Extra-esophageal manifestations of gastroesophageal reflux

Identifying causal relationships between gastroesophageal reflux and extraesophageal diseases: A Mendelian randomization study

Traditional observational and in vivo studies have suggested an etiological link between gastroesophageal reflux disease (GERD) and the development of extraesophageal diseases (EEDs), such as noncardiac chest pain. However, evidence demonstrating potential causal relationships is lacking. This study evaluated the potential causal relationship between GERD and EEDs, including throat and chest pain, asthma, bronchitis, chronic rhinitis, nasopharyngitis and pharyngitis, gingivitis and periodontal disease, cough, using multiple Mendelian randomization (MR) methods, and sensitivity analysis was performed. The Mendelian randomization Pleiotropy RESidual Sum and Outlier and PhenoScanner tools were used to further check for heterogeneous results and remove outliers. MR with inverse-variance weighted (IVW) showed a significant causal relationship between GERD and EEDs after Bonferroni correction. IVW results indicated that GERD increased the risk of chronic rhinitis, nasopharyngitis and pharyngitis (odds ratio [OR] = 1.482, 95% confidence interval [CI] = 1.267-1.734, P < .001], gingivitis and periodontal disease (OR = 1.166, 95% CI = 1.046-1.190, P = .001), throat and chest pain (OR = 1.585, 95% CI = 1.455-1.726, P < .001), asthma (OR = 1.539, 95% CI = 1.379-1.717, P < .001), and bronchitis (OR = 1.249, 95% CI = 1.168-1.335, P < .001). Sensitivity analysis did not detect pleiotropy. Leave-one-out analysis shows that MR results were not affected by individual single nucleotide polymorphisms. The funnel plot considers the genetic instrumental variables to be almost symmetrically distributed. This MR supports a causal relationship among GERD and EEDs. Precise moderation based on causality and active promotion of collaboration among multidisciplinary physicians ensure high-quality diagnostic and treatment recommendations and maximize patient benefit.

Extra-Esophageal Presentation of Gastroesophageal Reflux Disease: 2020 Update

Gastroesophageal reflux disease (GERD) is defined by the presence of symptoms induced by the reflux of the stomach contents into the esophagus. Although clinical manifestations of GERD typically involve the esophagus, extra-esophageal manifestations are widespread and less known. In this review, we discuss extra-esophageal manifestations of GERD, focusing on clinical presentations, diagnosis, and treatment. Common extra-esophageal manifestations of GERD include chronic cough, asthma, laryngitis, dental erosions, and gingivitis. Extra-esophageal involvement can be present also when classic GERD symptoms are absent, making the diagnosis more challenging. Although available clinical studies are heterogeneous and frequently of low quality, a trial with proton pump inhibitors can be suggested as a first-line diagnostic strategy in case of suspected extra-esophageal manifestations of GERD.

Upper digestive tract abnormalities in dogs with chronic idiopathic lymphoplasmacytic rhinitis

BACKGROUND

Chronic idiopathic lymphoplasmacytic rhinitis (CILPR) is a common inflammatory disorder of unknown etiology affecting the nasal cavity of dogs. The diagnosis is made by exclusion of other causes of nasal disease and specific therapeutic protocols are lacking. In human medicine, a relationship between CILPR and gastrointestinal clinical signs has been postulated, and remission of respiratory signs after clinical trials with medications for gastrointestinal disorders has been observed.

OBJECTIVES

To describe history, clinical presentation, endoscopic and histopathologic concurrent respiratory and digestive tract abnormalities, and to evaluate improvement of respiratory signs after treatment for gastrointestinal signs.

ANIMALS

Twenty-five dogs with CILPR.

METHODS

Prospective study. For inclusion, following information had to be available: respiratory and digestive clinical signs, airway and digestive tract endoscopic abnormalities, histologic evaluation of respiratory and gastrointestinal tract biopsy specimens, and clinical response to different treatment strategies.

RESULTS

Twenty-two dogs had endoscopic gastrointestinal lesions, whereas 13 dogs had concurrent gastrointestinal signs. Most esophageal and duodenal endoscopic abnormalities were classified as moderate or severe. Respiratory and gastrointestinal tract histologic evaluation identified mostly chronic inflammation. Remission or marked improvement of respiratory signs was observed in the majority of dogs treated only for gastrointestinal signs up to 12 months after endoscopy. No significant associations between treatments and follow-up information were found.

CONCLUSION AND CLINICAL IMPORTANCE

Nasal and upper digestive tract abnormalities coexist in some dogs with CILPR. Lack of standardized therapeutic protocols suggests caution when interpreting improvement in nasal clinical signs. Additional studies are needed to explore the possibility of a cause-effect relationship between the 2 processes.

Individualising care in severe bronchopulmonary dysplasia: a series of N-of-1 trials comparing transpyloric and gastric feeding

OBJECTIVE

Compare rates of hypoxaemia during transpyloric and gastric feedings in very preterm infants with severe bronchopulmonary dysplasia.

DESIGN

N-of-1 multiple crossover trials with individual patient and pooled data analyses.

SETTING

Level IV intensive care nursery.

PATIENTS

Infants receiving positive airway pressure between 36 and 55 weeks postmenstrual age were enrolled between December 2014-July 2016.

INTERVENTION

N-of-1 trial consisting of two blocks, each with a 4-day gastric and 4-day transpyloric feeding period assigned in random order.

MAIN OUTCOME MEASURES

The primary outcome was the frequency of daily intermittent hypoxaemic events (SpO₂ ≤80% lasting 10-180 s). Secondary outcomes included the daily proportion of time with an SpO₂ ≤80% and mean daily fraction of inspired oxygen.

RESULTS

Of 15 infants, 13 completed the trial and 2 stopped early for transient worsening in respiratory status during gastric feedings. In the intention-to-treat analyses, transpyloric feedings resulted in increased rates of intermittent hypoxaemia in five infants, greater time per day in hypoxaemia in three infants and more supplemental oxygen use in three infants. One infant received more supplemental oxygen during gastric feedings. The remaining study outcomes were similar between the feeding routes in all other infants. Pooling all data, transpyloric feedings resulted in a higher frequency of intermittent hypoxaemic events (median 7.5/day (IQR 1-23.5) vs 3/day (1-11); adjusted incidence rate ratio 1.8, 95% CI 1.3 to 2.5) and a greater proportion of daily hypoxaemia time (median 0.8% (IQR 0.1-2.3) vs 0.4% (0.07-1.8); adjusted mean difference 1.6, 95% CI 1.1 to 2.5).

CONCLUSIONS

Transpyloric compared with gastric feedings modestly increased rates of hypoxaemia among study participants.

TRIAL REGISTRATION NUMBER

NCT02142621.

[Investigation of laryngopharyngeal reflux prevalence and risk factors in otolaryngology]

Objective:To investigate the prevalence and related risk factors of laryngopharyngeal reflux in otolaryngology. Method:During January 2019 to March 2019, the inpatients in otolaryngology were investigated by the questionnaire of reflux symptom index scale and the laryngopharyngeal reflux related risk factors were analyzed. Result:Among the 227 patients, 33 patients with suspected LPR contained 19 patients（20.7%） of 92 patients in the laryngopharyngeal group, 10 patients（16.1%） of 62 patients in the nasal group, and 4 patients（5.5%） of 73 patients in the ear group. LPR prevalence in the laryngopharyngeal group was statistically different from that in the ear group（P<0.05）. Univariate logistic regression analysis showed that age, gender, smoking, drinking and BMI were risk factors of LPR（P<0.01）. Multivariate logistic regression analysis indicated that BMI was an independent risk factor of LPR（P<0.01）. Conclusion:LPR had a high prevalence rate in otolaryngology related diseases, and appropriate synergistic anti-LPR treatment could be carried out while treating otolaryngology related diseases.

Characteristics of upright versus supine reflux pattern in patients with laryngopharyngeal reflux

INTRODUCTION

Many laryngeal-related problems have been attributed to laryngopharyngeal reflux including dysphonia, frequent throat clearing, chronic cough, and globus sensation. However, there is still controversy regarding diagnosis and clinical presentation of this disorder.

OBJECTIVE

The main objective of this study is to describe laryngopharyngeal reflux characteristics of different reflux position patterns in laryngopharyngeal reflux patients diagnosed with oropharyngeal pH monitoring.

METHODS

A retrospective chart review was conducted for 161 laryngopharyngeal reflux patients diagnosed with 24h oro-pharyngeal pH monitoring. Study subjects were categorized into upright and supine laryngopharyngeal reflux groups based on the pH results. The two groups were compared regarding the clinical presentation and pH characteristics.

RESULTS

Significant higher rates of upright laryngopharyngeal reflux position than supine laryngopharyngeal reflux position (P<0.0001) were reported among the study group. Reflux symptoms index results were significantly higher in the upright larybgopharyngeal reflux group compared to the supine laryngopharyngeal reflux group. 24h oropharyngeal pH measurements composite Ryan score was significantly higher in the upright group compared to the supine group (P<0.0001). No significant difference was found between the upright and supine laryngopharyngeal reflux groups regarding the frequency of clinical presentation or voice handicap index ratings.

CONCLUSION

Laryngopharyngeal reflux was found to be more prevalent occurring in the upright position among the study group. Reflux-related characteristics including pH parameters were more evident in the upright laryngopharyngeal reflux position.

Updates in the field of non-esophageal gastroesophageal reflux disorder

Introduction: Gastroesophageal reflux disease (GERD) is one of the most prevalent conditions in Western Countries, normally presenting with heartburn and regurgitation. Extra-esophageal (EE) GERD manifestations, such as asthma, laryngitis, chronic cough and dental erosion, represent the most challenging aspects from diagnostic and therapeutic points of view because of their multifactorial pathogenesis and low response to proton pump inhibitors (PPIs). In fact, in the case of EE, other causes must by preventively excluded, but instrumental methods, such as upper gastrointestinal endoscopy and laryngoscopy, have low specificity and sensitivity as diagnostic tools. In the absence of alarm signs and symptoms, empirical therapy with a double-dose of PPIs is recommended as a first diagnostic approach. Subsequently, impedance-pH monitoring could help to define whether the symptoms are GERD-related. Areas covered: This article reviews the current literature regarding established and proposed EE-GERD, reporting on all available options for its correct diagnosis and therapeutic management. Expert opinion: MII-pH could help to identify a hidden GERD that causes EE. Unfortunately, standard MII-pH analysis results are often unable to define this association. New parameters such as the mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index may have an improved diagnostic yield, but prospective studies using impedance-pH are needed.

Matrix association region/scaffold attachment region: the crucial player in defining the positions of chromosome breaks mediated by bile acid-induced apoptosis in nasopharyngeal epithelial cells

Background

It has been found that chronic rhinosinusitis (CRS) increases the risk of developing nasopharyngeal carcinoma (NPC). CRS can be caused by gastro-oesophageal reflux (GOR) that may reach nasopharynx. The major component of refluxate, bile acid (BA) has been found to be carcinogenic and genotoxic. BA-induced apoptosis has been associated with various cancers. We have previously demonstrated that BA induced apoptosis and gene cleavages in nasopharyngeal epithelial cells. Chromosomal cleavage occurs at the early stage of both apoptosis and chromosome rearrangement. It was suggested that chromosome breaks tend to cluster in the region containing matrix association region/scaffold attachment region (MAR/SAR). This study hypothesised that BA may cause chromosome breaks at MAR/SAR leading to chromosome aberrations in NPC. This study targeted the AF9 gene located at 9p22 because 9p22 is a deletion hotspot in NPC.

Methods

Potential MAR/SAR sites were predicted in the AF9 gene by using MAR/SAR prediction tools. Normal nasopharyngeal epithelial cells (NP69) and NPC cells (TWO4) were treated with BA at neutral and acidic pH. Inverse-PCR (IPCR) was used to identify chromosome breaks in SAR region (contains MAR/SAR) and non-SAR region (does not contain MAR/SAR). To map the chromosomal breakpoints within the AF9 SAR and non-SAR regions, DNA sequencing was performed.

Results

In the AF9 SAR region, the gene cleavage frequencies of BA-treated NP69 and TWO4 cells were significantly higher than those of untreated control. As for the AF9 non-SAR region, no significant difference in cleavage frequency was detected between untreated and BA-treated cells. A few breakpoints detected in the SAR region were mapped within the AF9 region that was previously reported to translocate with the mixed lineage leukaemia (MLL) gene in an acute lymphoblastic leukaemia (ALL) patient.

Conclusions

Our findings suggest that MAR/SAR may be involved in defining the positions of chromosomal breakages induced by BA. Our report here, for the first time, unravelled the relation of these BA-induced chromosomal breakages to the AF9 chromatin structure.

Electronic supplementary material

The online version of this article (10.1186/s12920-018-0465-4) contains supplementary material, which is available to authorized users.

Establishment of a novel and effective reflux laryngitis model in rabbits: a preliminary study

PURPOSE

To establish a novel and effective reflux model with a modified nasogastric aspiration tube and to investigate the association between different types of nasogastric aspiration tubes and reflux laryngitis, we conducted this study.

METHODS

Thirty-eight healthy New Zealand albino rabbits (2.5-3.5 kg) were divided into three groups: control (CTR, n = 6)-non-intubated; normal nasogastric intubation (NNI, n = 16)-intubated with 4#, 6#, 8#, and 10# normal nasogastric aspiration tubes; and modified nasogastric intubation (MNI, n = 16)-intubated with 4#, 6#, 8#, and 10# modified nasogastric aspiration tubes. The laryngoscopy, body weight, and pH values at the esophageal entrance were recorded before and 1, 2, and 4 weeks after intubation. After the final laryngoscopy, the animals in groups with a pH below 4 were sacrificed to obtain histological and gene expression analysis results.

RESULTS

The reflux finding score (RFS) after 4 weeks showed that there was a statistically significant difference in the 8# NNI group (7 ± 0.816, P < 0.001), the 8# MNI group (11.5 ± 2.517, P < 0.001) and the 10# MNI (12.75 ± 1.893, P < 0.001) group compared with the control group (1.83 ± 1.602). The pH values of these three groups were lower than 4. However, the weight loss of the rabbits in the 10# NNI and 10# MNI groups was more obvious. Submucous gland hyperplasia and inflammation were significantly increased in the 8# NNI group, 8# MNI group and the 10# MNI group, but in the level of some pro-inflammatory cytokines and COX-2, the MNI group was significantly higher than the NNI group (8# NNI × 8# MNI, P < 0.01; 8# MNI × 10# MNI, P < 0.01).

CONCLUSION

This study showed that 8# modified nasogastric intubation (MNI) produces effective reflux laryngitis in the rabbits.

Prevalence and clinical characteristics of refractoriness to optimal proton pump inhibitor therapy in non-erosive reflux disease

BACKGROUND

The real size of the gastro-oesophageal reflux disease (GERD) population not responding to proton pump inhibitor (PPI) therapy has still not been fully elucidated. Causes of PPI refractoriness include incorrect diagnosis and lack of adherence to therapy, in terms of incorrect dosage and timing.

AIMS

To evaluate the prevalence of refractoriness to optimal PPI therapy and the contribution of non-erosive reflux disease (NERD), reflux hypersensitivity, and functional heartburn, to PPI refractoriness. The association of functional GI symptoms in non-responders was evaluated.

METHODS

Frequency and severity of GERD symptoms (heartburn, regurgitation, chest pain), dysphagia, belching, epigastric pain, postprandial distress, irritable bowel syndrome (IBS), globus, and ear nose and throat (ENT) symptoms were evaluated in patients previously classified as non-responders. Patients with at least one of the oesophageal symptoms with a frequency ≥3 /week were treated with esomeprazole 40 mg once daily for 8 weeks and then re-evaluated. Non-responders (patients with oesophageal symptoms ≥3 times per week) underwent 24 hour multichannel intraluminal impedance-pH monitoring.

RESULTS

Of 573 consecutive patients, 92 with oesophageal symptoms and classified as PPI-refractory underwent the esomeprazole trial; 60 did not respond. IBS, epigastric pain, and post-prandial distress episodes were associated with a poor response on multivariate analysis. NERD, reflux hypersensitivity, and functional heartburn patients constituted 32%, 42%, and 26%, respectively of the PPI-refractory group.

CONCLUSIONS

True refractoriness in patients with GERD symptoms attending a secondary care setting is lower than previously reported. Following a careful history and optimal PPI dosing, the rate of refractoriness was 20%. True NERD constitutes only a third of the PPI-refractory group.

Bile acids at neutral and acidic pH induce apoptosis and gene cleavages in nasopharyngeal epithelial cells: implications in chromosome rearrangement

BACKGROUND

Chronic rhinosinusitis (CRS) increases the risk of developing nasopharyngeal carcinoma (NPC) while nasopharyngeal reflux is known to be one of the major aetiological factors of CRS. Bile acid (BA), the component of gastric duodenal contents, has been recognised as a carcinogen. BA-induced apoptosis was suggested to be involved in human malignancies. Cells have the potential and tendency to survive apoptosis. However, cells that evade apoptosis upon erroneous DNA repair may carry chromosome rearrangements. Apoptotic nuclease, caspase-activated deoxyribonuclease (CAD) has been implicated in mediating translocation in leukaemia. We hypothesised that BA-induced apoptosis may cause chromosome breaks mediated by CAD leading to chromosome rearrangement in NPC. This study targeted the AF9 gene located at 9p22 because 9p22 is one of the most common deletion sites in NPC.

METHODS

We tested the ability of BA at neutral and acidic pH in inducing phosphatidylserine (PS) externalisation, reactive oxygen species (ROS) production, mitochondrial membrane potential (MMP) disruption, and caspase 3/7 activity in normal nasopharyngeal epithelial (NP69) and NPC (TWO4) cells. Inverse-PCR (IPCR) was employed to detect AF9 gene cleavages. To investigate the role of CAD in mediating these cleavages, caspase inhibition was performed. IPCR bands representing AF9 cleaved fragments were sequenced.

RESULTS

BA-treated cells showed higher levels of PS externalisation, ROS production, MMP loss and caspase 3/7 activity than untreated control cells. The effect of BA in the induction of these intracellular events was enhanced by acid. BA at neutral and acidic pH also induced significant cleavage of the AF9 gene. These BA-induced gene cleavages were inhibited by Z-DEVD-FMK, a caspase-3 inhibitor. Intriguingly, a few chromosome breaks were identified within the AF9 region that was previously reported to participate in reciprocal translocation between the mixed lineage leukaemia (MLL) and AF9 genes in an acute lymphoblastic leukaemia (ALL) patient.

CONCLUSIONS

These findings suggest a role for BA-induced apoptosis in mediating chromosome rearrangements in NPC. In addition, CAD may be a key player in chromosome cleavages mediated by BA-induced apoptosis. Persistent exposure of sinonasal tract to gastric duodenal refluxate may increase genomic instability in surviving cells.

Diagnosis of Lingual Atrophic Conditions: Associations with Local and Systemic Factors. A Descriptive Review

Atrophic glossitis is a condition characterised by absence of filiform or fungiform papillae on the dorsal surface of the tongue. Consequently, the ordinary texture and appearance of the dorsal tongue, determined by papillary protrusion, turns into a soft and smooth aspect.

Throughout the years, many factors, both local and systemic, have been associated with atrophic glossitis as the tongue is currently considered to be a mirror of general health. Moreover, various tongue conditions were wrongly diagnosed as atrophic glossitis. Oral involvement can conceal underlying systemic conditions and, in this perspective, the role of clinicians is fundamental.

Early recognition of oral signs and symptoms, through a careful examination of oral anatomical structures, plays a crucial role in providing patients with a better prognosis.

Correlation between laryngobronchoscopy and pepsin in the diagnosis of extra-oesophageal reflux

Objective:

This study aimed to investigate pepsin as a marker of extra-oesophageal reflux disease by examining its presence in tracheal aspirates and correlating it with macroscopic changes on laryngobronchoscopy, along with the results of standard tests for gastro-oesophageal reflux disease and clinical features.

Methods:

A retrospective review was undertaken of a cohort of 188 paediatric patients who underwent laryngobronchoscopy at a tertiary children's hospital and for whom pepsin assay results of tracheal aspirates were available. An association analysis was performed.

Results:

The mean patient age was 3.99 (3.40–4.58) years, with a male preponderance (55 per cent). Positive changes on laryngobronchoscopy were significantly associated with positive tracheal pepsin findings (p< 0.0001) but not with positive standard gastro-oesophageal reflux disease investigations. A positive pepsin assay was significantly associated with a history of recurrent croup (p= 0.0385) and a diagnosis of cystic fibrosis (p= 0.0232).

Conclusion:

Macroscopic changes on laryngobronchoscopy were significantly associated with positive tracheal pepsin findings in this paediatric population, suggesting that extra-oesophageal reflux disease may be a contributing aetiology.

Micronuclei and nuclear abnormalities in buccal mucosa cells in patients with anorexia and bulimia nervosa

The aim of this study is to assess the frequency of micronucleated cell (MNC) and nuclear abnormalities (NA) in the buccal mucosa cells of females with anorexia nervosa (AN) or bulimia nervosa (BN), compared with healthy women. Individuals with AN and BN have inadequate feeding and compensatory behaviour to avoid weight gain. These behaviours can cause extreme body stress, thereby inducing DNA damage. In a cross-sectional study, we assessed the frequency of MNC and NA in the buccal mucosa cells of female participants with AN or BN. All of these patients had been admitted to a private clinic for the treatment of eating disorders after diagnosis with AN (n = 10) or BN (n = 7) according to the DSM-IV. Age-matched healthy female participants (n = 17) composed the control group. Oral mucosa samples were collected, fixed, stained by aceto-orcein/fast green and microscopically examined. Normal cells, MNC and NAs were counted within a 2000 cell sample. The results were analyzed with the Kruskal-Wallis and Mann-Whitney tests. Differences were observed in the frequency of MNC in healthy females (1.2±0.9) versus that of patients with AN (3.4±1.5) (P < 0.0001) and BN (4.1±2.2) (P < 0.001). No differences were found among these groups in terms of NA. AN and BN are related to the loss of genetic material through chromosomal fractures and/or damage to the mitotic spindle (i.e. possibly a result of a deficiency in DNA precursors). Self-imposed compensatory behaviours in AN and BN, such as severe food restriction, potential malnutrition, vomiting, use of diuretics and laxatives and acute exhaustive exercise, are possible inducers of MNC and genotoxic damage. Of these compensatory behaviours, only vomiting has not been linked to genotoxic damage. This is the first report in women with BN, which should be studied in the future.

Dental approach to erosive tooth wear in gastroesophageal reflux disease

BACKGROUND

The duration of gastro-esophageal reflux disease (GERD), the frequency of reflux, the pH and type of acid, and the quality and quantity of saliva affect the severity of dental erosion due to GERD.

OBJECTIVE

To summarize the diagnostic protocol and treatment of dental erosion due to GERD.

METHODS

A Medline literature search was performed to identify articles associated with a dental approach to GERD.

RESULTS

The dental professional must carry out a diagnostic protocol, which includes collecting data on the patient's medical and dietary history, occupational/recreational history, dental history, and oral hygiene methods. Intraoral, head and neck, and salivary function examinations should be performed to expose the dental implications of GERD symptoms.

CONCLUSION

Diagnosing the cause of erosive tooth wear can help prevent further damage. Patients must be informed about how to prevent GERD.

Reflux-associated oxygen desaturations: usefulness in diagnosing reflux-related respiratory symptoms

BACKGROUND

Current diagnostic techniques establishing gastroesophageal reflux disease as the underlying cause in patients with respiratory symptoms are poor. Our aim was to provide additional support to our prior studies suggesting that the association between reflux events and oxygen desaturations may be a useful discriminatory test in patients presenting with primary respiratory symptoms suspected of having gastroesophageal reflux as the etiology.

METHODS

Thirty-seven patients with respiratory symptoms, 26 with typical symptoms, and 40 control subjects underwent simultaneous 24-h impedance-pH and pulse oximetry monitoring. Eight patients returned for post-fundoplication studies.

RESULTS

The median number (interquartile range) of distal reflux events associated with oxygen desaturation was greater in patients with respiratory symptoms (17 (9-23)) than those with typical symptoms (7 (4-11, p < 0.001)) or control subjects (3 (2-6, p < 0.001)). A similar relationship was found for the number of proximal reflux-associated desaturations. Repeat study in seven post-fundoplication patients showed marked improvement, with reflux-associated desaturations approaching those of control subjects in five patients; 20 (9-20) distal preoperative versus 3 (0-5, p = 0.06) postoperative; similar results were identified proximally.

CONCLUSIONS

These data provide further proof that reflux-associated oxygen desaturations may discriminate patients presenting with primary respiratory symptoms as being due to reflux and may respond to antireflux surgery.

Oral symptoms including dental erosion in gastroesophageal reflux disease are associated with decreased salivary flow volume and swallowing function

BACKGROUND

This preliminary clinical study aimed to evaluate the effects of salivary flow volume and swallowing function on oral symptoms including dental erosion in gastroesophageal reflux disease (GERD).

METHODS

The subjects were 40 GERD patients and 30 (15 younger, 15 older) healthy controls. Detailed medical, dietary, and dental histories were obtained to identify individual behavioral habits potentially associated with dental erosion. Oral examination evaluated dental erosion and determined scores for the decayed, missing, filled (DMF) index, the papillary, marginal, attached (PMA) index for gingivitis, and the Simplified Oral Hygiene Index (OHI-S). Salivary flow volume and swallowing function were evaluated by the Saxon test and repetitive saliva swallowing test, respectively.

RESULTS

The DMF index and OHI-S scores differed significantly between all 3 groups. The PMA index was significantly different between the GERD group and the two control groups. The prevalence of dental erosion was 24.3% in the GERD group (0% in the control groups). No specific relationship was found between the incidence of dental erosion and dietary history or behavioral habits. The Saxon test results were significantly lower in the GERD group than in both the control groups. Frequency of swallowing was significantly lower and time to first swallow was significantly longer in the GERD group than in the two control groups.

CONCLUSIONS

Oral symptoms in GERD are likely to be associated with impaired salivary flow volume or swallowing function. Treatment for the oral dryness induced by reduced salivary flow volume and rehabilitation for swallowing function could be indicated in patients with GERD.

Laryngoscopy findings and histological results in a rabbit gastroesophageal reflux model

The role of lower esophageal sphincter (LES) in laryngopharyngeal reflux is controversial. In this study, we used an animal model to investigate the association between LES dysfunction and reflux laryngitis. Twelve healthy New Zealand albino rabbits (2.5-3.5 kg) were utilized in this study. The animals were divided into two groups. Eight rabbits underwent total cardiomyectomy to induce reflux, and the remaining four rabbits underwent a control sham operation. A laryngoscopy and a 24-hour intra-esophageal pH-metry were performed prior to surgery and again 2 and 8 weeks postsurgery. After the final laryngoscopy, all animals were sacrificed to obtain histological results. Total cardiomyectomy significantly increased the reflux index, the duration of the longest reflux episode and the total number of episodes that occurred in 24 h postsurgery. No significant difference was observed in the reflux finding score (RFS) between preoperative and 2-week postoperative rabbits (P = 0.11). But there was a statistically significant change in the RFS before and 8 weeks after the induction of reflux from 4.6 ± 0.9 to 8.3 ± 3.6 (P = 0.02). Submucous gland hyperplasia and inflammation were significantly increased in the reflux group compared to the control group. The results of this study suggest that chronic lower esophageal sphincter dysfunction is associated with reflux laryngitis in rabbits.

Nocturnal gastroesophageal reflux revisited by impedance-pH monitoring

Background/Aims

Impedance-pH monitoring allows detailed characterization of gastroesophageal reflux and esophageal activity associated with reflux. We assessed the characteristics of nocturnal reflux and esophageal activity preceding and following reflux.

Methods

Impedance-pH tracings from 11 healthy subjects and 76 patients with gastroesophageal reflux disease off acid-suppressive therapy were analyzed. Characteristics of nocturnal supine reflux, time distribution and esophageal activity seen on impedance at 2 minute intervals preceding and following reflux were described.

Results

Patients had more nocturnal reflux events than healthy subjects (8 [4-12] vs 2 [1-5], P = 0.002), with lower proportion of weakly acidic reflux (57% [35-78] vs 80% [60-100], P = 0.044). Nocturnal reflux was mainly liquid (80%) and reached the proximal esophagus more often in patients (6% vs 0%, P = 0.047). Acid reflux predominated in the first 2 hours (66%) and weakly acidic reflux in the last 3 hours (70%) of the night. Most nocturnal reflux was preceded by aboral flows and cleared by short lasting volume clearance. In patients, prolonged chemical clearance was associated with less esophageal activity.

Conclusions

Nocturnal weakly acidic reflux is as common as acid reflux in patients with gastroesophageal reflux disease, and predominates later in the night. Impedance-pH can predict prolonged chemical clearance after nocturnal acid reflux.

Influence of experimental esophageal acidification on sleep bruxism: a randomized trial

The aim of this cross-over, randomized, single-blinded trial was to examine whether intra-esophageal acidification induces sleep bruxism (SB). Polysomnography with electromyogram (EMG) of masseter muscle, audio-video recording, and esophageal pH monitoring were performed in a sleep laboratory. Twelve healthy adult males without SB participated. Intra-esophageal infusions of 5-mL acidic solution (0.1 N HCl) or saline were administered. The frequencies of EMG bursts, rhythmic masticatory muscle activity (RMMA) episodes, grinding noise, and the RMMA/microarousal ratio were significantly higher in the 20-minute period after acidic infusion than after saline infusion. RMMA episodes including SB were induced by esophageal acidification. This trial is registered with the UMIN Clinical Trials Registry, UMIN000002923.

ABBREVIATIONS

ASDA, American Sleep Disorders Association; EMG, electromyogram; GER, gastroesophageal reflux; LES, lower esophageal sphincter; NREM, non-rapid eye movement; REM, rapid eye movement; RMMA, rhythmic masticatory muscle activity; SB, sleep bruxism; SD, standard deviation; UES, upper esophageal sphincter.

Randomised clinical trial: high-dose acid suppression for chronic cough - a double-blind, placebo-controlled study

BACKGROUND

Cough may be a manifestation of gastro-oesophageal reflux disease (GERD). The utility of acid suppression in GERD-related cough is uncertain.

AIM

To assess the impact of high-dose acid suppression with proton pump inhibitors (PPI) on chronic cough in subjects with rare or no heartburn.

METHODS

Subjects were nonsmokers without history of asthma, with chronic cough for >8 weeks. All subjects underwent a baseline 24-h pH/impedance study, methacholine challenge test and laryngoscopy. Subjects were randomised to either 40 mg of esomeprazole twice daily or placebo for 12 weeks. The primary outcome measure was the Cough-Specific Quality of Life Questionnaire (CQLQ). Secondary outcomes were response on Fisman Cough Severity/Frequency scores and change in laryngeal findings.

RESULTS

Forty subjects were randomised (22 PPI, 18 placebo) and completed the study. There was no difference between PPI and placebo in CQLQ (mean improvement 9.8 vs. 5.9 respectively, P = 0.3), or Fisman Cough Severity/Frequency scores. Proportion of patients who improved by >1 s.d. on the CQLQ was 27.8% (five of 18) and 31.8% (seven of 22) in the placebo and PPI groups respectively.

CONCLUSION

In subjects with chronic cough and rare or no heartburn, high-dose proton pump inhibitor does not improve cough-related quality of life or symptoms.

Pharyngolaryngeal reflux in patients who underwent cervical esophago-gastrostomy following esophagectomy

Pharyngolaryngeal reflux has been generally accepted as a cause for pharyngolaryngitis, hoarseness, aspiration pneumonia, chronic cough, and nocturnal asthma. Although patients who have undergone gastric conduit reconstruction after esophagectomy are at a high risk to pharyngolaryngeal reflux disease (PLRD), PLRD after esophagectomy is still unknown. The aim of this study is to investigate the correlation between reflux pharyngolaryngitis and acid reflux into the hypopharynx and into the cervical esophagus in patients who have undergone cervical esophagogastrostomy. We enrolled 62 patients who received follow-up endoscopy and 24-h pH monitoring after cervical esophagogastrostomy. These included 26 at 1 month after surgery and 36 at 1 year or more after surgery. We investigated: (i) the correlation between the extent of reflux pharyngolaryngitis and that of reflux esophagitis based on endoscopic findings; and (ii) the correlation between the extent of reflux pharyngolaryngitis and that of acid exposure -'% time pH < 4' measured by 24-h pH monitoring - in the hypopharynx and in the cervical esophagus, and of acidity in the gastric conduit. There was no difference in acid exposure between the hypopharynx and the cervical esophagus according to time after surgery. However, the acidity in the gastric conduit was significantly more at one year or more after surgery compared with acidity at 1 month after surgery (P= 0.001). There was a significant correlation between acid exposure in the hypopharynx and that in the cervical esophagus (P < 0.001), although acid exposure in the hypopharynx was significantly less than that in the cervical esophagus (P < 0.001). A significant correlation between reflux pharyngolaryngitis and reflux esophagitis was observed (P < 0.001). There was a significant correlation between reflux pharyngolaryngitis and acid exposure in the hypopharynx (P= 0.021), and also that in the proximal esophagus (P= 0.001). The correlation between the extent of reflux pharyngolaryngitis and the acidity in the gastric conduit was not observed. These findings are consistent with pharyngolaryngitis being caused by gastro-esophago-pharyngolaryngeal reflux in patients after cervical esophagogastrostomy, despite the upper esophageal sphincter strongly preventing acid reflux from the cervical esophagus into the hypopharynx.

Cross-organ sensitization of thoracic spinal neurons receiving noxious cardiac input in rats with gastroesophageal reflux

Gastroesophageal reflux (GER) frequently triggers or worsens cardiac pain or symptoms in patients with coronary heart disease. This study aimed to determine whether GER enhances the activity of upper thoracic spinal neurons receiving noxious cardiac input. Gastric fundus and pyloric ligations as well as a longitudinal myelotomy at the gastroesophageal junction induced acute GER in pentobarbital-anesthetized, paralyzed, and ventilated male Sprague-Dawley rats. Manual manipulations of the stomach and lower esophagus were used as surgical controls in another group. At 4-9 h after GER surgery, extracellular potentials of single neurons were recorded from the T3 spinal segment. Intrapericardial bradykinin (IB) (10 microg/ml, 0.2 ml, 1 min) injections were used to activate cardiac nociceptors, and esophageal distensions were used to activate esophageal afferent fibers. Significantly more spinal neurons in the GER group responded to IB compared with the control group (69.1 vs. 38%, P < 0.01). The proportion of IB-responsive neurons in the superficial laminae of GER animals was significantly different from those in deeper layers (1/8 vs. 46/60, P < 0.01); no difference was found in control animals (7/25 vs. 20/46, P > 0.05). Excitatory responses of spinal neurons to IB in the GER group were greater than in the control group [32.4 +/- 3.5 impulses (imp)/s vs. 13.3 +/- 2.3 imp/s, P < 0.01]. Forty-five of 47 (95.7%) neurons responded to cardiac input and ED, which was higher than the control group (61.5%, P < 0.01). These results indicate that acute GER enhanced the excitatory responses of thoracic spinal neurons in deeper laminae of the dorsal horn to noxious cardiac stimulus.

Reflux disease as an etiological factor of dental erosion

Introduction Gastroesophageal reflux is a frequent disease which has a significant influence on the development of dental erosions. Objective The aim of this research was to determine the frequency of dental erosions among the patients with gastroesophageal reflux, as well as to verify the most common symptoms of gastroesophageal disease. Methods The research comprised of two groups, each consisting of 30 patients aged 18-80 years. The experimental group comprised of patients diagnosed with gastroesophageal reflux disease (GERD), while the control group was composed of patients who were not diagnosed with GERD. Based on the illness history data, all patients of the experimental group were registered to have gastroesophageal and extraesophageal symptoms. Dental erosions were diagnosed during a stomatological inspection by using index system according to Eccles and Jenkins. Data processing was accomplished by the Statgraphics Centurion software package. Results Dental erosions were found in 76.7% of experimental group patients, and in 53.3% of control group patients. Fortynine percent of teeth of the experimental group patients and 31.1% of the control group patients showed erosive changes. On average, the number of teeth with erosions in the experimental group was 15.7 per person and in the control group 10 per person. The teeth of the front region of the upper jaw, as well as the lower first molars had the highest average value of dental erosion index. In the experimental group 12.8% of teeth and 24% of teeth in the control group were diagnosed to have dental erosion index value 1. Furthermore, 23.4% of teeth in the experimental group and 7.1% of teeth in the control group were registered to have dental erosion index value 2. Finally, the dental erosion index value 3 was found in 13.0% of teeth in the experimental group only. The highest average value of regional erosion index in the experimental group was found in the region 13-23 equalling 1.0. The same value in the control group equalled 0.6. In the experimental group the average value of dental erosion index for the upper jaw was 0.9, while this value for the lower jaw equalled 0.8. The analysis of the illness history data obtained showed that there was a statistically significant difference between the two observed groups in terms of burning pain (noncardiac in origin) around the heart area, bad breath and dentine hypersensitivity as the dominant symptom of dental erosion (p<0.05). Conclusion Dental erosions could be considered to be the extraesophageal manifestation of gastroesophageal reflux. .

Endoscopic classification for reflux pharyngolaryngitis

The quality of life in patients who have undergone surgery for esophageal cancer is frequently disturbed by postoperative gastroesophageal reflux disease or pharyngolaryngeal reflux disease. Recently, there have been many reports on gastroesophageal reflux disease after esophagectomy, and only a few on pharyngolaryngeal reflux disease. There is not yet any convenient endoscopic classification of reflux pharyngolaryngitis. We designed a new classification for reflux pharyngolaryngitis based on endoscopic findings. Our new classification consists of the five grades from 0 to IV based on (i) the extent and severity of erythema and/or edema in the pharynx and the larynx, and (ii) the extent and severity of granulation or scarring stenosis in the vocal cords. Ninety-three patients after cervical esophagogastrostomy after esophagectomy (the CEG group) and 28 patients after intrathoracic esophagogastrostomy (the TEG group) were reviewed in this study. We investigated the relation between the severity of reflux pharyngolaryngitis and clinical symptoms in these patients, and the correlation between this new classification of reflux pharyngolaryngitis and the Los Angeles classification of reflux esophagitis. Reflux esophagitis was more severe in the TEG group than in the CEG group, while there was no difference in the grading of reflux pharyngolaryngitis between the two groups. The pharyngolaryngeal symptoms and F-scale scores were not correlated with the severity of reflux pharyngolaryngitis in each group. The grading of reflux pharyngolaryngitis and that of reflux esophagitis was correlated in each group (P<0.001 in the CEG group and P=0.002 in the TEG group). We proposed a new endoscopic classification of reflux pharyngolaryngitis. The new classification of reflux pharyngolaryngitis correlated fairly well with the Los Angeles classification of reflux esophagitis, although this classification did not correlate with the clinical symptoms in patients who underwent esophagectomy. Follow-up attention including upper endoscopy should be paid to reflux pharyngolaryngitis in patients after esophagogastrostomy as well as reflux esophagitis, because there is often a lack in symptoms regardless of high incidence of pharyngolaryngitis.

Role of esophageal motility in the development of laryngopharyngeal reflux

AIM: To evaluate the role of esophageal motility in the development of laryngopharyngeal reflux.

METHODS: Esophageal manometry and 24-hour esophageal pH monitoring were performed in 22 patients suffering from reflux laryngitis (LPR group) caused by gastroesophageal reflux and 23 patients with typical gastroesophageal reflux symptoms (acid regurgitation and heartburn) but without laryngitis-related symptoms (GERD group).

RESULTS: The upper esophageal sphincter (UES) pressure and the contractile force of esophageal segment 8 cm above the lower esophageal sphincter (LES) in the LPR group were significantly lower than those in the GERD group (41.23 ± 19.61 mmHg vs 55.82 ± 20.51 mmHg, P = 0.009; 58.77 ± 30.84 mmHg vs 77.40 ± 36.12 mmHg, P = 0.035). No significant differences were noted in UES length, LES length, LES pressure and the contractile force of the remaining segments of the esophagus (3, 13, and 18 cm above LES) between the two groups. The incidence of pathological acid reflux in the LPR group was significantly lower than that in the GERD group (χ² = 3.979, P = 0.046).

CONCLUSION: UESP and the contractile force of the lower esophagus play an important role in preventing the development of laryngopharyngeal reflux.

The impact of normalization of esophageal acid profile by incremental protein pump inhibitors dosing in difficult asthma patients with proven gastro-esophageal acid reflux

BACKGROUND

GER is common in patients with asthma and some, although not all, studies have shown benefit from identification and treatment of GER.

METHODS

patients with persistent symptoms after optimisation of asthma therapy underwent pH monitoring and adjustment of GER therapy based on the results of repeated pH monitoring. Gastrointestinal symptom scores and asthma therapy requirements were recorded.

RESULTS

Over a 2 year period, 51 patients with a definite diagnosis of asthma underwent pH monitoring with GER being identified in 32 (63%). Normal oesophageal acid exposure was achieved in 11 patients, 7 requiring a daily PPI dose greater than 20 mg; 8 patients had persisting abnormal oesophageal acid exposure (OAE) despite daily PPI doses up to 80 mg. 13 patients declined further pH studies. 8 (73%) patients with normalisation of OAE had meaningful reductions in long term asthma therapy with 2 patients stopping and 2 patients reducing long term oral corticosteroids and 4 others halving the dose of inhaled corticosteroids. No patient who had persisting GER had asthma therapy reduced, neither did any of the group of patients in whom GER was not identified.

CONCLUSION

Tailoring GER therapy with repeated pH studies had a major impact in a subgroup of patients, greater than any other intervention employed in our clinic over the same period. This uncontrolled data adds to the evidence that effective management of GER reduces asthma symptomatology and allows therapy to be reduced in a subgroup of patients with difficult to control asthma.

Clinical course of laryngo-respiratory symptoms in gastro-oesophageal reflux disease during routine care--a 5-year follow-up

BACKGROUND

Gastro-oesophageal reflux disease (GERD) can be associated with laryngo-respiratory symptoms (LRS) such as chronic cough, asthma or laryngeal symptoms.

AIM

To analyse the long-term clinical course of LRS in a large population with GERD and LRS.

METHODS

ProGERD is a prospective multicentre cohort study of 6215 adult out-patients with GERD. At baseline, the prevalence of LRS was assessed. Initial standardized treatment was esomeprazole for up to 8 weeks. After 5 years of follow-up, patients were interviewed for LRS and a multivariate analysis was performed with resolved vs. persistent symptoms for chronic cough, asthma and laryngeal symptoms.

RESULTS

In all, 2886 patients (46.4%) were available for analysis at baseline and at 5 years. The prevalence of chronic cough and laryngeal disorders had decreased while the prevalence of asthma had increased. Resolution of LRS was independent of clinical reflux characteristics or PPI medication.

CONCLUSIONS

In a large population with GERD, only few patients reported persistent LRS over 5 years. Resolution of LRS was independent of the stage of GERD and PPI treatment. Accordingly, data on the direction of causality between GERD and LRS are lacking and the strength of the association between the two must remain controversial.

Utility of non-endoscopic investigations in the practical management of oesophageal disorders

The current available methods for diagnosis of GORD are symptom questionnaires, catheter and wireless pH-metry, impedance-pH monitoring and Bilitec(@). Osophageal pH monitoring allows both quantitative analysis of acid reflux and assessment of reflux-symptom association. Impedance-pH monitoring detects all types of reflux (acid and non-acid) and allows assessment of proximal extent of reflux, a relevant parameter for understanding symptoms perception and extraoesophageal symptoms. Bilitec provides a quantitative assessment of duodeno-gastro-oesophageal reflux. Oesophageal motor abnormalities have been associated with GORD symptoms as well as chest pain and dysphagia. High-resolution manometry contributed to re-classify oesphageal motor disorders. However, barium swallows are still essential for evaluation of oesophageal anatomy and combined oesophageal manometry-impedance can assess oesophageal motility and bolus transit simultaneously in a non-radiological way. Still in experimental phase, high-frequency ultrasound allows monitoring of the oesophageal wall thickness and exaggerated longitudinal muscle contraction that might be associated to chest pain and dysphagia. This chapter provides a critical evaluation of the clinical application of these techniques.

Association of gastroesophageal reflux and O2 desaturation: a novel study of simultaneous 24-h MII-pH and continuous pulse oximetry

BACKGROUND

Proof of the relationship between gastroesophageal reflux disease (GERD) and respiratory symptoms remains a challenge. Our aim was to determine the association between reflux events and O(2) desaturation in GERD patients with primary respiratory symptoms (RS) compared to those with primary esophageal symptoms (ES) using ambulatory monitoring systems.

METHODS

One thousand eight hundred fifty-one reflux episodes were detected by multichannel intraluminal impedance (MII)-pH testing in 30 patients with symptoms of GERD (20 RS, ten ES.) All patients underwent simultaneous 24-h MII-pH and continuous O(2) saturation monitoring via pulse oximetry. Reflux-associated desaturation events were determined by correlating synchronized 24-h esophageal pH and/or impedance and O(2) desaturation.

RESULTS

One thousand one hundred seventeen reflux events occurred in patients with RS and 734 in those with ES. Nearly 60% of these 1,851 reflux events were associated with O(2) desaturation. Markedly more events were associated with O(2) desaturation in patients with RS (74.5%, 832/1,117) than in patients with ES (30.4%, 223/734, p < 0.0001). The difference in reflux desaturation association was more profound with proximal reflux--80.3% with RS vs. 29.4% with ES (p < 0.0001).

CONCLUSIONS

A remarkably high prevalence of O(2) desaturation associated with gastroesophageal reflux was noted in patients with RS. Given further study, simultaneous combined esophageal reflux and O(2) saturation monitoring may prove a useful diagnostic tool in this difficult group of patients.

Helicobacter pylori infection and disease: from humans to animal models

Informative and tractable animal models that are colonized by well-defined microbial pathogens represent ideal systems for the study of complex human diseases. Helicobacter pylori colonization of the stomach is a strong risk factor for peptic ulceration and distal gastric cancer. However, gastritis has no adverse consequences for most hosts and emerging evidence suggests that H. pylori prevalence is inversely related to gastroesophageal reflux disease and allergic disorders. These observations indicate that eradication may not be appropriate for certain populations due to the potentially beneficial effects conferred by persistent gastric inflammation. Animal models have provided an invaluable resource with which to study H. pylori pathogenesis and carcinogenesis, and have permitted the development of a focused approach to selectively target human populations at high-risk of disease.

An animal model of intrinsic dental erosion caused by gastro-oesophageal reflux disease

OBJECTIVES

To explore the association between dental erosion and gastro-oesophageal reflux disease (GORD), we used an animal model of GORD.

MATERIALS AND METHODS

We performed an operation to force gastro-duodenal contents reflux in male Wistar rats, and examined the teeth in the reflux rats at 15 or 30 weeks postoperatively. Dental erosion was evaluated based on a slightly modified index from a previous report. Estimation of pH was employed in the oesophageal and gastric contents.

RESULTS

Macroscopically, dental erosion was only detected in the reflux rats. Histopathologically, dentin exposure was detected in three of the seven cases after 30 weeks. Alveolar bone destruction and osteomyelitis were also noted in severe cases. The pH of the oesophageal and stomach contents was 6.93 +/- 0.15 and 3.7 +/- 0.39, respectively.

CONCLUSIONS

We confirmed the relationship between dental erosion and GORD. First step of dental erosion caused by GORD is the loss of surface enamel induced by regurgitation of an acidic liquid and acidic gas. Subsequently, further destruction of dental hard tissues and tooth supporting structure is accelerated by mixed juice with gastric and duodenal contents. The reflux animal model is a useful tool to examine the mechanism of dental erosion in GORD.

Gastroesophageal reflux and pulmonary fibrosis in scleroderma: a study using pH-impedance monitoring

RATIONALE

Interstitial lung disease (ILD) in patients with systemic sclerosis (SSc) is associated with increased morbidity and mortality. Gastroesophageal reflux (GER) is considered a contributing factor in the pathogenesis of ILD.

OBJECTIVES

To characterize GER (acid and nonacid) in patients with SSc with and without ILD.

METHODS

Patients with SSc underwent pulmonary high-resolution computer tomography (HRCT) scan and 24-hour impedance-pH monitoring off-proton pump inhibitor therapy. The presence of pulmonary fibrosis was assessed using validated HRCT-scores. Reflux monitoring parameters included number of acid and nonacid reflux episodes, proximal migration of the refluxate, and distal esophageal acid exposure. Unless otherwise specified, data are presented as median (25th-75th percentile).

MEASUREMENTS AND MAIN RESULTS

Forty consecutive patients with SSc (35 female; mean age, 53 yr; range, 24-71; 15 patients with diffuse and 25 with limited SSc) were investigated; 18 (45%) patients with SSc had pulmonary fibrosis (HRCT score >or= 7). Patients with SSc with ILD had higher (P < 0.01) esophageal acid exposure (10.3 [7.5-15] vs. 5.2 [1.5-11]), higher (P < 0.01) number of acid (41 [31-58] vs. 19 [10-23]) and nonacid (25 [20-35] vs. 17 [11-19]) reflux episodes, and higher (P < 0.01) number of reflux episodes reaching the proximal esophagus (42.5 [31-54] vs. 15 [8-22]) compared with patients with SSc with normal HRCT scores. Pulmonary fibrosis scores (HRCT score) correlated well with the number of reflux episodes in the distal (r(2) = 0.637) and proximal (r(2) = 0.644) esophagus.

CONCLUSIONS

Patients with SSc with ILD have more severe reflux (i.e., more reflux episodes and more reflux reaching the proximal esophagus). Whether or not the development of ILD in patients with SSc can be prevented by reflux-reducing treatments needs to be investigated.

Ambulatory monitoring of GERD: current technology

Various techniques have been devised to diagnose, characterize, and classify gastroesophageal reflux (GER). Stationary techniques, such as fluoroscopy and scintigraphy, provide interesting anatomic and functional information related to GER but are not sensitive enough and are usually performed in nonphysiologic conditions. Ambulatory techniques for GER monitoring have been developed and used since 1974. The current available techniques include catheter and wireless pH-metry, Bilitec, and impedance-pH monitoring. Prolonged wireless pH monitoring can be useful to evaluate patients off and on proton pump inhibitor (PPI) treatment. Impedance-pH monitoring is being used increasingly in patients who have persistent symptoms on PPI therapy because it can establish an association between symptoms and weakly acidic or nonacid reflux. Bilitec is performed in patients suspected to have increased duodenogastroesophageal reflux (DGER). This article discusses the technical details, clinical indications, and applications of these diagnostic techniques.

Airway colonization and gastric aspiration after lung transplantation: do birds of a feather flock together?

BACKGROUND

Both gastroesophageal reflux and airway colonization with Pseudomonas aeruginosa (P aeruginosa) are common in lung transplantation (LTx) recipients. There is mounting evidence that, due to their interaction with the epithelium, both may be involved in chronic allograft dysfunction/bronchiolitis obliterans syndrome (BOS) after LTx. We investigated whether gastric aspiration and airway colonization with P aeruginosa after LTx are associated.

METHODS

In this retrospective, cross-sectional, case-control study, 24 stable double (SS) LTx recipients were included. Markers of gastroesophageal reflux (pepsin, bile acids) and airway inflammation (neutrophilia and interleukin-8 (IL-8)) were evaluated in bronchoalveolar lavage (BAL) samples of post-operatively colonized (n = 12) and non-colonized matched-control LTx recipients (n = 12).

RESULTS

BAL bile acid levels, but not pepsin levels, as well as neutrophilia and IL-8 protein levels were significantly elevated in colonized compared with non-colonized patients. Furthermore, bile acid levels, but not pepsin levels, correlated positively with BAL neutrophilia and IL-8 protein levels.

CONCLUSIONS

Bile acid aspiration and airway colonization by P aeruginosa after LTx seem to be associated. This relationship between reflux and airway colonization and their role in the development of chronic allograft dysfunction/BOS after LTx should be further elucidated; nevertheless, induction of IL-8-mediated neutrophilic airway inflammation may be a putative mechanism.

Gastrointestinal illnesses and their effects on the oral cavity

Many disease processes affecting the gastrointestinal (GI) tract may cause observable changes to the oral cavity. In fact, oral cavity changes may represent the first clinical manifestation of an underlying GI condition. Recognition and appropriate referral of a possible GI condition contribute to overall health and wellness in patients. Some of the more important GI conditions that may manifest oral cavity involvement include: reflux disorders, inherited GI polyposis syndromes, and inflammatory bowel disease. This article briefly reviews the aforementioned topics.

Laryngopharyngeal reflux in patients with reflux esophagitis

AIM: To assess the prevalence of laryngopharyngeal reflux (LPR) in patients with reflux esophagitis and disclose factors contributing to the development of LPR.

METHODS: A total of 167 patients who proved to have reflux esophagitis by endoscopy were enrolled. They received laryngoscopy to grade the reflux findings for the diagnosis of LPR. We used validated questionnaires to identify the presence of laryngopharyngeal symptoms, and stringent criteria of inclusion to increase the specificity of laryngoscopic findings. The data of patients were analyzed statistically to find out factors related to LPR.

RESULTS: The prevalence rate of LPR in studied subjects with reflux esophagitis was 23.9%. Age, hoarseness and hiatus hernia were factors significantly associated with LPR. In 23 patients with a hiatus hernia, the group with LPR was found to have a lower trend of esophagitis grading.

CONCLUSION: Laryngopharyngeal reflux is present in patients with reflux esophagitis, and three predicting factors were identified. However, the development of LPR might be different from that of reflux esophagitis. The importance of hiatus hernia deserves further study.

Systematic review: gastro-oesophageal reflux disease and dental lesions

BACKGROUND

Dental erosion (DE), which is the irreversible loss of tooth substance that does not involve bacteria ranging from a minimal loss of surface enamel to the partial or complete exposure of dentine by a chemical process, is acknowledged as an established extra-oesophageal manifestation of gastro-oesophageal reflux disease (GERD). However, the real impact of GERD in the genesis of this lesion remains unclear.

AIM

To review the existing literature to assess the relationship between DE and GERD.

METHODS

Studies that assessed the prevalence of DE in individuals with GERD or vice versa were identified in Medline and the Cochrane Controlled Trials Register via a systematic research strategy.

RESULTS

Seventeen studies met the selection criteria. Studies, however, differed greatly as far as design, population methods of diagnosing GERD, duration of follow-up and, consequently, findings. The median prevalence of DE in GERD patients was 24%, with a large range (5-47.5%), and the median prevalence of GERD in DE adults patients was 32.5% (range: 21-83%) and in paediatric population 17% (range: 14-87%). Children with GERD are found by a majority of studies at increased risk of developing DEs in comparison with healthy subjects, as are intellectually disabled people.

CONCLUSIONS

This systematic review shows that there is a strong association between GERD and DE. The severity of DEs seems to be correlated with the presence of GERD symptoms, and also, at least in adults, with the severity of proximal oesophageal or oral exposure to an acidic pH. The inspection of the oral cavity in search for DEs should become a routine manoeuvre in patients with GERD.