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Abstract
Esophageal symptoms are common and may indicate the presence of gastroesophageal reflux disease (GERD), structural processes, motor dysfunction, behavioral conditions, or functional disorders. Esophageal physiologic tests are often performed when initial endoscopic evaluation is unrevealing, especially when symptoms persist despite empiric management. Commonly used esophageal physiologic tests include esophageal manometry, ambulatory reflux monitoring, and barium esophagram. Functional lumen imaging probe (FLIP) has recently been approved for the evaluation of esophageal pressure and dimensions using volumetric distension of a catheter-mounted balloon and as an adjunctive test for the evaluation of symptoms suggestive of motor dysfunction. Targeted utilization of esophageal physiologic tests can lead to definitive diagnosis of esophageal disorders but can also help rule out organic disorders while making a diagnosis of functional esophageal disorders. Esophageal physiologic tests can evaluate obstructive symptoms (dysphagia and regurgitation), typical and atypical GERD symptoms, and behavioral symptoms (belching and rumination). Certain parameters from esophageal physiologic tests can help guide the management of GERD and predict outcomes. In this ACG clinical guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to describe performance characteristics and clinical value of esophageal physiologic tests and provide recommendations for their utilization in routine clinical practice.
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Kuo CFJ, Kao CH, Dlamini S, Liu SC. Laryngopharyngeal reflux image quantization and analysis of its severity. Sci Rep 2020; 10:10975. [PMID: 32620899 PMCID: PMC7335083 DOI: 10.1038/s41598-020-67587-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 06/10/2020] [Indexed: 12/21/2022] Open
Abstract
Laryngopharyngeal reflux (LPR) is a prevalent disease affecting a high proportion of patients seeking laryngology consultation. Diagnosis is made subjectively based on history, symptoms, and endoscopic assessment. The results depend on the examiner's interpretation of endoscopic images. There are still no consistent objective diagnostic methods. The aim of this study is to use image processing techniques to quantize the laryngeal variation caused by LPR, to judge and analyze its severity. This study proposed methods of screening sharp images automatically from laryngeal endoscopic images and using throat eigen structure for automatic region segmentation. The proposed image compensation improved the illumination problems from the use of laryngoscope lens. Fisher linear discriminant was used to find out features and classification performance while support vector machine was used as the classifier for judging LPR. Evaluation results were 97.16% accuracy, 98.11% sensitivity, and 3.77% false positive rate. To evaluate the severity, quantized data of the laryngeal variation was used. LPR images were combined with reflux symptom index score chart, and severity was graded using a neural network. The results indicated 96.08% accuracy. The experiment indicated that laryngeal variation induced by LPR could be quantized by using image processing techniques to assist in diagnosing and treating LPR.
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Affiliation(s)
- Chung-Feng Jeffrey Kuo
- Department of Material Science and Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Road, Da'an District, Taipei, Taiwan, ROC
| | - Chih-Hsiang Kao
- Department of Material Science and Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Road, Da'an District, Taipei, Taiwan, ROC
| | - Sifundvolesihle Dlamini
- Department of Material Science and Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Road, Da'an District, Taipei, Taiwan, ROC
| | - Shao-Cheng Liu
- Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Cheng-Gong Road, Neihu District, Taipei, 114, Taiwan, ROC.
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Yadlapati R, Pandolfino JE. Personalized Approach in the Work-up and Management of Gastroesophageal Reflux Disease. Gastrointest Endosc Clin N Am 2020; 30:227-238. [PMID: 32146943 PMCID: PMC7083512 DOI: 10.1016/j.giec.2019.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Patients with gastroesophageal reflux disease (GERD) present with heterogeneous symptoms, response to treatment, and physiologic profiles, requiring distinct and personalized management. This article provides a stepwise framework to phenotype GERD beginning with (1) characterization of symptom profile and response to acid suppression; (2) endoscopic evaluation of mucosal and anatomic integrity; (3) ambulatory reflux monitoring to characterize reflux burden and sensitivity; and (4) esophageal physiologic testing to assess gastroesophageal reflux mechanism and effectors of reflux clearance, and evaluate for alternate causes.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, 9500 Gilman Drive MC 0956, La Jolla, CA 92093, USA.
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Chicago, IL 60611, USA
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Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66:516-554. [PMID: 29470322 PMCID: PMC5958910 DOI: 10.1097/mpg.0000000000001889] [Citation(s) in RCA: 456] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2009 clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) in infants and children and is intended to be applied in daily practice and as a basis for clinical trials. Eight clinical questions addressing diagnostic, therapeutic and prognostic topics were formulated. A systematic literature search was performed from October 1, 2008 (if the question was addressed by 2009 guidelines) or from inception to June 1, 2015 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Clinical Trials. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to define and prioritize outcomes. For therapeutic questions, the quality of evidence was also assessed using GRADE. Grading the quality of evidence for other questions was performed according to the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) and Quality in Prognostic Studies (QUIPS) tools. During a 3-day consensus meeting, all recommendations were discussed and finalized. In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique. With this approach, recommendations regarding evaluation and management of infants and children with GERD to standardize and improve quality of care were formulated. Additionally, 2 algorithms were developed, 1 for infants <12 months of age and the other for older infants and children.
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Affiliation(s)
- Rachel Rosen
- Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Children's Hospital Boston, Boston, MA
| | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Michael Cabana
- Division of General Pediatrics, University of California, San Francisco, CA
| | - Carlo DiLorenzo
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Frederic Gottrand
- CHU Lille, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lille, France
| | - Sandeep Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois, Peoria, IL
| | - Miranda Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples ‘‘Federico II,’’ Naples, Italy
| | - Nikhil Thapar
- Great Ormond Street Hospital for Children, London, UK
| | - Neelesh Tipnis
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS
| | - Merit Tabbers
- Emma Children's Hospital/AMC, Amsterdam, The Netherlands
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Mahoney LB, Nurko S, Rosen R. The Prevalence of Rome IV Nonerosive Esophageal Phenotypes in Children. J Pediatr 2017; 189:86-91. [PMID: 28711175 PMCID: PMC6158020 DOI: 10.1016/j.jpeds.2017.06.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/15/2017] [Accepted: 06/07/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To assess the prevalence of Rome IV nonerosive esophageal phenotypes in children using multichannel intraluminal impedance testing and to describe the rates of proton pump inhibitor (PPI) responsiveness and the frequency of microscopic esophagitis in these patients. STUDY DESIGN We conducted a retrospective review of all children ≥5 years of age who underwent esophagogastroduodenoscopy and multichannel intraluminal impedance testing off PPI therapy for evaluation of typical gastroesophageal reflux symptoms. Only children with symptoms during the multichannel intraluminal impedance testing were included. Children were categorized into the following nonerosive esophageal phenotypes using Rome IV criteria: nonerosive reflux disease, reflux hypersensitivity, and functional heartburn. Rates of esophagitis and responsiveness to acid suppression therapy were assessed. RESULTS Forty-five children were included: 27% were categorized as having nonerosive reflux disease, 29% with reflux hypersensitivity (27% acid and 2% nonacid), and 44% with functional heartburn. Older children reported significantly more heartburn (P < .001) than younger children, whereas younger children were more likely to report nonspecific pain (P = .047). There were no differences between groups in other reflux symptoms, rates of responsiveness to PPIs, or the presence of microscopic esophagitis on biopsy. CONCLUSIONS Functional heartburn is the most common Rome IV nonerosive esophageal phenotype in children. Neither microscopic esophagitis nor PPI responsiveness can predict phenotype in pediatric patients.
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Affiliation(s)
- Lisa B Mahoney
- Aerodigestive and Motility and Functional Gastrointestinal Disorders Centers, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Samuel Nurko
- Aerodigestive and Motility and Functional Gastrointestinal Disorders Centers, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Rachel Rosen
- Aerodigestive and Motility and Functional Gastrointestinal Disorders Centers, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA.
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Wen T, Rothenberg ME. Clinical Applications of the Eosinophilic Esophagitis Diagnostic Panel. Front Med (Lausanne) 2017; 4:108. [PMID: 28770203 PMCID: PMC5509802 DOI: 10.3389/fmed.2017.00108] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 06/30/2017] [Indexed: 12/19/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a recently recognized upper gastrointestinal allergic disorder characterized by esophageal dysfunction (e.g., dysphagia) and esophageal eosinophilia of ≥15 eosinophils/high-power field in patients who have persistent esophagitis even on proton pump inhibitor (PPI) therapy. The histologic method is the gold standard of EoE diagnosis. However, EoE clinical symptoms do not always correlate with histology, and the histologic method has sensitivity and specificity issues due to the patchiness of EoE and the subjective nature of the method. The “EoE transcriptome” was initially discovered in 2006, which led to the invention of the EoE diagnostic panel (EDP). In addition to providing a definitive EoE diagnosis with high accuracy, the EDP has been useful in elucidating several key elements about the disease including the efficacy of specific drugs such as swallowed glucocorticoids and anti-IL-13 humanized antibody therapy, the relationship between EoE and PPI-responsive esophageal eosinophilia, and predicting the disease course and responsiveness to therapy. The EDP’s long-term potential arises from its plasticity to incorporate new genes and uncover novel disease pathogenesis. We expect that the EDP will be increasingly helpful for personalized medicine approaches and improved diagnostics and disease monitoring.
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Affiliation(s)
- Ting Wen
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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Frazzoni M, de Bortoli N, Frazzoni L, Furnari M, Martinucci I, Tolone S, Farioli A, Marchi S, Fuccio L, Savarino V, Savarino E. Impairment of chemical clearance and mucosal integrity distinguishes hypersensitive esophagus from functional heartburn. J Gastroenterol 2017; 52:444-451. [PMID: 27241210 DOI: 10.1007/s00535-016-1226-9] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/15/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hypersensitive esophagus (HE) is defined by endoscopy-negative heartburn with a normal acid exposure time but positive symptom association probability (SAP) and/or symptom index (SI) on impedance-pH monitoring, and proton pump inhibitor (PPI) responsiveness. Functional heartburn (FH) is distinguished by negative SAP/SI and PPI refractoriness. The clinical value of SAP and SI has been questioned. We aimed to investigate whether impairment of chemical clearance and of mucosal integrity, expressed by the postreflux swallow-induced peristaltic wave (PSPW) index and the mean nocturnal baseline impedance (MNBI), characterize HE independently of SAP and SI. METHODS Impedance-pH tracings from PPI-responsive endoscopy-negative patients, 125 with nonerosive reflux disease and 108 with HE, distinguished by an abnormal and a normal acid exposure time, and from 70 patients with FH were retrospectively selected and blindly reviewed. RESULTS The mean PSPW index and MNBI were significantly lower in nonerosive reflux disease (30 %, 1378 Ω) than in HE (51 %; 2274 Ω) and in both of them as compared with FH (76 %; 3445 Ω) (P = 0.0001). Both the PSPW index (adjusted odds ratio 0.863, P = 0.001) and the MNBI (adjusted odds ratio 0.998, P = 0.001) were independent predictors of HE; with their combined assessment, the area under the curve on receiver operating characteristic analysis was 0.957. SAP and/or SI was positive in 67 of the 108 HE patients (62 %), whereas the PSPW index and/or MNBI was abnormal in 99 of the 108 HE patients (92 %; P < 0.0001). CONCLUSIONS HE is characterized by impairment of chemical clearance and mucosal integrity, which explains the increased reflux perception. When SAP and SI afford uncertain results, the PSPW index and MNBI should be analyzed.
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Affiliation(s)
- Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Viale Giardini, 1355, 41100, Modena, Italy.
| | - Nicola de Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Manuele Furnari
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Irene Martinucci
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Salvatore Tolone
- General and Bariatric Surgery Unit, Department of Surgery, 2nd University of Napoli, Naples, Italy
| | - Andrea Farioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Santino Marchi
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Cheng FKF, Moawad FJ. Reply. Clin Gastroenterol Hepatol 2016; 14:1061. [PMID: 26997264 DOI: 10.1016/j.cgh.2016.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Fong-Kuei F Cheng
- Department of Medicine, Gastroenterology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Fouad J Moawad
- Department of Medicine, Gastroenterology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
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Furnari M, Tolone S, Savarino E. Caution About Overinterpretation of Number of Reflux Episodes in Reflux Monitoring for Refractory Gastroesophageal Reflux Disease. Clin Gastroenterol Hepatol 2016; 14:1060. [PMID: 26051393 DOI: 10.1016/j.cgh.2015.05.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 05/29/2015] [Accepted: 05/29/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Manuele Furnari
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Salvatore Tolone
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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