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Runggaldier D, Adam R, Ermanni C, Colotto-Vith U, van Beek MEF, Posovszky C, Righini Grunder F, Pohl D, Bohlender JE. [Gastric vs. supragastric belching, singultus, aerophagia, and differential diagnoses : An interdisciplinary perspective for otorhinolaryngologists]. HNO 2024; 72:657-667. [PMID: 38935275 PMCID: PMC11339109 DOI: 10.1007/s00106-024-01495-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 06/28/2024]
Abstract
Belching is the act of expelling air from the stomach or esophagus into the pharynx. Although the process is regarded as physiological, excessive belching might be associated with a significant burden for affected patients in the sense of a belching disorder. Diagnosis of a belching disorder is often challenging, and its differentiation from other conditions such as rumination syndrome, singultus, or aerophagia can be difficult. Treatment of these disorders also represents a challenge for otorhinolaryngologists. Hence, the aim of this review is to provide an interdisciplinary overview of these clinical syndromes and provide practical guidance for their diagnosis and treatment.
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Affiliation(s)
- Daniel Runggaldier
- Klinik für Otorhinolaryngologie, Head and Neck Surgery, Abt. Phoniatrie und Klinische Logopädie, Universitätsspital Zürich, Frauenklinikstrasse 24, 8091, Zürich, Schweiz.
- Universität Zürich, Zürich, Schweiz.
| | - Roman Adam
- Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich, Zürich, Schweiz
| | - Chiara Ermanni
- Klinik für Otorhinolaryngologie, Head and Neck Surgery, Abt. Phoniatrie und Klinische Logopädie, Universitätsspital Zürich, Frauenklinikstrasse 24, 8091, Zürich, Schweiz
- Universität Zürich, Zürich, Schweiz
- Klinik für Otorhinolaryngologie, Head and Neck Surgery, Universitätsspital Zürich, Frauenklinikstrasse 24, 8091, Zürich, Schweiz
| | - Ursula Colotto-Vith
- Klinik für Otorhinolaryngologie, Head and Neck Surgery, Abt. Phoniatrie und Klinische Logopädie, Universitätsspital Zürich, Frauenklinikstrasse 24, 8091, Zürich, Schweiz
- Universität Zürich, Zürich, Schweiz
| | - Miriam E F van Beek
- Klinik für Otorhinolaryngologie, Head and Neck Surgery, Abt. Phoniatrie und Klinische Logopädie, Universitätsspital Zürich, Frauenklinikstrasse 24, 8091, Zürich, Schweiz
- Universität Zürich, Zürich, Schweiz
| | - Carsten Posovszky
- Gastroenterologie, Hepatologie und Ernährung, Universitäts-Kinderspital Zürich, Zürich, Schweiz
| | - Franziska Righini Grunder
- Gastroenterologie, Hepatologie und Ernährung, Universitäts-Kinderspital Zürich, Zürich, Schweiz
- Gastroenterologie, Hepatologie und Ernährung, Kinderspital Zentralschweiz, Luzern, Schweiz
| | - Daniel Pohl
- Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich, Zürich, Schweiz
| | - Jörg E Bohlender
- Klinik für Otorhinolaryngologie, Head and Neck Surgery, Abt. Phoniatrie und Klinische Logopädie, Universitätsspital Zürich, Frauenklinikstrasse 24, 8091, Zürich, Schweiz
- Universität Zürich, Zürich, Schweiz
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Gastroesophageal Reflux Treatment in Infancy Through Young Adulthood. Am J Gastroenterol 2023; 118:452-458. [PMID: 36717189 DOI: 10.14309/ajg.0000000000002160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/20/2022] [Indexed: 02/01/2023]
Abstract
Gastroesophageal reflux treatment varies greatly across the pediatric age spectrum. Infant reflux treatments rely heavily on nutritional interventions, whereas reflux in older children is treated more commonly with medications. However, because of the broad differential diagnosis, treatment nonresponse merits a re-evaluation of the diagnosis being treated and additional testing to provide a more precision-medicine approach to care.
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Garza JM. Airway Impedance: In search of a new tool. J Pediatr 2023:113328. [PMID: 36646246 DOI: 10.1016/j.jpeds.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/11/2023] [Indexed: 01/15/2023]
Affiliation(s)
- Jose M Garza
- Neurogastroenterology and Motility program Children's Healthcare of Atlanta, Gi Care for Kids
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Woodley FW, Williams K, Di Lorenzo C, Michel HK. Significant Temporal Association of Esophageal Air Events (Supragastric Belches, Air Swallows, and Gastric Belches) With Hiccups: A Case Study in an Adolescent. JPGN REPORTS 2022; 3:e209. [PMID: 37168628 PMCID: PMC10158523 DOI: 10.1097/pg9.0000000000000209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 04/11/2022] [Indexed: 05/13/2023]
Abstract
We previously reported our ability to objectively assess the strength of temporal relationships between gastroesophageal reflux (GER) disease-like symptoms with esophageal air events (EAEs) (air swallows, gastric belching, and supragastric belching) using impedance-pH monitoring. Recently, we similarly evaluated an adolescent female who presented to our clinic with symptoms of recurrent hiccups and with what appeared to be numerous EAEs. Hiccups were associated with GER (symptom association probability [SAP] = 100%), air swallows (SAP = 99.7%), supragastric belches (SAP = 100%), and gastric belches (SAP = 100%), with almost twice as many of the supragastric belches preceding a hiccup than any of the other 3 esophageal disturbance types (EDs) (P < 0.00001). Our data showing a significant temporal association between EAEs and hiccups support a previous report in which belching was suspected of being associated with hiccups in an adult male. Reports such as this underscore the importance of considering the assessment of temporal relationships between extra-esophageal symptoms and EDs that include not only GER, but also EAEs, such as air swallows, gastric belches and supragastric belches, when devising strategies for clinical management of patients with hiccups.
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Affiliation(s)
- Frederick W. Woodley
- From the Center for Motility Disorders, Nationwide Children’s Hospital, Columbus, OH
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Kent Williams
- From the Center for Motility Disorders, Nationwide Children’s Hospital, Columbus, OH
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Carlo Di Lorenzo
- From the Center for Motility Disorders, Nationwide Children’s Hospital, Columbus, OH
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Hilary K. Michel
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
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Masui D, Nikaki K, Sawada A, Sonmez S, Yazaki E, Sifrim D. Belching in children: Prevalence and association with gastroesophageal reflux disease. Neurogastroenterol Motil 2022; 34:e14194. [PMID: 34190371 DOI: 10.1111/nmo.14194] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/24/2021] [Accepted: 05/13/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Excessive belching is frequently reported in adult patients with gastro-oesophageal reflux disease (GORD) and dyspepsia. Although postprandial gastric belching (GB) is considered a physiological mechanism for gastric venting, supra-gastric belching (SGB) is considered a distinct behavioural disorder. We aimed to define the prevalence of different types of belching and its association with reflux disease in paediatric patients. METHODS We retrospectively analysed reflux monitoring studies from 287 patients (median age: 7.0 years; interquartile range 3.0-11.3 years) with a suspicion of GORD. Based on oesophageal acid exposure time (AET) patients were divided in 3 groups: (a) physiological AET, (b) borderline AET and (c) pathological AET. MII-pH studies were manually edited and reflux disease parameters were measured together with quantification of GB and SGB. KEY RESULTS Two hundred one children (70.0%) had physiological AET (median: 0.8; interquartile range 0.3-1.6), 52 (18.1%) had borderline AET (median: 4.2; interquartile range 3.4-5.3) and 34 (11.9%) had pathologic AET (median: 10.7; interquartile range 9.1-14.2). Gastric belching was observed in all studies. Gastric belching related reflux was more frequently observed in patients with borderline and pathological AET (p < 0.001). This was more common in older children. SGB were observed in only 7 (2.4%) children (age range: 8-17years) in our population and all patients had Physiological AET. Only 3 (1%) patients had pathological number of SGB (>13/24 h). CONCLUSIONS AND INFERENCES Gastric belching related reflux is observed in children with increased AET. SGB is very rare in the paediatric population.
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Affiliation(s)
- Daisuke Masui
- Barts and The London School of Medicine and Dentistry, Upper GI Physiology Unit Royal London Hospital, Wingate Institute of Neurogastroenterology, Blizard Institute, Queen Mary University of London, London, UK.,Department of Pediatric Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Kornilia Nikaki
- Barts and The London School of Medicine and Dentistry, Upper GI Physiology Unit Royal London Hospital, Wingate Institute of Neurogastroenterology, Blizard Institute, Queen Mary University of London, London, UK
| | - Akinari Sawada
- Barts and The London School of Medicine and Dentistry, Upper GI Physiology Unit Royal London Hospital, Wingate Institute of Neurogastroenterology, Blizard Institute, Queen Mary University of London, London, UK.,Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shirley Sonmez
- Barts and The London School of Medicine and Dentistry, Upper GI Physiology Unit Royal London Hospital, Wingate Institute of Neurogastroenterology, Blizard Institute, Queen Mary University of London, London, UK
| | - Etsuro Yazaki
- Barts and The London School of Medicine and Dentistry, Upper GI Physiology Unit Royal London Hospital, Wingate Institute of Neurogastroenterology, Blizard Institute, Queen Mary University of London, London, UK
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Upper GI Physiology Unit Royal London Hospital, Wingate Institute of Neurogastroenterology, Blizard Institute, Queen Mary University of London, London, UK
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Rosen R. Novel Advances in the Evaluation and Treatment of Children With Symptoms of Gastroesophageal Reflux Disease. Front Pediatr 2022; 10:849105. [PMID: 35433543 PMCID: PMC9010502 DOI: 10.3389/fped.2022.849105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/18/2022] [Indexed: 12/03/2022] Open
Abstract
Gastroesophageal reflux disease has long been implicated as a cause for multiple pediatric symptoms ranging from abdominal pain and regurgitation to cough and dental erosions. Diagnostic testing has evolved greatly over the last 20 years; initial testing with pH-metry to measure esophageal acid reflux burden has evolved into measurement of both acid and non-acid reflux and liquid and gas reflux. However, measuring reflux burden alone only tells a small part of the GERD story and many symptoms originally thought to be reflux related are, in fact, related to other disorder which mimic reflux. The current paradigm which involves empiric treatment of symptoms with acid suppression has been replaced with early testing for not only gastroesophageal reflux but also for other diagnostic masqueraders. The focus for interventions has shifted away from acid suppression toward motility interventions and includes a greater recognition of both functional and motility disorders which present with reflux symptoms.
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Affiliation(s)
- Rachel Rosen
- Boston Children's Hospital, Boston, MA, United States
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Aerophagia Study in Indonesia: Prevalence and Association With Family-related Stress. J Clin Gastroenterol 2021; 55:772-777. [PMID: 33009193 DOI: 10.1097/mcg.0000000000001434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/31/2020] [Indexed: 12/10/2022]
Abstract
BACKGROUND Aerophagia is a functional gastrointestinal disorder characterized by repeated air swallowing leading to chronic abdominal distension. Symptoms can be long lasting, lead to frustration, and distress. This study describes prevalence, related factors, and symptomatology of aerophagia, together with its relationship with emotional stress. MATERIALS AND METHODS Cross-sectional study. Adolescents aged 10 to 17 years from selected state schools by convenient sampling from Jakarta, Indonesia, were recruited. Rome III self-administered questionnaire was used to compile data on gastrointestinal symptoms. Data on sociodemographic characteristics, intestinal and extraintestinal symptoms, and stressful life events were collected using a separate questionnaire. RESULTS A total of 1796 questionnaires were included in the analysis [males 732 (40.8%), mean age 13.58 (SD 0.992) years]. There were 81 (4.5%) subjects diagnosed with aerophagia. When the criterion of belching was removed from the diagnosis of aerophagia, the prevalence drops to only 2 (0.1%). subjects. Bivariate analysis showed that sociodemographic factors have no correlation with aerophagia. In subjects with aerophagia, among the intestinal-related and extraintestinal symptoms, only loss of appetite was significantly more common in the aerophagia population (33.3%) when compared with controls (22.8%). Death of a close family member [adjusted odds ratio (OR), 2.78; 95% confidence interval (CI), 1.46-5.31; P=0.002], divorce or separation of parents (adjusted OR, 2.54; 95% CI, 1.38-4.66; P=0.003), and divorce followed by separate individual remarriage of parents (adjusted OR, 2.01; 95% CI, 1.01-3.98; P=0.046) were found to be significantly associated with aerophagia by multivariate analysis. CONCLUSIONS The prevalence of aerophagia was found in 4.5% of Indonesian school-aged children according to Rome III criteria, but the prevalence was found only 0.1% if the belching is removed from the criteria. Besides the main symptoms, only loss of appetite was significantly more common in aerophagia among intestinal-related and extraintestinal symptoms. Family-related stress showed a significant correlation with aerophagia.
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Novel Use of Impedance Technology Shows That Esophageal Air Events Can Be Temporally Associated With Gastroesophageal Reflux Disease-like Symptoms. J Pediatr Gastroenterol Nutr 2020; 70:e7-e11. [PMID: 31880681 DOI: 10.1097/mpg.0000000000002514] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
A few studies have shown that esophageal air events (EAEs), such as air-swallows, may be associated with symptoms that have historically been associated with gastroesophageal reflux disease (GERD). To objectively test a hypothesis that all EAE types (air-swallows, supragastric belches and gastric belches) can be associated with GERD-like symptoms, we removed the impedance "tags" from the GER episodes (placed during autoscan) and instead tagged either air-swallows, supragastric belches or gastric belches in each of 3 copies of the 24-hour impedance tracing for 2 infant patients who presented with symptoms suggestive of GER as an etiology. Impedance system software (MMS) analyses revealed that, in both infants, all EAE types were significantly associated (SAP >95%) with 1 or more of the GERD-like symptom types (cough, pain/crying, back-arching, and gagging). These data underscore the importance of considering other diagnoses when developing management strategies for treating GERD-like symptoms in infants.
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Quitadamo P, Tambucci R, Mancini V, Cristofori F, Baldassarre M, Pensabene L, Francavilla R, Di Nardo G, Caldaro T, Rossi P, Mallardo S, Maggiora E, Staiano A, Cresi F, Salvatore S, Borrelli O. Esophageal pH-impedance monitoring in children: position paper on indications, methodology and interpretation by the SIGENP working group. Dig Liver Dis 2019; 51:1522-1536. [PMID: 31526716 DOI: 10.1016/j.dld.2019.07.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/02/2019] [Accepted: 07/20/2019] [Indexed: 12/11/2022]
Abstract
Multichannel intraluminal impedance pH (MII-pH) monitoring currently represents the gold standard diagnostic technique for the detection of gastro-esophageal reflux (GER), since it allows to quantify and characterize all reflux events and their possible relation with symptoms. Over the last ten years, thanks to its strengths and along with the publication of several clinical studies, its worldwide use has gradually increased, particularly in infants and children. Nevertheless, factors such as the limited pediatric reference values and limited therapeutic options still weaken its current clinical impact. Through an up-to-date review of the available scientific evidence, our aim was to produce a position paper on behalf of the working group on neurogastroenterology and acid-related disorders of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) on MII-pH monitoring technique, indications and interpretation in pediatric age, in order to standardise its use and to help clinicians in the diagnostic approach to children with GER symptoms.
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Affiliation(s)
- Paolo Quitadamo
- Department of Pediatrics, A.O.R.N. Santobono-Pausilipon, Naples, Italy; Department of Translational Medical Science,"Federico II", University of Naples, Italy.
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Valentina Mancini
- Department of Pediatrics and Neonatology, Saronno Hospital, Saronno, Italy
| | - Fernanda Cristofori
- Department of Pediatrics, Giovanni XXIII Hospital, Aldo MoroUniversity of Bari, Bari, Italy
| | - Mariella Baldassarre
- Department of Biomedical Science and Human Oncology-neonatology and Nicu section, University "Aldo Moro", Bari, Italy
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Ruggiero Francavilla
- Department of Pediatrics, Giovanni XXIII Hospital, Aldo MoroUniversity of Bari, Bari, Italy
| | - Giovanni Di Nardo
- NESMOS Department, School of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Rossi
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Saverio Mallardo
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Elena Maggiora
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science,"Federico II", University of Naples, Italy
| | - Francesco Cresi
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Silvia Salvatore
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, UCL Institute ofChild Health and Great OrmondStreet Hospital, London, UK
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Rajindrajith S, Hettige S, Gulegoda I, Jayawickrama N, De Silva SC, Samarakoon HK, de Silva RL, Abeyagunawardena S, Devanarayana NM. Aerophagia in adolescents is associated with exposure to adverse life events and psychological maladjustment. Neurogastroenterol Motil 2018; 30. [PMID: 28971549 DOI: 10.1111/nmo.13224] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 09/10/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Aerophagia is a common childhood functional gastrointestinal disorder. We studied the association between adverse life events (ALEs), psychological maladjustment, somatization, and aerophagia (AP) in adolescents. We also assessed the impact of AP on their health-related quality of life (HRQoL). METHODS A cross-sectional survey was conducted on 2500 subjects of 13-18 years in 8 randomly selected schools in Sri Lanka. Translated, validated, and self-administered questionnaires were used to collect data. Aerophagia was diagnosed using Rome III criteria. KEY RESULTS A total of 2453 questionnaires were analyzed (males 1200 [48.9%], mean age 14.8 years, SD 1.6 years). Of them, 371 adolescents had AP (15.1%). Aerophagia was associated with exposure to physical abuse (20.4% vs. 12.7% in controls, P < .0001), emotional abuse (20.3% vs. 8.2% in controls, P < .0001), and other ALEs (22% vs. 10.2% in controls, P < .001). One hundred and ninety (51.2%) adolescents with AP and 775 (37.2%) controls had a personality score above the international cutoff value of 105, indicating psychological maladjustment (odds ratio 1.77, 95% confidence interval 1.42-2.21, P < .0001). Those with AP had higher somatization (16.4 vs. 8.9) and lower overall HRQoL scores (77.0 vs. 85.1, P < .0001). HRQoL scores of adolescents with AP were lower in all domains, namely, physical (80.6 vs. 86.9), emotional (69.1 vs. 80.3), social (83.8 vs. 90.5), and school (72.6 vs. 82.5) functioning (P < .0001). CONCLUSIONS AND INFERENCES Aerophagia was associated with exposure to ALEs and psychological maladjustment. Affected teenagers suffer from more somatic symptoms and has a poor HRQoL.
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Affiliation(s)
- S Rajindrajith
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - S Hettige
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - I Gulegoda
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - N Jayawickrama
- Department of Physiology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - S C De Silva
- Department of Physiology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - H K Samarakoon
- Department of Physiology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - R L de Silva
- Department of Physiology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | | | - N M Devanarayana
- Department of Physiology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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Abstract
BACKGROUND Swallowed gas is an important source of abdominal gas, and aerophagia is often believed as a putative cause of gas-related abdominal symptoms. However, altered gas-swallow during meals has not been demonstrated. Our aim was to characterize the number of gas swallows during meals in patients complaining of excessive belching and gaseousness and a control group without abdominal symptoms during a 24-h period. METHODS A 24-h pH-impedance monitoring was performed in 10 patients with excessive belching, and 11 patients without digestive symptoms or reflux in the pH-impedance study. During the study, patients followed their daily routine and customary meals, without any specific limitation. In each patient the number and content of swallows and belches were analyzed. KEY RESULTS Total meal periods were similar in controls (75±26 min) and patients (79±21 min; P=.339), but the number of gaseous swallows was greater in patients (114±13 swallows) than controls (71±8 swallows; P=.007), due to a greater frequency of gaseous swallows during meals (15±2 swallows/10 min vs 10±1 swallows/10 min, respectively; P=.008). During the 24-h study period, 66±13 belches were recorded in patients, but only 13±3 belches in controls (P<.001), mainly gastric belches (80±4% and 92±2% of belches, patients, and controls, respectively) which showed a good correlation with the number of gaseous swallows performed during meals (r=.756; P=.011). CONCLUSION AND INFERENCES Gas is frequently swallowed during meals. Patients complaining of excessive belching have a different swallow pattern during meals, with an increased ingestion of gas that correlates with increased gastric belching events.
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Affiliation(s)
- N Caballero
- Motility and Functional Gut Disorders Unit, University Hospital Germans Trias i Pujol, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.,Department of Medicine, Autonomous University of Barcelona, Badalona, Spain
| | - J Serra
- Motility and Functional Gut Disorders Unit, University Hospital Germans Trias i Pujol, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.,Department of Medicine, Autonomous University of Barcelona, Badalona, Spain
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12
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Mutalib M, Rawat D, Lindley K, Borrelli O, Perring S, Auth MKH, Thapar N. BSPGHAN Motility Working Group position statement: paediatric multichannel intraluminal pH impedance monitoring-indications, methods and interpretation. Frontline Gastroenterol 2017; 8:156-162. [PMID: 28839903 PMCID: PMC5558281 DOI: 10.1136/flgastro-2016-100796] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/18/2017] [Accepted: 02/23/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Combined pH-impedance monitoring has been suggested as the investigation of choice for diagnosing gastro-oesophageal reflux in children. Although it is superior to oesophageal pH monitoring in detecting all types of reflux episodes (acid, weakly acidic and alkaline) with the ability to evaluate symptom association with reflux events, it is still limited by the lack of true paediatric normal value and the high cost involved (equipment and personnel). OBJECTIVE To produce a position statement on behalf of the Motility Working Group of the British Society of Paediatric Gastroenterology, Hepatology and Nutrition on the indications and practical application of combined oesophageal pH-impedance monitoring in children. METHODS Up-to-date review of available evidence. RESULTS This document provides a practical guide to clinician on indications, methods and results interpretation of paediatric multichannel intraluminal impedance pH (MII-pH). CONCLUSIONS MII-pH is increasingly used by paediatricians as the diagnostic tool for assessing gastro-oesophageal reflux disease and symptom association. There is wide variation in paediatric practice and a need for standardised practice.
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Affiliation(s)
- Mohamed Mutalib
- Paediatric Gastroenterology Department, Evelina London Children's Hospital, London, UK
| | - David Rawat
- Paediatric Gastroenterology Department, Royal London Hospital, London, UK
| | - Keith Lindley
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, UK
| | - Osvaldo Borrelli
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, UK
| | - Steve Perring
- Department of Medical Physics, Poole Hospital, Poole, UK
| | - Marcus K H Auth
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Nikhil Thapar
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, UK
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Effects of Esophageal Acidification on Troublesome Symptoms: An Approach to Characterize True Acid GERD in Dysphagic Neonates. Dysphagia 2017; 32:509-519. [PMID: 28365873 DOI: 10.1007/s00455-017-9792-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 03/21/2017] [Indexed: 02/07/2023]
Abstract
To quantify and compare maximal extent (height) of acid reflux events (AREs) on symptom generation in dysphagic neonates. Dysphagic neonates (N = 53), born at 30 ± 5.3 weeks gestation, underwent 24-hour pH-impedance study for the evaluation of troublesome symptoms purported to be due to gastroesophageal reflux disease (GERD). AREs (pH < 4 for >4 s) detected by impedance (Z) were categorized by maximal extent as refluxate reaching distal (Z6, Z5), middle (Z4, Z3), or proximal (Z2, Z1) impedance channels. AREs reaching the pH sensor only were categorized as distal. Symptom correlation (%, symptom index, symptom sensitivity index, and symptom associated probability) and temporal characteristics (clearance times) of AREs were analyzed using linear mixed and GEE models comparing height categories presented as mean ± SEM, median (IQR), and OR (95% CI). Of the 2003 AREs, 1) distal extent AREs (n = 1642) had increased frequency (p < 0.05), decreased ACT (p < 0.05), and decreased acidity (p < 0.05); 2) in middle and proximal AREs, acid clearance was longer than bolus clearance, (p < 0.01); and 3) the odds of having cardiorespiratory (cough or sneeze) symptoms are increased with proximal and middle AREs (p < 0.05). Most proximal ascent of AREs into middle or proximal esophagus likely activates protective aerodigestive reflexes (peristalsis) or vigilant states to facilitate bolus and chemical clearance. Heightened esophageal sensitivity, acid neutralization delays, or clearance mechanism delays may accentuate multi-systemic troublesome symptoms.
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Rinsma NF, Mauritz FA, van Heurn LWE, Sloots CEJ, Siersema PD, Houwen RHJ, van der Zee DC, Masclee AAM, Conchillo JM, Van Herwaarden-Lindeboom MYA. Impact of laparoscopic antireflux surgery on belching in pediatric GERD patients. Neurogastroenterol Motil 2016; 28:1525-32. [PMID: 27151185 DOI: 10.1111/nmo.12850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 04/11/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Laparoscopic antireflux surgery (LARS) is a well-established treatment option for children with proton pomp inhibitor (PPI)-resistant gastroesophageal reflux disease (GERD). Besides preventing reflux of gastric fluid and solid content, LARS may also impair the ability of the stomach to vent intragastric air (i.e. gastric belching) and induce gas-related complications, such as bloating and/or hyperflatulence. Furthermore, it was previously hypothesized that LARS induces a behavioral type of belching, not originating from the stomach, called supragastric belching. The aim of this study was to objectively evaluate the impact of LARS on gastric (GB) and supragastric belching (SGB) in children with GERD. METHODS We performed a prospective, Dutch multicenter cohort study including 25 patients (12 males, median age 6 (range 2-18) years) with PPI-resistant GERD who were scheduled for LARS. Twenty-four-hour multichannel intraluminal impedance pH monitoring (MII-pH monitoring) was performed before and 3 months after fundoplication. Impedance pH tracings were analyzed for reflux episodes and GBs and SGBs. KEY RESULTS LARS reduced acid exposure time from 8.5% (6.0-16.2%) to 0.8% (0.2-2.8%), p < 0.001. The number of GBs also significantly decreased after LARS (59 [43-77] VS 5 [2-12], p < 0.001). The number of air swallows remained unchanged after LARS. SGBs were infrequent before LARS with no change in the number of SGB observed after the procedure. Postoperative belching symptoms were associated with GBs, not with SGBs. CONCLUSION & INFERENCES LARS significantly reduces the number of GBs in children with GERD, whereas the number of air swallows remains unchanged. Postoperative symptomatic belching is associated with GBs, but not with SGBs. These findings suggest that LARS does not induce the occurrence of SGBs in children, but longer follow-up is required.
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Affiliation(s)
- N F Rinsma
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - F A Mauritz
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L W E van Heurn
- Department of Pediatric Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - C E J Sloots
- Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R H J Houwen
- Department of Pediatric Gastroenterology and Hepatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - D C van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - A A M Masclee
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - J M Conchillo
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
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Abstract
PURPOSE OF REVIEW Supragastric belching has recently gained recognition as a belching disorder of behavioral origin that can be accurately diagnosed on esophageal impedance monitoring. Its contribution to numerous other gastrointestinal disorders is beginning to be appreciated. Improved knowledge of its pathophysiology has enabled identification of therapeutic goals, some of which have been subject to formal study and demonstrated good outcomes. This review sets out to present and discuss new findings related to the improved understanding of the relationship between supragastric belching and other gastrointestinal disorders, as well as fresh concepts in terms of management. RECENT FINDINGS Supragastric belching is now shown to be associated with globus, as well as reflux symptoms in proton pump inhibitor nonresponders. Patients with supragastric belching experience higher frequency of belching events if they have concurrent esophageal hypomotility. Gum chewing and sleeve gastrectomy have no impact on supragastric belching. Pediatric studies suggest an overlap with aerophagia that is not observed in adults. Successful treatments trialed recently include psychoeducation and behavioral therapy delivered by a health psychologist with expertise in gastroenterology. SUMMARY With the foreseeable increase in recognition and diagnosis of pathological supragastric belching, there is a clear need to better understand its pathophysiology, especially in terms of its emerging importance in relation to other gastrointestinal disorders. Further study is justified to uncover additional therapeutic options for this benign but disabling condition.
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Lee GH, Jang HJ, Hwang JB. Clonazepam treatment of pathologic aerophagia in children with mental retardation. Pediatr Gastroenterol Hepatol Nutr 2014; 17:209-13. [PMID: 25587520 PMCID: PMC4291445 DOI: 10.5223/pghn.2014.17.4.209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 09/17/2014] [Accepted: 09/29/2014] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Pathologic aerophagia (PA) may lead to bowel perforation or volvulus in mentally retarded patients. The authors investigated the effects of clonazepam on the management of PA in children with severe to profound mental retardation (MR). METHODS This study was undertaken as a retrospective case analysis of 21 PA patients with MR who were followed for over 12 months and diagnosed as having PA. Patients were assigned to two management groups, that is, to a clonazepam randomized open-labeled, treatment group or a reassurance group. The following were recorded and analyzed; age, response, remission rate to clonazepam treatment, and the side effect of clonazepam. It was defined positive response (response+) as being symptom-free for a whole week within 1 month of commencing treatment and remission(+) as being symptom-free for a whole month within 6 months of treatment. RESULTS The average age of the 21 PA children with MR was 10 years and 13 patients were female. Symptom duration before diagnosis of PA was 7 months. Clinical features of the clonazepam-trial group (n=11) and the reassurance group (n=10) were non-significantly different. Response(+) was achieved by 2 patients (18.2%) in the clonazepam-trial group and by no patient in the reassurance group. Remission(+) was achieved by 6 patients (54.5%) in the clonazepam-trial group and by one patient (10%) in the reassurance group (p=0.040). CONCLUSION When PA children with MR with severe bowel distention are considered for surgical treatment to prevent acute abdomen, a trial of clonazepam could be recommended.
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Affiliation(s)
- Ga-Hyun Lee
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Hyo-Jeong Jang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Bok Hwang
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
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