PH monitoring in the distal and proximal esophagus in symptomatic infants

Serum interleukin--4 and tumor necrosis factor alpha concentrations in children with primary acid gastroesophageal reflux and acid gastroesophageal reflux secondary to cow's milk allergy

AIM

The possible role of serum interleukin 4 (IL-4) and tumor necrosis factor alpha (TNF- α) in pathogenesis of the reflux symptoms in children with primary acid gastroesophageal reflux (GER) and acid GER secondary to cow's milk allergy (CMA).

MATERIAL AND METHODS

Out of 264 children, 76 (28.8%) patients with primary GER and 62 (23.5%) patients with GER secondary to CMA (pH - monitoring) serum IL-4 and TNF- α concentrations were assessed before treatment, 1 and 2 years after the initiation of the periodically administered pharmacotherapy.

RESULTS

Children with primary GER had mean IL-4 concentrations 0.17 ± 0.06 pg/ml before treatment, 0.08 ± 0.07 pg/ ml after 1-year and 0.07 ± 0.06 pg/ml after 2-years of treatment. The mean IL-4 concentrations were 1.07 ± 0.24, 0.5 ± 0.22 and 0.44 ± 0.19 pg/ml respectively in children with GER secondary to CMA. The mean serum TNF- α concentrations was 3.62 ± 1.30 pg/ml before treatment , 2.16 ± 1,35 pg/ ml after 1 year and 1.65 ± 1.16 pg/ml after 2 years of treatment in children with primary GER. In group with GER secondary to CMA mean serum TNF- α concentrations were 4.95 ± 1.88, 2.53 ± 0.80 and 2.02 ± 0.78 pg/ml respectively. Statistical analysis of the concentration of both cytokines showed their differentiation between them and in the study groups.

CONCLUSIONS

The highest mean serum IL-4 and TNF-α concentrations were observed in children with GER secondary to CMA and in children in control group (with cow's milk allergy and/or other food allergy diagnosed - CMA/FA) before the treatment administration.

Serum gastrin concentrations in children with primary gastroesophageal reflux and gastroesophageal reflux secondary to cow's milk allergy

PURPOSE

The assessment of the serum gastrin concentrations and the role of enterohormone in children with primary acid gastroesophageal reflux (GER) and GER secondary to cow's milk allergy (CMA).

MATERIALS/METHODS

138 children were diagnosed with pathological acid GER on the basis of pH-metric examination. 76 (28.8%) patients had primary GER and 62 (23.5%) patients had GER secondary to CMA.Serum gastrin concentration (fasting and postprandial) was assessed before treatment and 1 and 2 years after initiation of the therapy.

RESULTS

The children with primary GER had the fasting gastrin concentration 69.46 ± 11.87 μU/ml before treatment, 77.86 ± 26.35 μU/ml after 1 year and 83.78 ± 25.21 μU/ml after 2 years of treatment. The children with GER secondary to CMA had gastrin concentrations 89.61 ± 26.75, 73.17 ± 19.49 and 73.90 ± 20.31 μU/ml respectively. The mean postprandial gastrin concentration after treatment was higher than before treatment in children with both primary and secondary GER. The primary GER group had postprandial gastrin concentration 96.07 ± 33.51 μU/ml before treatment and 116.06 ± 33.95 μU/ml and 118.48 ± 33.96 μU/ml after 1st and 2nd year of therapy respectively. The secondary GER group had postprandial gastrin concentration 85.33 ± 14.12 μU/ml before treatment and 106.55 ± 24.51 μU/ml and 110.36 ± 24.67 μU/ml after 1st and 2nd year of therapy respectively.

CONCLUSIONS

The mean fasting serum gastrin concentrations in patients with primary and secondary GER were similar and mean postprandial concentrations were higher than fasting concentrations in both study groups.

Combined oesophageal impedance-pH monitoring in preterm newborn: comparison of two options for layout analysis

Gastro-oesophageal reflux (GOR) is common in preterm infants. Combined multichannel intraluminal impedance and pH monitoring (pH-MII) is emerging as an useful tool to study both acid and non-acid GOR in this population. We aimed to highlight main advantages and limits of pH-MII in preterm infants and to test whether the inclusion of GOR episodes detected only by pH monitoring details better the features of GOR. Fifty-two symptomatic preterm infants underwent a 24-hour, continuous and simultaneous measurement of pH-MII. Each layout was analyzed using two different options: option 1 included GOR episodes detected by MII and then classified as acid or non-acid according to the associated pH change; option 2 included GOR episodes detected by MII and also GOR episodes detected only by pH sensor. By adopting option 1, a total number of 2834 GOR episodes was detected by MII: 2162 of them were characterized as non-acid and 672 were characterized as acid. The median (range) number of acid MII-GOR episodes was 10 (1-52); the median (range) number of non-acid MII-GOR episodes was 36.5 (2-119). Median (range) acid MII-GOR-bolus exposure index was 0.28% (0.02-2.73%); median (range) non-acid MII-GOR-bolus exposure index was 1.03% (0.06-38.15%). By adopting option 2, an average of 53.2 acid GOR episodes and an average of 11% oesophageal exposure to acid GOR more than by option 1 was detected. An accurate and detailed description of GOR in preterm infants can be obtained only by including in the analysis all acid GOR episodes detected by pH sensor.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

Acid gastroesophageal reflux and intensity of symptoms in children with gastroesophageal reflux disease. Comparison of primary gastroesophageal reflux and gastroesophageal reflux secondary to food allergy

The ability to differentiate between primary and secondary causes of gastroesophageal reflux (GER) is extremely important during the diagnostic procedure. At the same time, the quality of symptoms and the intensity of the course of gastroesophageal reflux disease (GERD) should be estimated. Acid GER is assessed using 24-hour esophageal pH monitoring; the results of this diagnostic test should always be interpreted alongside the clinical picture.

PURPOSE

To establish the interdependence between the intensity of the clinical symptoms and the acid reflux index in children with primary GER and GER secondary to cow's milk protein allergy (CMA) and/or other food allergies (FA).

MATERIALS AND METHODS

A total of 138 children of various ages with symptoms of GERD were included in the study. The diagnostic procedure included 24-hour pH monitoring of the esophagus with a 2-channel probe (distal and proximal lead). For this purpose, ESPGAN diagnostic criteria were implemented. The type and intensity of typical manifestations of GERD were assessed with the help of our own scoring system. This diagnostic and therapeutic algorithm which includes an oral food challenge test, was applied to 138 children in order to differentiate primary GER from GER secondary to CMA/FA.

RESULTS

Primary GERD was diagnosed in 76 patients (55.1%) with a mean age: x=25.20 months+/-27.28 (group 1) and GERD secondary to CMA/FA was confirmed in 62 children (44.9%) with a mean age: x=21.53 months+/-17.79 (group 2). The most important pH-metric parameter analyzed in study groups 1 and 2 was the GER index: total and supine. An assessment of the intensity of symptoms and a comparative analysis of intensity was evaluated against the GER index: total and supine. Among study group 1, the following gradation of symptoms was found: in 31 children (40.8%)-degree 3, in 33 children (43.4%)-degree 4, and in 12 children (15.8%)-degree 5, whereas among the patients in group 2:25 (40.3%) were in degree 3, 27 (43.6%) were in degree 4, and 10 (16.1%) were in degree 5. It was estimated that the higher the GER result in both total and supine positions (for both leads), the higher the level of symptoms noted. This interdependence was demonstrated for both groups.

CONCLUSIONS

In seeking to determine any etiopathogenetic connection between primary GER or GER secondary to CMA/FA and their clinical consequences, 24-hour esophageal pH monitoring with a 2-channel probe is recommended, since it provides for better clinical control of GERD and its appropriate treatment.

Manometric study of lower esophageal sphincter in children with primary acid gastroesophageal reflux and acid gastroesophageal reflux secondary to food allergy

PURPOSE

The comparison of values of selected lower esophageal sphincter (LES) manometric parameters measured in children suspected of gastroesophageal reflux disease (GERD) (preliminary study) and in children with primary acid GER and acid GER secondary to cow's milk allergy and/or other food (CMA/FA) in relation to the duration of the disease (prospective study).

MATERIAL AND METHODS

A 24-hour esophageal pH monitoring was performed on 264 children of both sexes suspected of GERD (mean age x=20.78+/-17.23 months). Pathological acid gastroesophageal reflux (GER) was diagnosed and divided into primary and secondary reflux in 138 children (52.3%). 76 patients (28.8%) (x=25.2+/-27.28 months) with primary GER made up Group 1. Group 2 consisted of 62 patients (23.5%) (x=21.53+/-17.79 months) with GER secondary to CMA/FA. 32 patients (12.1%) (x=23.7+/-12.63 months) with CMA/FA symptoms made up Group 3 (reference group). Prospective assessment of LES manometric parameters, i.e. resting LES pressure and LES length, was performed on 138 children with GER. Manometric parameters, resting LES pressure and LES length, measured at the preliminary study (0) and control studies (after 1, 2 and 8 years), were prospectively assessed in 138 children. The assessment resulted from clinical observation and/or conservative treatment.

RESULTS

The mean value of resting LES pressure (mm Hg) before treatment was x=11.75+/-3.98 in Group 1, x=11.05+/-3.31 in Group 2, and x=14.17+/-3.86 in Group 3 (reference group). After 2 years of clinical observation, the mean value of resting LES pressure accounted for x=13.71+/-3.88 in Group 1, x=13.01+/-2.94 in Group 2, and x=17.92+/-3.36 in Group 3. The mean LES length (cm) before treatment accounted for x=1.68+/-0.72 in Group 1, x=1.78+/-0.70 in Group 2, and x=2.0+/-0.86 in Group 3. After 2 years of clinical observation, the mean LES length was x=2.80+/-0.40 in Group 1, x=2.76+/-0.40 in Group 2, and x=2.97+/-0.48 in Group 3. 12 children with persistent GERD (Group 1) and 8 children with persistent GERD and food allergy (Group 2) underwent manometric evaluation of LES after 8 years. No statistical differentiation of the mean values of resting LES pressure and LES length were shown in examined children of Groups 1 and 2 during prospective studies.

CONCLUSIONS

Manometric studies of LES assessing only resting LES pressure and its length in the examined children with acid GER do not clearly differentiate GER into primary and secondary refluxes to food allergy.

24-hour esophageal pH-monitoring in children suspected of gastroesophageal reflux disease: Analysis of intraesophageal pH monitoring values recorded in distal and proximal channel at diagnosis

AIM: To assess values of 24-h esophageal pH-monitoring parameters with dual-channel probe (distal and proximal channel) in children suspected of gastroesophageal reflux disease (GERD).

METHODS: 264 children suspected of gastroesophageal reflux (GER) were enrolled in a study (mean age χ = 20.78 ± 17.23 mo). The outcomes of this study, immunoallerrgological tests and positive result of oral food challenge test with a potentially noxious nutrient, enabled to qualify children into particular study groups.

RESULTS: 32 (12.1%) infants (group 1) had physiological GER diagnosed. Pathological acid GER was confirmed in 138 (52.3%) children. Primary GER was diagnosed in 76 (28.8%) children (group 2) and GER secondary to allergy to cow milk protein and/or other food (CMA/FA) in 62 (23.5%) children (group 3). 32 (12.1%) of them had CMA/FA (group 4-reference group), and in remaining 62 (23.5%) children neither GER nor CMA/FA was confirmed (group 5). Mean values of pH monitoring parameters measured in distal and proximal channel were analyzed in individual groups. This analysis showed statistically significant differentiation of mean values in the case of: number of episodes of acid GER, episodes of acid GER lasting > 5 min, duration of the longest episode of acid GER in both channels, acid GER index total and supine in proximal channel. Statistically significant differences of mean values among examined groups, especially between group 2 and 3 in the case of total acid GER index (only distal channel) were confirmed.

CONCLUSION: 24-h esophageal pH monitoring confirmed pathological acid GER in 52.3% of children with typical and atypical symptoms of GERD. The similar pH-monitoring values obtained in group 2 and 3 confirm the necessity of implementation of differential diagnosis for primary vs secondary cause of GER.

[Predominant respiratory symptoms in indications for prolonged esophageal pH-monitoring in children]

BACKGROUND

An increasing prevalence of extraesophageal complications of gastroesophageal reflux (GER) has been seen. Evaluation of clinical profiles of patients submitted to prolonged esophageal pH monitoring could help to identify the patients who could benefit from the early diagnosis of GER.

OBJECTIVE

To evaluate the population, indications and results of esophageal pH-monitoring for the diagnosis of GER in a pediatric gastroenterology clinic.

PATIENTS AND METHODS

Data from 190 children and adolescents who had esophageal pH-monitoring were analyzed. A descriptive analysis of the population was performed and the children were categorized in five groups according to the age. The equipment used was a Digitrapper MKIII (Synetics) and all data were analyzed by using a software EsopHogram 5.7. Reflux index was established for analysis.

RESULTS

The most frequent indications for the exam were: asthma (26.8%), apnea/cyanosis (20%), recurrent pulmonary infections (18.4%), wheezing infant syndrome (15.8%) and chronic cough/horseness (11%). The most frequent groups of age for the respiratory symptoms were: asthma--above 5 years (92.2%); apnea/cyanosis--under 3 months (55.3%); recurrent pulmonary infections and wheezing infant syndrome--3 to 12 months (31.4% and 83.3%). Reflux index of patients with positive exam for GER was significantly higher in patients under 2 years than above 2 years of age.

CONCLUSION

Respiratory symptoms were predominant among the indications for esophageal pH-monitoring in children. The knowledge of the clinical profile of the patients who had esophageal pH monitoring could help to improve the technical quality of the exam.

Outcome of laparoscopic Nissen-Rossetti fundoplication in children with gastroesophageal reflux disease and supraesophageal symptoms

BACKGROUND

The role of surgery is debated for children with gastroesophageal reflux disease (GERD), particularly when they show atypical symptoms. This study was designed to evaluate the safety and outcome of laparoscopic Nissen-Rossetti fundoplication performed in a selected population of children with gastroesophageal reflux and atypical supraesophageal symptoms.

METHODS

This prospective study included 595 patients younger than 14 years with GERD who reported recurrent respiratory symptoms and had no benefit from standard medical treatment. Surgery was performed for 48 patients with anatomic anomalies, life-threatening events, or respiratory complications after ineffective medical treatment. The subjective and objective outcomes were evaluated.

RESULTS

No major intraoperative complications were experienced, and there was no recurrence of gastroesophageal reflux during a postoperative follow-up period of 12 months. The parents' final subjective evaluation of the outcomes 12 months after surgery was positive in 44 cases and negative in 4 cases.

CONCLUSIONS

Children with difficult-to-treat chronic respiratory symptoms must be evaluated for GERD, even if the need for surgery is low (8%), because complete eradication of reflux is mandatory. Radical treatment of GERD allows the pulmonologist to perform correct respiratory treatment and to prevent the development chronic and life-threatening complications.