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Al-Momani H, Mashal S, Al Balawi D, Almasri M, Al-Shudifat AE, Khasawneh AI, Pearson J, Ward C. A prospective study of extraesophageal reflux and potential microaspiration in patients hospitalized with COVID-19 in Jordan. BMC Pulm Med 2023; 23:341. [PMID: 37697259 PMCID: PMC10496175 DOI: 10.1186/s12890-023-02638-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 09/07/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) lung infection has represented a global challenge. Intriguingly, it has been shown that the alveolar lung epithelium expresses little Angiotensin Converting Enzyme receptor protein (ACE2), the entry receptor for SARS-CoV-2. Upper airway establishment of infection and translocation to the lung is well documented but other anatomical niches may be relevant to potentially serious lung infection. ACE2 is heavily expressed in the gastrointestinal tract and gastrointestinal symptoms support a clinical diagnosis of Coronavirus disease 2019 (COVID-19). This suggests a research question and the need to gather patient data exploring potential aerodigestive links in SARS-CoV-2 tranlocation and infection which may be relevant in the peripheral lung. This recognizes anatomical proximity and concepts of bi-directional movement between the Gastrointestinal and lung systems in normal physiology and disease. We have therefore explored the potential for gastro oesophageal reflux disease (GORD) micro aspiration and aeorodigestive pathophysiology in a novel prospective investigation of patients hospitalized with COVID-19. METHODS This is a prospective descriptive cohort study of 210 patients who were hospitalized with a confirmed diagnosis of COVID-19. The cohort was divided into three groups of patients based on symptom severity and radiological results. The Reflux Symptom Index (RSI) was used to evaluate the presence and severity of GOR. An RSI greater than 13 is considered to be abnormal. Patients' saliva samples were tested using enzyme-linked immunosorbent assay (ELISA) to determine the level of salivary pepsin among the cohort of patients. RESULTS A total of 210 patients with COVID-19 were enrolled in the study with 55.2% (116/210) classified as mildly ill, 31.9% (67/210) moderately ill and 12.9% (27/210) as severely ill. 34% (72/210) of the patients had an RSI score of over 13 and a median salivary pepsin value of 54 ± 29 ng/ml which suggested an incidence of extraesophageal reflux (EOR) in around a third of patients. The presence of respiratory comorbid conditions, an RSI score of over 13 and a salivary pepsin level of > 76ng/ml increased the risk of developing a more severe COVID-19 infection. CONCLUSION The study showed a high prevalence of EOR among the study cohort and provide the first prospective evidence suggesting the potential for aerodigestive pathophysiology including microaspiration in COVID-19 disease. We believe that the results of our study support the need for more extensive research.
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Affiliation(s)
- Hafez Al-Momani
- Department of Microbiology, Pathology and Forensic medicine, Faculty of Medicine, The Hashemite University, Zarqa, 13133, Jordan.
| | - Safaa Mashal
- Department of Microbiology, Pathology and Forensic medicine, Faculty of Medicine, The Hashemite University, Zarqa, 13133, Jordan
| | - Dua'a Al Balawi
- Faculty of Applied Medical Sciences, The Hashemite University, Zarqa, 13133, Jordan
| | - Muna Almasri
- Faculty of Applied Medical Sciences, The Hashemite University, Zarqa, 13133, Jordan
| | - Abdel-Ellah Al-Shudifat
- Department of Internal and family Medicine, Faculty of Medicine, The Hashemite University, Zarqa, 13133, Jordan
| | - Ashraf I Khasawneh
- Department of Microbiology, Pathology and Forensic medicine, Faculty of Medicine, The Hashemite University, Zarqa, 13133, Jordan
| | - Jeffrey Pearson
- Translational and clinical research and Biosciences institutes, Newcastle University Medical School, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Christopher Ward
- Translational and clinical research and Biosciences institutes, Newcastle University Medical School, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
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Gan J, Chan YK, Segaran DC, Kovalik JP, Eng A, Lee PC, Tan J, Lim CH. Pepsin in saliva for the diagnosis of erosive esophagitis post-sleeve gastrectomy: a prospective observational study. Surg Endosc 2023:10.1007/s00464-023-10050-9. [PMID: 37055666 DOI: 10.1007/s00464-023-10050-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/26/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has become the preferred bariatric procedure in many countries. However, new onset erosive esophagitis (EE) is a major shortcoming. Current recommendation is esophago-gastro-duodenoscopy (EGD) should be performed routinely at 1 year and subsequently every 2-3 years to enable the early detection of Barrett's or esophageal adenocarcinoma. This would put significant strains on resources and costs of bariatric program. Our study assesses the association between and diagnostic value of salivary pepsin concentration and endoscopically proven EE in post-LSG patients as a surrogate for EGD. METHODS Twenty patients on routine post-LSG endoscopy between June and September 2022 were recruited for this correlational pilot study. Under supervision, fasting and post-prandial saliva sample was collected and analyzed by Peptest lateral flow device. EGD examinations were performed, and patients completed a validated 25-item QoLRAD questionnaire. RESULTS We found a significant correlation between positive endoscopy findings of EE and salivary pepsin concentrations. The normal group had a lower mean fasting pepsin level (13.13 ng/mL ± 18.97) versus the EE-group (90.55 ng/mL ± 81.28, p = 0.009) and lower mean post-prandial pepsin level (30.50 ng/mL ± 57.72) versus the EE-group (135.09 ng/mL ± 130.17, p = 0.02). The predictive probabilities from the binary regression of fasting and post-prandial pepsin concentrations yield AUC of 0.955 ± 0.044 (95% CI 0.868 to 1.000, p < 0.001). CONCLUSION Our study distinctively identified salivary pepsin to have excellent sensitivity and negative predictive value in EE, potentially useful to preclude the need for post-LSG EGD in asymptomatic patients with low salivary pepsin.
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Affiliation(s)
- Jinyuan Gan
- Duke-NUS Medical School, SingHealth, Singapore, Singapore
| | - Yarn Kit Chan
- Duke-NUS Medical School, SingHealth, Singapore, Singapore
| | - Deepa Chandra Segaran
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore
| | - Jean-Paul Kovalik
- Division of Medicine, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Alvin Eng
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore
| | - Phong Ching Lee
- Division of Medicine, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Jeremy Tan
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore
| | - Chin Hong Lim
- Division of Surgery, Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Singapore, Singapore.
- Department of Upper Gastrointestinal & Bariatric Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore.
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Farooqi MS, Podury S, Crowley G, Javed U, Li Y, Liu M, Kwon S, Grunig G, Khan AR, Francois F, Nolan A. Noninvasive, MultiOmic, and Multicompartmental Biomarkers of Reflux Disease: A Systematic Review. GASTRO HEP ADVANCES 2023; 2:608-620. [PMID: 38009162 PMCID: PMC10673619 DOI: 10.1016/j.gastha.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
BACKGROUND AND AIMS Gastroesophageal reflux disease (GERD) is a prevalent gastrointestinal disorder that may complicate conditions such as obstructive airway disease. Our group has identified predictive biomarkers of GERD in particulate exposed first responders with obstructive airway disease. In addition, GERD diagnosis and treatment is costly and invasive. In light of these clinical concerns, we aimed to systematically review studies identifying noninvasive, multiOmic, and multicompartmental biomarkers of GERD. METHODS A systematic review of PubMed and Embase was performed using keywords focusing on reflux disease and biomarkers and registered with PROSPERO. We included original human studies in English, articles focusing on noninvasive biomarkers of GERD published after December 31, 2009. GERD subtypes (non-erosive reflux disease and erosive esophagitis) and related conditions (Barrett's Esophagus [BE] and Esophageal Adenocarcinoma). Predictive measures were synthesized and risk of bias assessed (Newcastle-Ottawa Scale). RESULTS Initial search identified n = 238 studies andn 13 articles remained after applying inclusion/exclusion criteria. Salivary pepsin was the most studied biomarker with significant sensitivity and specificity for GERD. Serum assessment showed elevated levels of Tumor Necrosis Factor-alpha in both GERD and Barrett's. Exhaled breath volatile sulfur compounds and acetic acid were associated with GERD. Oral Microbiome: Models with Lautropia, Streptococcus, and Bacteroidetes showed the greatest discrimination between BE and controls vs Lautropia; ROCAUC 0.94 (95% confidence interval; 0.85-1.00). CONCLUSION Prior studies identified significant multiOmic, multicompartmental noninvasive biomarker risks for GERD and BE. However, studies have a high risk of bias and the reliability and accuracy of the biomarkers identified are greatly limited, which further highlights the need to discover and validate clinically relevant noninvasive biomarkers of GERD.
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Affiliation(s)
- Muhammad S. Farooqi
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University Grossman School of Medicine (NYUGSoM), New York, New York
| | - Sanjiti Podury
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University Grossman School of Medicine (NYUGSoM), New York, New York
| | - George Crowley
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University Grossman School of Medicine (NYUGSoM), New York, New York
| | - Urooj Javed
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University Grossman School of Medicine (NYUGSoM), New York, New York
| | - Yiwei Li
- Department of Population Health, Division of Biostatistics, NYUGSoM, New York, New York
| | - Mengling Liu
- Department of Population Health, Division of Biostatistics, NYUGSoM, New York, New York
| | - Sophia Kwon
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University Grossman School of Medicine (NYUGSoM), New York, New York
| | - Gabriele Grunig
- Department of Environmental Medicine, NYUGSoM, New York, New York
| | - Abraham R. Khan
- Department of Medicine, Center for Esophageal Health, NYUGSoM, New York, New York
- Department of Medicine, Division of Gastroenterology, NYUGSoM, New York, New York
| | - Fritz Francois
- Department of Medicine, Division of Gastroenterology, NYUGSoM, New York, New York
| | - Anna Nolan
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University Grossman School of Medicine (NYUGSoM), New York, New York
- Department of Environmental Medicine, NYUGSoM, New York, New York
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Ergun P, Kipcak S, Dettmar PW, Fisher J, Woodcock AD, Bor S. Pepsin and pH of Gastric Juice in Patients With Gastrointestinal Reflux Disease and Subgroups. J Clin Gastroenterol 2022; 56:512-517. [PMID: 34049376 DOI: 10.1097/mcg.0000000000001560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 03/24/2021] [Indexed: 12/10/2022]
Abstract
GOAL The aim of this study was to investigate the pepsin values and pH results of gastric juice among the subtypes of gastroesophageal reflux disease (GERD) and functional heartburn. BACKGROUND The major destructive agents of GERD on the esophageal epithelium are gastric acid and pepsin. No precise information about pepsin concentration in gastric juice exists. STUDY Ninety patients with GERD, 39 erosive reflux disease (ERD) Los Angeles (LA) grade A/B, 13 ERD LA grade C/D, 19 nonerosive reflux disease (NERD), 8 esophageal hypersensitivity, 11 functional heartburn, and 24 healthy controls were included in the study. During endoscopy gastric juices from the patients were aspirated and their pH readings immediately recorded. Gastric juice samples were analyzed using Peptest, a lateral flow device containing 2 unique human monoclonal antibodies to detect any pepsin present in the gastric juice sample. RESULTS The highest mean gastric pepsin concentration (0.865 mg/mL) and the lowest median gastric pH (1.4) was observed in the LA grade C/D group compared with the lowest mean gastric pepsin concentration (0.576 mg/mL) and the highest median gastric pH (2.5) seen in the NERD group. Comparing pH, the NERD patient group was significantly higher (P=0.0018 to P=0.0233) when compared with all other GERD patient groups. CONCLUSIONS The basal gastric pepsin level in the healthy control group was comparable to literature values. There was good correlation and a significant linear relationship between the gastric pepsin level and gastric pH within the patient groups. The severity of the GERD disease is related to the lowest pH and the highest pepsin concentration in gastric juice.
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Affiliation(s)
- Pelin Ergun
- Departments of Medical Biochemistry
- Ege Reflux Study Group, Division of Gastroenterology, Division of Internal Medicine, Ege Faculty of Medicine, Izmir, Turkey
| | - Sezgi Kipcak
- Medical Biology
- Ege Reflux Study Group, Division of Gastroenterology, Division of Internal Medicine, Ege Faculty of Medicine, Izmir, Turkey
| | | | | | | | - Serhat Bor
- Ege Reflux Study Group, Division of Gastroenterology, Division of Internal Medicine, Ege Faculty of Medicine, Izmir, Turkey
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Guo Z, Jiang J, Wu H, Zhu J, Zhang S, Zhang C. Salivary peptest for laryngopharyngeal reflux and gastroesophageal reflux disease: A systemic review and meta-analysis. Medicine (Baltimore) 2021; 100:e26756. [PMID: 34397878 PMCID: PMC8360476 DOI: 10.1097/md.0000000000026756] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/06/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND A rapid lateral flow test (Peptest) to detect pepsin in saliva/sputum has been considered as a valuable method for diagnosing laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD). The aim of this meta-analysis is to analyze the utility of Peptest for diagnosis of LPR and GERD. METHODS PubMed, EMBASE, and the Cochran Library (from January 1980 to 26 January 2020) were searched for pepsin in saliva for LPR/GERD diagnosis. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the curve data were summarized to examine the accuracy. RESULTS A total of 16 articles that included 2401 patients and 897 controls were analyzed. The pooled sensitivity and specificity for the diagnosis of GERD/LPR with Peptest were 62% (95% confidence interval [CI] 49%-73%) and 74% (95% CI 50%-90%), respectively. The summarized diagnostic odds ratio and area under the curve were 5.0 (95% CI 2-19) and 0.70 (95% CI 0.66-0.74), respectively. CONCLUSION Peptest shows moderate diagnostic value for LPR and GERD. More studies with standard protocols should be done to verify its usefulness.
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Affiliation(s)
- Zihao Guo
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China
| | - Jiali Jiang
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China
| | - Hao Wu
- Department of Cardiovascular diseases, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China
| | - Jinxia Zhu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing, China
- Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, China
| | - Chuan Zhang
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China
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