typical symptoms and are diagnosed with GERD if they respond to empiric trials of acid suppression. Many tests are available to help with diagnosing GERD in patients who either present with atypical symptoms or who do not respond to acid suppression; however, each test has its own shortcomings. The only test that directly measures whether acid is refluxing into the esophagus is the pH probe, but this test is uncomfortable for the patient, can be difficult to interpret, and may not be necessary in all cases. This article reviews the indications for pH monitoring, its technique, its advantages and limitations, and its role the diagnosis of GERD.
Collapse
Affiliation(s)
- Babak Sarani
- Department of Surgery, George Washington University Medical Center, Washington, DC 20037, USA
| | | | | |
Collapse
|
268
|
Wu JCY, Chan FKL, Wong SKH, Lee YT, Leung WK, Sung JJY. Effect of Helicobacter pylori eradication on oesophageal acid exposure in patients with reflux oesophagitis. Aliment Pharmacol Ther 2002; 16:545-52. [PMID: 11876709 DOI: 10.1046/j.1365-2036.2002.01189.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The effect of Helicobacter pylori eradication on reflux oesophagitis is unclear. AIM To study the effect of H. pylori eradication on oesophageal acid exposure and disease severity in patients with reflux oesophagitis. METHODS Patients with reflux oesophagitis and H. pylori infection were recruited for 24-h oesophageal pH-metry. They were then randomly assigned to receive either treatment for H. pylori eradication (1-week omeprazole-based triple therapy, followed by 7-week omeprazole) or omeprazole alone (8-week omeprazole). Uninfected patients were recruited as controls. Endoscopy, pH monitoring and symptom assessment were repeated at 26 weeks. RESULTS Forty patients (25 H. pylori-positive and 15 uninfected) with erosive oesophagitis were studied. Fourteen were randomized to receive treatment for H. pylori eradication and 11 to receive omeprazole alone. There was no difference in the percentage of time the oesophageal pH < 4 before and 26 weeks after treatment among the three groups. However, the percentage of time the oesophageal pH < 2 (P=0.01) and pH < 3 (P=0.02) was significantly increased in patients receiving treatment for H. pylori eradication. Three (21%) patients in the group receiving treatment for H. pylori eradication had worsening of reflux oesophagitis. CONCLUSIONS H. pylori eradication increases oesophageal acid exposure and may adversely affect the clinical course of reflux disease in a subset of patients.
Collapse
Affiliation(s)
- J C Y Wu
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
| | | | | | | | | | | |
Collapse
|
269
|
Marzo M, Alonso P, Bonfill X, Fernández M, Ferrandiz J, Martínez G, Mearín F, Mascort JJ, Piqué JM, Ponce J, Sáez M. [Clinical practice guideline on the management of patients with gastroesophageal reflux disease (GERD)]. GASTROENTEROLOGIA Y HEPATOLOGIA 2002; 25:85-110. [PMID: 11841764 DOI: 10.1016/s0210-5705(02)70245-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- M Marzo
- Centro Cochrane Iberoamericano, Casa de la Convalecencia, Sant Antoni, Barcelona Spain
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
270
|
Moraes-Filho J, Cecconello I, Gama-Rodrigues J, Castro L, Henry MA, Meneghelli UG, Quigley E. Brazilian consensus on gastroesophageal reflux disease: proposals for assessment, classification, and management. Am J Gastroenterol 2002; 97:241-8. [PMID: 11866257 DOI: 10.1111/j.1572-0241.2002.05476.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The Brazilian Consensus on Gastroesophageal Reflux Disease considers gastroesophageal reflux disease to be a chronic disorder related to the retrograde flow of gastroduodenal contents into the esophagus and/or adjacent organs, resulting in a variable spectrum of symptoms, with or without tissue damage. Considering the limitations of classifications currently in use, a new classification is proposed that combines three criteria-clinical, endoscopic, and pH-metric-providing a comprehensive and more complete characterization of the disease. The diagnosis begins with the presence of heartburn, acid regurgitation, and alarm manifestations (dysphagia, odynophagia, weight loss, GI bleeding, nausea and/or vomiting, and family history of cancer). Also, atypical esophageal, pulmonary, otorhinolaryngological, and oral symptoms may occur. Endoscopy is the first approach, particularly in patients over 40 yr of age and in those with alarm symptoms. Other exams are considered in particular cases, such as contrast radiological examination, scyntigraphy, manometry, and prolonged pH measurement. The clinical treatment encompasses behavioral modifications in lifestyle and pharmacological measures. Proton pump inhibitors in manufacturers' recommended doses are indicated, with doubling of the dose in more severe cases of esophagitis. The minimum time of administration is 6 wk. Patients who do not respond to medical treatment, including those with atypical manifestations, should be considered for surgical treatment. Of the complications of gastroesophageal reflux disease, Barrett's esophagus presents a potential development of adenocarcinoma; biopsies should be performed, independent of Barrett's esophagus extent or location. In this regard the designation "short Barrett's" is not important in terms of management and prognosis.
Collapse
|
271
|
Ofman JJ, Dorn GH, Fennerty MB, Fass R. The clinical and economic impact of competing management strategies for gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2002; 16:261-73. [PMID: 11860409 DOI: 10.1046/j.1365-2036.2002.01167.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastro-oesophageal reflux disease (GERD) is a common disorder in the primary care setting. Traditional management strategies consist of sequentially intensive therapeutic trials followed by invasive diagnostic testing for nonresponders. A high dose proton pump inhibitor trial (the "proton pump inhibitor test") has been shown to be an accurate diagnostic alternative, and may be an efficient initial approach to patients with GERD symptoms. AIM To examine the clinical, economic and policy implications of alternative management strategies for GERD. METHODS Decision analysis was used to calculate the clinical and economic outcomes of competing management strategies. The traditional strategy incorporates sequential therapeutic trials with more intensive therapy ("step-up" approach) followed by sequential invasive diagnostic testing of nonresponders. The "proton pump inhibitor test" strategy includes an initial "proton pump inhibitor test" (7 days of omeprazole; 40 mg AM + 20 mg PM daily) followed by less intensive therapeutic trials in those testing positive ("step-down" approach) with sequential invasive diagnostic testing as needed. Cost estimates were based on Medicare reimbursement and average wholesale drug prices. Probability estimates were derived from a systematic review of the published medical literature. Model results are reported as the average and incremental cost-per-symptom free patient and cost-per-quality-adjusted life-years (QALYs) gained. RESULTS The average cost per patient was 1045 US dollars for the traditional step-up management strategy, compared to 1172 US dollars for the "proton pump inhibitor test" and step-down strategy. The percentage of patients who were symptom-free at 1 year was 50% for the traditional management strategy compared to 75% for the "proton pump inhibitor test" strategy. The "proton pump inhibitor test" strategy results in QALY gains of 0.01-0.05 depending on the utility estimate employed. The incremental cost-effectiveness ratio for the "proton pump inhibitor test" strategy is 510 US dollars per additional symptomatic cure over 1 year, and between 2822-10,160 US dollars per QALY gained. The traditional management strategy resulted in a greater than 5-fold increase in the utilization of upper endoscopy, which was partially offset by a 47% reduction in the use of ambulatory 24-h oesophageal pH monitoring. The reduced effectiveness of the traditional management strategy may be attributed in part to a 118% increase in the use of "high-dose" H2RAs while reducing the use of standard dose proton pump inhibitors by only 42% and "high-dose" proton pump inhibitors by 57%. CONCLUSIONS Based on the results of this analysis, strategies utilizing the initial PPI test followed by a "step-down" approach may result in improved symptom relief and quality of life over 1 year, and more appropriate utilization of invasive diagnostic testing at a small marginal increase in total costs. These findings warrant a prospective trial comparing these competing management strategies.
Collapse
Affiliation(s)
- Joshua J Ofman
- Departments of Medicine and Health Services Research, Division of Gastroenterology, Cedars-Sinai Health System, Los Angeles, CA, USA
| | | | | | | |
Collapse
|
272
|
Ylitalo R, Ramel S. Gastroesophagopharyngeal reflux in patients with contact granuloma: a prospective controlled study. Ann Otol Rhinol Laryngol 2002; 111:178-83. [PMID: 11860073 DOI: 10.1177/000348940211100213] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study was to compare the incidences of gastroesophagopharyngeal reflux in patients with contact granuloma and healthy controls. A 24-hour ambulatory esophagopharyngeal pH monitoring technique was used to measure reflux parameters in the pharynx and distal esophagus. Pharyngeal acid reflux events occurred in 17 of 26 granuloma patients (1 to 20 episodes per patient) and 5 of 19 controls (1 to 8 episodes per patient). The reflux episodes were typically short and occurred predominantly in an upright position. A comparison between the groups showed a significant difference in the number of pharyngeal reflux episodes (p = .009) and in the total time of pH below 4 (p = .006). On the other hand, we found no significant differences in any esophageal reflux parameters, except for the percentage of distal esophageal reflux episodes that reached the pharynx (p = .006). In this study, pharyngeal acid exposure was significantly more prevalent in patients with contact granuloma than in healthy controls.
Collapse
Affiliation(s)
- Riitta Ylitalo
- Department of Logopedics and Phoniatrics, Huddinge University Hospital and Karolinska Institute, Stockholm, Sweden
| | | |
Collapse
|
273
|
Abstract
GOALS Review of research directions in the etiology, evaluation, and treatment of patients with noncardiac chest pain. The author proposes a combined practical approach to noncardiac chest pain that incorporates these findings, which is useful in a clinical practice setting. BACKGROUND Several major schools of thought have emerged in the etiology of noncardiac chest pain: acid reflux, motor disorder, altered pain threshold/hypersensitivity, and association with psychiatric dysfunction. There is significant overlap among these. Occult gastroesophageal reflux disease (GERD) is more common than motor disorders and is found in 30% to 40% of these patients; a subset has hypersensitivity, with a normal pH profile. Esophageal motility testing and endoscopy have a more limited role than 24-hour pH testing. Impedance planimetry and balloon sensory provocative testing remain research tools. Provocative testing with hydrochloric acid or edrophonium is less helpful than pH monitoring. Gastroesophageal reflux disease-induced chest pain requires high-dose long-term proton pump inhibitors (PPIs): at least 4 to 8 weeks. Psychotropics are superior to placebo, both in patients with and without psychiatric dysfunction. RESULTS The author found combined PPIs and psychotropics helpful in patients with esophageal hypersensitivity and GERD, although supporting data is scant. CONCLUSIONS A brief 1-week high-dose PPI challenge, i.e., omeprazole test, may be cost-effective in a primary care setting. However, this approach may not be useful in a referral setting, where pH data and diary assessment of associated symptoms provide useful management help. A behavioral model approach, with early emphasis on patient education, integrated with physiologic data helps the most.
Collapse
Affiliation(s)
- V Alin Botoman
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida 33331, USA.
| |
Collapse
|
274
|
Ouatu-Lascar R, Lin OS, Fitzgerald RC, Triadafilopoulos G. Upright versus supine reflux in gastroesophageal reflux disease. J Gastroenterol Hepatol 2001; 16:1184-90. [PMID: 11903733 DOI: 10.1046/j.1440-1746.2001.02581.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postural measures are early recommendations in the management of heartburn, and are aimed at preventing acid reflux through an incompetent lower esophageal sphincter (LES). However, LES incompetence is found in only a minority of patients, and transient LES relaxations, primarily in the upright position, are currently recognized as the main pathophysiological abnormality in gastroesophageal reflux disease (GERD). We investigated the importance of supine acid reflux in patients with GERD. METHODS Upon review of their clinical, manometric, pH monitoring and endoscopic characteristics, 85 patients with reflux symptoms were classified into three groups: Group A (n=22), consisting of symptomatic patients without esophagitis or pathological reflux; group B (n=38), symptomatic patients with reflux but no endoscopic esophagitis; and group C (n=25), symptomatic patients with both ulcerative or complicated esophagitis and pathological reflux. RESULTS All groups were similar in age distribution. Groups B and C had a higher prevalence of hiatal hernia and reflux symptoms. Manometry revealed similar LES pressures in groups A and B, but lower LES pressure in group C (P < 0.005). In groups A and B, supine reflux, in terms of percentage of time with pH < 4, was less pronounced than upright reflux (P < 0.0001). In contrast, group C supine reflux was as pronounced as the upright reflux. CONCLUSIONS The majority of patients reflux in the upright position. Only patients with complicated esophagitis have significant bipositional acid reflux. These findings suggest that unless the patient has severe reflux disease, postural measures may not be indicated.
Collapse
Affiliation(s)
- R Ouatu-Lascar
- Gastroenterology Section, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, USA
| | | | | | | |
Collapse
|
275
|
Kaynard A, Flora K. Gastroesophageal reflux disease. Control of symptoms, prevention of complications. Postgrad Med 2001; 110:42-4, 47-8, 51-3. [PMID: 11570205 DOI: 10.3810/pgm.2001.09.1017] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
GERD is a common disease that has a significant impact on patients' quality of life. Many surveys have shown that up to 60% of the population suffers from GERD at some time. Heartburn and acid regurgitation are the classic symptoms, but manifestations are variable. Of the several extraesophageal manifestations of GERD, reflux-induced asthma may be the most important. Complications of GERD include peptic strictures of the esophagus and Barrett's metaplasia. Clinical diagnosis of GERD can be confirmed by response to antisecretory therapy. A high-dose trial of a PPI is becoming an accepted diagnostic technique for uncomplicated mild or moderate GERD. Endoscopic examination and ambulatory esophageal pH monitoring still have a role in the evaluation of severe GERD or when other diseases are suspected. Lifestyle changes rarely are beneficial, and antisecretory therapy remains the mainstay of GERD treatment. PPIs have been shown to be more effective than H2 blockers. Antireflux surgery is indicated in some patients. Healing of esophagitis can take up to 8 weeks; failure to control symptoms necessitates the use of higher drug doses. Failure to control symptoms with high-dose PPI treatment raises the likelihood of other causes.
Collapse
Affiliation(s)
- A Kaynard
- Division of Gastroenterology, Department of Medicine, Oregon Health and Science University School of Medicine, Oregon Clinic, Portland, USA
| | | |
Collapse
|
276
|
Madsen E, Aksglaede K, Jacobsen NO, Funch-Jensen P, Thommesen P. Gastro-oesophageal reflux demonstrated by radiography. . A supplement to 24-h pH monitoring. Acta Radiol 2001. [DOI: 10.1034/j.1600-0455.2001.420514.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
277
|
Vidal Gispert E, Ros Rahola E. [Clinical relevance and diagnosis of gastroesophageal reflux]. Rev Clin Esp 2001; 201:469-72. [PMID: 11599162 DOI: 10.1016/s0014-2565(01)70883-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- E Vidal Gispert
- Servicio de Gastroenterología y Hepatología, Institut Universitari Dexeus, Paseo Bonanova, 67-69, 08017 Barcelona
| | | |
Collapse
|
278
|
Abstract
Endoscopy-negative reflux disease (ENRD) is more prevalent than reflux esophagitis, especially in a primary care setting. Acid-sensitive esophagus (ie, reflux-related symptoms with normal acid exposure at 24-hour pH monitoring) is part of the gastroesophageal reflux disease spectrum. ENRD is not a mild disease (symptoms return frequently and have an impact on quality of life), but it rarely progresses to the erosive stage. In patients with atypical or extra-esophageal manifestations, pH monitoring remains useful, and symptom analysis (symptom index or symptom-associated probability) is of pivotal importance. A proton pump inhibitor (PPI) test may represent a cost-effective alternative to 24-hour pH monitoring. However, well-designed validation studies are necessary to assess the diagnostic value of PPI tests and improve specificity without reducing sensitivity. Management of ENRD is based on the same principles as that of reflux esophagitis. Restoration of quality of life is the major goal. Proton pump inhibitors are not more (and are sometimes even less) effective in non-erosive reflux disease than in reflux esophagitis. Different long-term strategies (continuous maintenance, intermittent or on-demand therapy) are available, depending on the needs of the patient. Antireflux surgery may be indicated in carefully selected patients. In the future, pharmacologic approaches targeted to transient lower esophageal sphincter relaxation or visceral perception should be developed.
Collapse
Affiliation(s)
- J P Galmiche
- Department of Gastroenterology and Hepatology and INSERM U 539, Hôtel-Dieu, CHU Nantes, 44093 NANTES Cedex, France.
| | | |
Collapse
|
279
|
Abstract
OBJECTIVE A crucial methodological aspect of ambulatory 24-h esophageal pH monitoring is electrode placement. Lower esophageal sphincter (LES) location is recommended for standard electrode positioning. The aim of the present study was to evaluate prospectively whether LES manometric location and intragastric pH acid confirmation suffice to guarantee that the pH electrode is properly placed. METHODS We evaluated data from 402 consecutive patients undergoing esophageal pH monitoring. LES location was determined by manometry, and the pH electrode was introduced until a pH recording <3 was obtained. Subsequently, it was positioned 5 cm above the proximal LES border. Thereafter, adequate catheter placement and absence of bends or loops were checked by fluoroscopy. Patients with bent or rolled catheters were instructed to have breakfast immediately, and catheter placement was checked again by fluoroscopy. RESULTS When checked by fluoroscopy, the catheter was properly placed in 383 patients (95.3%). In the other 19 (4.7%), it was not located in the distal part of the esophagus owing to bending or rolling: 14 in the esophagus and five in the pharynx. After breakfast, 14 of the 19 malpositioned catheters were properly positioned whereas five remained bent or rolled. Those bent in the esophagus were more prone to unbending (12 of 14) than those bent or rolled in the pharynx (two of five). CONCLUSIONS After LES location by manometry and demonstration of acid pH during the pH step-up technique, the pH electrode was properly placed in more than 95% of cases. Nevertheless, it cannot be completely guaranteed that the pH catheter will not bend or roll, and the pH electrode will not be malpositioned. Eating immediately after electrode placement resolves this problem in the majority (75%) of cases. Therefore, we recommend that patients undergoing esophageal pH-metric studies be instructed to eat as soon as possible after electrode placement to minimize these possible pitfalls.
Collapse
Affiliation(s)
- J Monés
- Digestive Diseases Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | |
Collapse
|
280
|
Abstract
Nonerosive reflux disease is defined as the presence of typical symptoms of gastroesophageal reflux disease caused by intraesophageal acid in the absence of visible esophageal mucosal injury at endoscopy. Recent studies demonstrate that it is a chronic disease with a significant impact on quality of life, and it is very common in primary care settings. Treatment with acid inhibitory agents is effective, and proton pump inhibitors are the most effective form of therapy.
Collapse
Affiliation(s)
- R Fass
- Section of Gastroenterology, Southern Arizona VA Health Care System and University of Arizona Health Sciences Center, Tucson, USA
| | | | | |
Collapse
|
281
|
Smit CF, Copper MP, van Leeuwen JA, Schoots IG, Stanojcic LD. Effect of cigarette smoking on gastropharyngeal and gastroesophageal reflux. Ann Otol Rhinol Laryngol 2001; 110:190-3. [PMID: 11219528 DOI: 10.1177/000348940111000216] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Gastropharyngeal reflux appears to be associated with various otolaryngological complaints. Cigarette smoking is known to affect adversely the defense mechanisms against reflux of acid gastric contents into the esophagus. To study the relationship between gastropharyngeal, as well as gastroesophageal, reflux and cigarette smoking, 15 subjects underwent 24-hour double-probe pH monitoring while smoking their daily amount of cigarettes. The percentage of time the pH was below 4 during the smoking period was significantly higher than the percentage of time the pH was below 4 during the nonsmoking period, proximal, at the level of the upper esophageal sphincter, as well as distal, above the lower esophageal sphincter. These findings demonstrate that smoking increases gastropharyngeal and gastroesophageal reflux. Smokers with complaints and disorders caused by reflux should therefore be advised to stop smoking in order to reduce reflux.
Collapse
Affiliation(s)
- C F Smit
- Department of Otorhinolaryngology-Head and Neck Surgery, Academic Medical Center, University of Amsterdam, The Netherlands
| | | | | | | | | |
Collapse
|
282
|
Smit CF, Mathus-Vliegen LM, Devriese PP, Schouwenburg PF, Kupperman D. Diagnosis and consequences of gastropharyngeal reflux. CLINICAL OTOLARYNGOLOGY AND ALLIED SCIENCES 2000; 25:440-55. [PMID: 11122278 DOI: 10.1046/j.1365-2273.2000.00418.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- C F Smit
- Department of Otorhinolaryngology/Head and Neck Surgery, University Hospital, Vrije Universiteit, Amsterdam, The Netherlands.
| | | | | | | | | |
Collapse
|
283
|
Abstract
Management of gastro-oesophageal reflux disease (GORD) patients must consider two issues: (i) how to optimize the treatment of a presenting symptom complex, and (ii) how to manage risk of adenocarcinoma associated with GORD. In most cases the need for, and potency of, pharmacological therapy used is decided by symptom assessment. Considering cost effectiveness, the three increments of pharmacological therapy are: (i) generic histamine(2)receptor antagonists, (ii) standard dose proton pump inhibitors, and (iii) higher dose proton pump inhibitors. Endoscopy is warranted if there is doubt regarding the diagnosis of GORD or if the patient relays alarm symptoms suggesting more ominous diagnoses (dysphagia, bleeding, weight loss, odynophagia). The other major indication for endoscopy is to screen for adenocarcinoma or Barrett's metaplasia in the patient with chronic symptoms. In most patients, the need for maintenance medical therapy is determined by the rapidity of symptom recurrence during a trial period off the medication.
Collapse
Affiliation(s)
- P J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Medical School, Searle Building 10th Floor, Chicago, IL 60611, USA
| |
Collapse
|
284
|
Hanson DG, Conley D, Jiang J, Kahrilas P. Role of esophageal pH recording in management of chronic laryngitis: an overview. THE ANNALS OF OTOLOGY, RHINOLOGY & LARYNGOLOGY. SUPPLEMENT 2000; 184:4-9. [PMID: 11051423 DOI: 10.1177/0003489400109s1002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chronic laryngitis typically produces symptoms of frequent throat-clearing, soreness, decreased voice quality with use, nonproductive cough, globus sensation, and odynophagia. The endoscopic laryngeal examination usually demonstrates posterior glottic edema, erythema, and increased vascularity and nodularity. There is increasing support for the hypothesis that reflux of acidic gastric contents is often responsible for the symptoms and findings of chronic laryngitis. Prospective trials of acid suppression therapy demonstrate not only efficacy in symptom reduction, but also objective improvement in measurements of voice quality and mucosal erythema. Although traditionally considered the "gold standard" for diagnosis of reflux causing laryngitis, routine esophageal pH recording may result in false negatives in up to 50% of patients. This may confound the diagnosis of chronic laryngitis and delay treatment. Conversely, a positive study during comprehensive therapy may help identify patients who need additional treatment. A single distal probe is probably insufficient for evaluation of a supraesophageal disorder. Current recommendations for double-probe pH study in the evaluation of chronic laryngitis fall into 2 categories: 1) a double-probe pH study is indicated if there is ongoing moderate-to-severe laryngitis despite antireflux precautions and proton pump inhibitor treatment for at least 6 to 12 weeks; and 2) a double-probe pH study is indicated as a baseline measurement before Nissen or Toupet fundoplication. The pH study would also be indicated in patients who have symptoms after fundoplication. There is clearly much more work to be done on the technical issues of obtaining accurate objective data related to laryngeal acidification. In addition, although acid reflux appears to be causative in many cases of chronic laryngitis, further work is indicated to identify reliable testing methods that will predict treatment success.
Collapse
Affiliation(s)
- D G Hanson
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University School of Medicine, Chicago, Illinois 60611, USA
| | | | | | | |
Collapse
|
285
|
Ulualp SO, Toohill RJ. Laryngopharyngeal reflux: state of the art diagnosis and treatment. Otolaryngol Clin North Am 2000; 33:785-802. [PMID: 10918661 DOI: 10.1016/s0030-6665(05)70244-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Gastroesophageal reflux has been implicated in the pathogenesis of a wide variety of otolaryngologic disorders. Patients with otolaryngologic disorders associated with gastroesophageal reflux infrequently have the classic symptoms of gastroesophageal reflux, such as heartburn. Clinical presentation of laryngopharyngeal reflux is commonly characterized by chronic intermittent symptoms. A meticulous synthesis of the information obtained from a complete otolaryngologic examination, diagnostic tests, and response to treatment is essential for the efficient management of patients with otolaryngologic disorders associated with laryngopharyngeal reflux.
Collapse
Affiliation(s)
- S O Ulualp
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | |
Collapse
|
286
|
Harding SM, Guzzo MR, Richter JE. The prevalence of gastroesophageal reflux in asthma patients without reflux symptoms. Am J Respir Crit Care Med 2000; 162:34-9. [PMID: 10903216 DOI: 10.1164/ajrccm.162.1.9907072] [Citation(s) in RCA: 142] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Gastroesophageal reflux is a potential trigger of asthma that may be clinically silent. This study examines the prevalence of gastroesophageal reflux in asthma patients without reflux symptoms. This prospective cohort study evaluated 26 patients with stable asthma without reflux symptoms using esophageal manometry and 24-h esophageal pH testing. Gastroesophageal reflux was considered present if esophageal acid contact times were abnormal. Demographic variables were analyzed to determine if they predicted the presence of gastroesophageal reflux. Asthma patients with asymptomatic gastroesophageal reflux were compared with 30 age-matched asthma patients with symptomatic gastroesophageal reflux. The prevalence of abnormal 24-h esophageal pH tests in asthma patients without reflux symptoms was 62% (16 of 26). Demographic variables did not predict abnormal 24-h esophageal pH tests in asthma patients with asymptomatic gastroesophageal reflux. Asthma patients with asymptomatic gastroesophageal reflux had higher amounts of proximal esophageal acid exposure (p < 0.05) compared with asthma patients with symptomatic gastroesophageal reflux. Because demographic variables do not predict abnormal 24-h esophageal pH tests in asthma patients without reflux symptoms, 24-h esophageal pH testing is required. This study suggests that gastroesophageal reflux is present in asthma patients, even in the absence of esophageal symptoms.
Collapse
Affiliation(s)
- S M Harding
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA
| | | | | |
Collapse
|
287
|
|
288
|
Abstract
Gastroesophageal reflux disease (GERD) causes chronic cough and triggers asthma. Mechanisms of reflux-associated chronic cough include micro- and macroaspiration, laryngeal injury, and a vagally mediated reflex. An empiric trial of a proton pump inhibitor in patients without other etiologies of cough found through diagnostic testing may be an effective diagnostic strategy for GERD-associated cough. In GERD-associated asthma, there is evidence of neurogenic inflammation. Medical or surgical therapy of GERD results in asthma symptom improvement in about 70% of patients. A 3-month empiric trial of omeprazole, 20 mg daily, followed by esophageal pH testing in drug nonresponders, is the most cost-effective way of diagnosing asthma triggered by GERD.
Collapse
Affiliation(s)
- J P Lazenby
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham 35294, USA
| | | |
Collapse
|
289
|
Ladas SD, Tassios PS, Raptis SA. Selection of patients for successful maintenance treatment of esophagitis with low-dose omeprazole: use of 24-hour gastric pH monitoring. Am J Gastroenterol 2000; 95:374-80. [PMID: 10685738 DOI: 10.1111/j.1572-0241.2000.t01-1-01756.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Treating patients with erosive esophagitis and maintaining remission in a cost-effective fashion is a desirable goal in clinical practice. There are no established criteria to identify patients with healed esophagitis who will subsequently remain in remission with low-dose omeprazole therapy. We investigated whether 24-h esophageal-gastric pH monitoring could provide criteria to select patients for low-dose omeprazole maintenance therapy. METHODS Seventy consecutive symptomatic outpatients with grade 2-3 reflux esophagitis were prospectively investigated. They were treated with 20 mg/day omeprazole for 2 months. Those with healed esophagitis were given alternate-evening 20-mg omeprazole maintenance therapy for 6 months. Clinical evaluation, endoscopy, and 24-h esophageal-gastric pH were done at the end of each treatment period. Results of pH studies of patients in remission were compared with those with endoscopically documented relapse of esophagitis. RESULTS In 63/70 patient (intention-to-treat, 90%; 95% confidence interval [CI], 83-97%) esophagitis was healed at 2 months. During the 6-month maintenance period esophagitis remain healed in 28 (G1) (40%; 95% CI, 29-52%), but recurred in 32 patients (G2). During healing with omeprazole 20 mg/day the 24-h gastric pH was below 4 for <10% of the time in 96% of the patients, who subsequently remained in long-term remission with low-dose maintenance therapy (G1), but not in any patient with recurrence of esophagitis (G2). The 10% threshold value has a specificity of 1.00 and sensitivity of 0.96. CONCLUSIONS The 24-h intragastric pH monitoring during 20 mg/day omeprazole therapy provides criteria by which to preselect patients with reflux esophagitis who will remain in remission with low-dose omeprazole therapy.
Collapse
Affiliation(s)
- S D Ladas
- Second Department of Internal Medicine, Evangelismos Hospital, Athens University, Greece
| | | | | |
Collapse
|
290
|
|
291
|
Abstract
Gastroesophageal reflux disease (GERD) describes the clinical manifestations of reflux of gastric contents and the associated symptoms and patterns of tissue injury. Although its exact prevalence is difficult to determine, there is no doubt the GERD is the most common esophageal disease and probably among the most prevalent conditions seen in the primary care setting. GERD has a wide clinical spectrum, making the diagnostic evaluation challenging and complicated at times. Confirmatory test are rarely needed in patients with typical symptoms of heartburn or regurgitation who have a good clinical response to GERD therapy. This article describes the diagnostic tests necessary for some cases of GERD.
Collapse
Affiliation(s)
- Z Younes
- Department of Gastroenterology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | | |
Collapse
|
292
|
Dinelli M, Passaretti S, Di Francia I, Fossati D, Tittobello A. Area under pH 4: a more sensitive parameter for the quantitative analysis of esophageal acid exposure in adults. Am J Gastroenterol 1999; 94:3139-44. [PMID: 10566704 DOI: 10.1111/j.1572-0241.1999.01505.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Traditional quantitative analysis of 24-h esophageal pH monitoring data does not include the pH of reflux episodes. Area under pH 4 (AU4) is a recently introduced parameter that describes the acid exposure rate through both duration and depth of pH falls. METHODS In Study A, we enrolled 20 healthy controls and 42 patients (18 without esophagitis, 24 with Savary I-III esophagitis) in a study evaluating reference values for 24-h reflux time at pH <4 (RT) and 24-h AU4 by means of receiver operating characteristic (ROC) discriminant analysis. For Study B, we next prospectively applied the resulting cutoffs to 16 healthy controls and to 110 gastroesophageal reflux (GERD) patients (55 with esophagitis) to adjust sensitivity, specificity, and predictive values of both RT and AU4. RESULTS In Study A, the best cutoff values were 5.1% for RT (Area Index +/- SE, 0.899 +/- 0.038; 95% confidence interval [C.I.], 0.796 +/- 0.961) and 36.1 pH x min for AU4 (Area Index +/- SE, 0.935 +/- 0.03; 95% C.I., 0.842 +/- 0.981); AU4 gave the best performance (p = 0.038 vs RT) in discriminating controls and GERD patients. In Study B, RT was abnormal in three controls and 79 patients; AU4 identified all the controls and patients with abnormal RT and also 10/31 patients (32.3%) with so-called "normal" acid exposure (according to RT). In the whole GERD group of patients, AU4 and RT specificity was 81.2%, whereas sensitivity was 71.8% for RT and 80.9% for AU4 (chi2, 61.831; DF, 1; p < 0.005); PPV/NPV were 96.3%/29.5% for RT, and 96.7%/38.2% for AU4. CONCLUSIONS AU4 appears to be a simple and sensitive quantitative parameter to measure the esophageal acid exposure in adults submitted to 24-h pH monitoring, and it could be an useful clinical aid in evaluating normal RT tests where, from a clinical point of view, a reflux disease is highly likely.
Collapse
Affiliation(s)
- M Dinelli
- Gastroenterology Unit, S. Raffaele Hospital, University of Milan, Italy
| | | | | | | | | |
Collapse
|
293
|
Huang X, Zhu HM, Deng CZ, Porro GB, Sangaletti O, Pace F. Gastroesophageal reflux: the features in elderly patients. World J Gastroenterol 1999; 5:421-423. [PMID: 11819480 PMCID: PMC4688612 DOI: 10.3748/wjg.v5.i5.421] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the features of gastroesophageal reflux disease between elderly and younger patients.
METHODS: Twenty-four hour pH-monitoring and endoscopy were per formed for the 66 elderly patients with typical gastroesophageal reflux symptoms, and the results were compared with 112 symptomatic younger patients.
RESULTS: The results of 24-h pH-monitoring and endoscopy showe d that the elderly patients had pathological reflux and reflux esophagitis more frequently than the younger patients. Percentage time with pH < 4 in elderly patients with reflux esophagitis was 32.5% in 24 h, as compared with 12.9% in the younger patients with reflux esophagitis (P < 0.05). The elderly patients with reflux esophagitis have longer periods of acid reflux in both upright and supine positions than the younger patients. Endoscopy showed that 20.8% of elderly patients had grade III/IV esophagitis, whereas only 3.4% of younger patients had grade III/IV esophagitis (P < 0.002). Percentages of grades I/II esophagitis in the two groups were 12.5% and 26.5%, respectively (P < 0.002).
CONCLUSION: Elderly patients, as compared with younger patients, have more severe gastroesophageal reflux and esophageal lesions. The incompetence of lower esophageal sphincter and the presence of hiatal hernia may be important factors leading to the difference in incidence and severity of reflux esophagitis between elderly and younger patients.
Collapse
|
294
|
Abstract
Gastroesophageal reflux (GER) is common in those with asthma, with 77% of asthmatics complaining of heartburn, with 41% experiencing reflux-associated respiratory symptoms. Likewise, 24% of those with asthma that is difficult to control have "clinically silent" GER. There are no studies examining nocturnal reflux symptoms in asthmatics. Esophageal dysmotility is also common, and abnormal esophageal acid contact times on 24h esophageal pH tests were found in 82% of asthmatics examined consecutively. Most asthmatics with GER also have abnormal esophageal acid contact times while in the supine position, reflecting sleep time. Endoscopic evidence of esophagitis was found in 43% of asthmatics. Two mechanisms of bronchoconstriction induced by esophageal acid have been proposed: a vagally mediated reflex, by which esophageal acid in the distal esophagus causes reflex bronchoconstriction, and microaspiration. Although there is conflicting evidence, distal esophageal acid causes a decrease in peak expiratory flow rates, an increase in respiratory resistance, and an increase in minute ventilation. If microaspiration is present, there is further augmentation of this airway response. Although only a few studies have been performed in those with nocturnal asthma with GER, one study in a pediatric population showed that esophageal acid infusions caused more airway responses at 04:00 than at 24:00. Also, asthmatic children with nocturnal asthma symptoms have a higher reflux score, with a positive correlation between reflux score and nighttime-associated wheezing. Despite these findings in children, a study performed in sleeping adults with nocturnal asthma noted no alterations in airflow resistance with esophageal acid, concluding that GER contributed little to the nocturnal worsening of asthma. There are also gastroesophageal circadian issues that may influence GER in asthmatics. Gastric acid secretion peaks at approximately 21:00, and gastric emptying is delayed when a meal is given at 20:00 versus 08:00. Esophageal acid clearance is delayed significantly during sleep, and acid clearance occurs during arousals. Upper esophageal sphincter (UES) pressure also decreases with sleep onset, which may predispose to microaspiration. Further research is needed to clarify what role nocturnal reflux has on nocturnal asthma and airway inflammation and whether circadian rhythm factors alter airway responses to esophageal acid.
Collapse
Affiliation(s)
- S M Harding
- UAB Sleep/Wake Disorders Center, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, 35294, USA.
| |
Collapse
|
295
|
Hookman P, Barkin JS. The diagnosis and management of unexplained chest pain--is less more? Am J Gastroenterol 1999; 94:2310-3. [PMID: 10445575 DOI: 10.1111/j.1572-0241.1999.02310.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- P Hookman
- University of Miami, School of Medicine, Mt. Sinai Medical Center, Miami Beach, Florida, USA
| | | |
Collapse
|
296
|
Theodoropoulos DS, Lockey RF, Boyce HW, Bukantz SC. Gastroesophageal reflux and asthma: a review of pathogenesis, diagnosis, and therapy. Allergy 1999; 54:651-61. [PMID: 10442520 DOI: 10.1111/j.1398-9995.1999.00093.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastroesophageal reflux disease (GERD) occurs in up to one-third of the adult US population. Most affected individuals are either unaware of their condition or do not seek medical help, relying on nonprescription acid suppressants and antacids for relief. GERD, a common disorder of infancy, old age, and pregnancy, is particularly prevalent in patients with asthma. A causal relationship between the two diseases has been postulated by many investigators. The physiologic changes of asthma exacerbations and the actions of some of the medications used to treat asthma both aggravate GERD. The adverse effect of GERD on asthma and the pathophysiology of this relationship are still under debate. Some studies showed no objective improvement by spirometry of asthmatics treated for GERD, but recognized improvement in asthma symptoms and decreased use of asthma medication. Other studies, supporting GERD induction of asthma, have been performed to test two hypotheses: that asthma is exacerbated by endotracheal aspiration of gastric contents or by a reflex response to stimulation of esophageal receptors. Clinical experience has shown that early diagnosis and treatment of GERD often leads to better control of asthma.
Collapse
Affiliation(s)
- D S Theodoropoulos
- Division of Allergy and Immunology, University of South Florida College of Medicine and James A. Haley Veterans' Hospital, Tampa 33612-4799, USA
| | | | | | | |
Collapse
|
297
|
Ho KY, Kang JY. Reflux esophagitis patients in Singapore have motor and acid exposure abnormalities similar to patients in the Western hemisphere. Am J Gastroenterol 1999; 94:1186-91. [PMID: 10235190 DOI: 10.1111/j.1572-0241.1999.01063.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Endoscopic esophagitis is less common in the East than in the West. The reason for this is unknown. This study examines prospectively the relationship between endoscopic esophagitis and lower esophageal sphincter pressure, distal esophageal contractility, esophageal peristaltic performance, esophageal acid exposure, gastric acid output, and Helicobacter pylori (H. pylori) status in a consecutive series of Asian patients. METHODS Esophageal manometry and ambulatory pH monitoring were carried out in 48 patients with endoscopic esophagitis and 208 patients with symptoms suspicious of gastroesophageal reflux disease but without esophagitis. Gastric acid output and H. pylori serology were determined in 22 of the esophagitis group and 36 of the nonesophagitis group. RESULTS Compared to the nonesophagitis patients, esophagitis patients had a higher prevalence of hypotensive lower esophageal sphincter (49% vs 24%, p < 0.001), impaired esophageal contractility (45% vs 22%, p < 0.005), poor peristaltic performance (23% vs 12%, p < 0.05), and pathological acid reflux (48% vs 27%, p < 0.005). However, there was no difference in the two groups with respect to gastric acid output and H. pylori positivity. CONCLUSIONS Lower esophageal sphincter competence, esophageal peristaltic contractility, and esophageal acid exposure were important factors in the pathogenesis of reflux esophagitis--results identical to Western studies. Gastric acid output per se and H. pylori infection might not be responsible for susceptibility to esophagitis.
Collapse
Affiliation(s)
- K Y Ho
- Department of Medicine, National University of Singapore, Singapore
| | | |
Collapse
|
298
|
Walsh SV, Antonioli DA, Goldman H, Fox VL, Bousvaros A, Leichtner AM, Furuta GT. Allergic esophagitis in children: a clinicopathological entity. Am J Surg Pathol 1999; 23:390-6. [PMID: 10199468 DOI: 10.1097/00000478-199904000-00003] [Citation(s) in RCA: 220] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Infiltration of esophageal epithelium by eosinophils is seen in reflux esophagitis and allergic gastroenteritis. This study was performed to identify differences between patients with acid reflux esophagitis and those with non-acid reflux, possibly allergic, esophagitis. Intraepithelial eosinophils were demonstrated in posttherapy esophageal biopsy specimens in 28 children treated for gastroesophageal reflux disease (GERD). These patients were divided into three groups based on their response to treatment and the results of esophageal pH probe monitoring. Eleven patients (Group A) had incomplete clinical response and normal pH probe monitoring results. Ten patients (Group B) had incomplete response but did not have pH probe monitoring. These two groups formed the index population. Seven patients (Group C) had clinical improvement with GERD therapy and abnormal pH probe monitoring characteristic of GERD; they constituted the control population. Clinical, laboratory, and pathologic features were evaluated to detect differences between index and control populations. Dysphagia, food impaction, failure to thrive, peripheral eosinophilia, and abnormal allergen skin test results were detected only in Group A and B patients. Biopsy specimens of the distal 9 cm of the esophagus, after GERD therapy, contained larger numbers of eosinophils in Groups A and B than in Group C as shown on high-power fields (HPF) (A: 31/HPF +/- 19.5; B: 28/HPF +/-23.7; versus C: 5/HPF +/-6.7; p = 0.009). Eosinophil aggregates were identified only in Groups A and B (p = 0.07). Eosinophils located preferentially in the superficial layers of the squamous epithelium were noted only in Groups A and B (p = 0.02). Group A and B patients demonstrated clinical improvement when given antiallergic therapy. The authors identified a group of pediatric patients characterized by an allergic history, lack of adequate response to GERD therapy, normal esophageal pH probe monitoring results, and large numbers of eosinophils in esophageal biopsy specimens obtained after GERD treatment. On the basis of these features, the authors propose that these patients represent examples of allergic esophagitis.
Collapse
Affiliation(s)
- S V Walsh
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | | | | |
Collapse
|
299
|
Eckardt VF, Dilling B, Bernhard G. The impact of open access 24-h pH-metry on the diagnosis and management of esophageal reflux disease. Am J Gastroenterol 1999; 94:616-21. [PMID: 10086640 DOI: 10.1111/j.1572-0241.1999.00923.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study investigates whether the results of 24-h pH-metry can be predicted from clinical information and whether they affect patient management. METHODS A total of 200 consecutive patients referred for 24-h pH-metry underwent structured interviews as well as endoscopic and manometric investigations. The most recent 53 patients were prospectively followed to determine the impact of pH monitoring on long term management. RESULTS Among a variety of risk factors, the presence of lower esophageal sphincter hypotension (OR = 3.3) and erosive esophagitis (OR = 2.3) were highly predictive of a pathological pH test result. If both abnormalities were present, the risk for an abnormal 24-h pH study increased by a factor of seven. Twenty-four-hour pH monitoring led to an immediate change in management in 42% of all investigated patients. However, such alterations in therapy were maintained for prolonged periods in less than half of them and only 6% of all patients associated changes in management with an improvement of symptoms. CONCLUSIONS The results of "open access" 24-h pH-metry are often predictable, and only a minority of patients benefit from this procedure in terms of a change in therapy and an improvement of symptoms.
Collapse
Affiliation(s)
- V F Eckardt
- Gastroenterology Institute Wiesbaden, Germany
| | | | | |
Collapse
|
300
|
Harding SM, Guzzo MR, Richter JE. 24-h esophageal pH testing in asthmatics: respiratory symptom correlation with esophageal acid events. Chest 1999; 115:654-9. [PMID: 10084471 DOI: 10.1378/chest.115.3.654] [Citation(s) in RCA: 119] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Gastroesophageal reflux (GER) may be a trigger for asthma and may be clinically silent. Twenty-four-hour esophageal pH testing accurately diagnoses GER in asthmatics. There are no reports correlating respiratory symptoms with esophageal acid events. This study examines the prevalence and severity of GER in asthmatics with and without reflux symptoms and examines respiratory symptom correlation with esophageal acid. METHODS All esophageal manometry and 24-h esophageal pH tests performed were reviewed in asthmatics who met entrance criteria from July 1, 1989, through November 1, 1994. GER was present if esophageal pH tests were abnormal. Results of esophageal tests were compared for asthmatics with reflux symptoms and GER and asthmatics without reflux symptoms and GER. Respiratory symptoms correlated with esophageal acid events if the esophageal pH was < 4 simultaneously with the respiratory event or within 5 min before its onset. RESULTS Of 199 asthmatics who qualified for analysis, 164 (82%) had reflux symptoms. The results of 24-h esophageal pH tests were abnormal in 118 of 164 asthmatics with reflux symptoms (72%), compared with 10 of 35 asthmatics without reflux symptoms (29%). Among asthmatics with GER, 119 of 151 respiratory symptoms (78.8%) were associated with esophageal acid. Seventy-six of 84 reported coughs (90.5%) were associated with esophageal acid. Theophylline did not alter esophageal parameters. CONCLUSIONS There is a strong correlation between esophageal acid events and respiratory symptoms in asthmatics with GER. Respiratory symptom correlation with esophageal acid events further supports that GER may be a trigger for asthma.
Collapse
Affiliation(s)
- S M Harding
- Department of Medicine, University of Alabama at Birmingham, 35294, USA.
| | | | | |
Collapse
|