Esophageal testing: What we have so far

Bronchoscopic detection of aspiration in patients with bronchiectasis and Mycobacterium avium complex pulmonary infection

RATIONALE

To investigate whether gastroesophageal reflux with laryngopharyngeal reflux and aspiration play a role in the pathogenesis of bronchiectasis and Mycobacterium avium complex (MAC) pulmonary infection.

METHODS

In this prospective case-control study, subjects included 31 patients with bronchiectasis undergoing bronchoscopy to investigate suspected MAC infection and 9 control subjects undergoing bronchoscopy for alternative reasons. Patients drank 45 mL of FD&C Blue #1 mixed with 200 mL of tap water the night prior to bronchoscopy. During bronchoscopy, the bronchial mucosa was inspected for the presence of blue dye staining. Bronchoalveolar lavage (BAL) samples were obtained from the most affected segments on CT scan and were cultured for mycobacteria and assayed for pepsin and bile acids. Gastric aspirate samples were obtained for mycobacterial culture.

RESULTS

93.8% of patients with confirmed pulmonary MAC infection and 91.7% of patients with evidence of bronchiectasis by CT scan, but negative mycobacterial cultures, had blue dye staining of the bronchial mucosa vs. 11.3% of control patients (p < 0.001). Areas of abnormality on CT correlated with airways demonstrating blue staining by bronchoscopy in 100% of MAC patients and 90.9% of patients with bronchiectasis and negative mycobacterial cultures. MAC patients had higher median BAL pepsin levels compared to combined MAC negative patients (subjects with bronchiectasis and negative mycobacterial cultures and true controls), 5.4 ng/mL vs. 3.4 ng/mL (p = 0.019). 78.6% of MAC patients vs. 26.3% of combined MAC negative patients had BAL bile acid concentrations of >/= 0.493 uM (p = 0.005). There was no significant difference in age, supraglottic index, reflux symptoms, gastric pH, or proton pump inhibitor use between the MAC positive vs. MAC negative patients. 42.8% of patients with growth of MAC on BAL also had growth of MAC in the gastric aspirate.

CONCLUSIONS

Reflux and aspiration of gastric contents into the airways show a strong association with bronchiectasis and may be associated with MAC pulmonary disease. The novel method introduced in this study of drinking blue dye the evening prior to bronchoscopy should be utilized in the evaluation of infectious and inflammatory lung diseases in which aspiration may play a role.

Applying Lyon consensus criteria in the work-up of patients with extra-oesophageal symptoms - A multicentre retrospective study

BACKGROUND

The diagnosis of gastro-oesophageal reflux disease (GERD) based on otolaryngologist's assessment of laryngoscopic findings remains contentious in terms of sensitivity and specificity.

AIMS

To evaluate GERD prevalence, applying Lyon 2.0 Consensus criteria, in patients with extra-oesophageal symptoms undergoing laryngoscopic examination and impedance-pH monitoring.

METHODS

In this retrospective assessment, we included 470 patients with extra-oesophageal symptoms, either isolated or combined with typical symptoms, who had been referred to six tertiary Italian Gastroenterology Units between January and December 2020. Of these, 274 underwent 24-h impedance-pH monitoring and laryngoscopy off PPI therapy. GERD diagnosis followed Lyon Consensus 2.0 criteria, incorporating mean nocturnal baseline impedance when pH-impedance monitoring was inconclusive.

RESULTS

Laryngoscopic examination revealed pathological findings (predominantly posterior laryngitis) in 71.2% (195/274). GERD was diagnosed in 29.2% (80/274) via impedance-pH monitoring. The prevalence of GERD in patients with positive or negative laryngoscopy was similar (32.3% vs. 21.5%, p = 0.075). No significant difference in proximal reflux occurrences was noted between positive and negative laryngoscopy groups (33.3% vs. 24.1%, p = 0.133). Laryngoscopy demonstrated sensitivity and specificity of 78.8% and 32.0%, respectively, with a positive predictive value (PPV) of 32.3% and negative predictive value (NPV) of 28.4%. In contrast, a threshold of four concurrent laryngoscopic signs, identified in only eight patients, demonstrated a PPV of 93.8% and a NPV of 73.6% (sensitivity 25.4%, specificity 99.2%).

CONCLUSION

This study underscores the limited diagnostic accuracy of laryngoscopy, emphasising the necessity of impedance-pH monitoring for confirming GERD diagnoses using Lyon 2.0 criteria in patients with suspected extra-oesophageal symptoms.

The Dubai Definition and Diagnostic Criteria of Laryngopharyngeal Reflux: The IFOS Consensus

OBJECTIVE

The objective of this work was to gather an international consensus group to propose a global definition and diagnostic approach of laryngopharyngeal reflux (LPR) to guide primary care and specialist physicians in the management of LPR.

METHODS

Forty-eight international experts (otolaryngologists, gastroenterologists, surgeons, and physiologists) were included in a modified Delphi process to revise 48 statements about definition, clinical presentation, and diagnostic approaches to LPR. Three voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 8/10. Votes were anonymous and the analyses of voting rounds were performed by an independent statistician.

RESULTS

After the third round, 79.2% of statements (N = 38/48) were approved. LPR was defined as a disease of the upper aerodigestive tract resulting from the direct and/or indirect effects of gastroduodenal content reflux, inducing morphological and/or neurological changes in the upper aerodigestive tract. LPR is associated with recognized non-specific laryngeal and extra-laryngeal symptoms and signs that can be evaluated with validated patient-reported outcome questionnaires and clinical instruments. The hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing can suggest the diagnosis of LPR when there is >1 acid, weakly acid or nonacid hypopharyngeal reflux event in 24 h.

CONCLUSION

A global consensus definition for LPR is presented to improve detection and diagnosis of the disease for otolaryngologists, pulmonologists, gastroenterologists, surgeons, and primary care practitioners. The approved statements are offered to improve collaborative research by adopting common and validated diagnostic approaches to LPR.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:1614-1624, 2024.

The Controversy of Pepsinogen A/Pepsin A in Detecting Extra-Gastroesophageal Reflux

BACKGROUND

Pepsinogen A (PGA)/pepsin A is often used as a diagnostic marker of extra-gastroesophageal reflux. We aimed to explore whether its positivity in upper aerodigestive tract (UADT) was specific enough to diagnose reflux.

METHODS

PGA/pepsin A protein levels were examined in 10 types of tissues and 10 types of body fluid by immunological staining, western blot or Elisa, using three different commercially available brands simultaneously. Liquid chromatography-tandem mass spectrometry parallel reaction monitoring (LC-MS/MS PRM) served as a gold reference for the detection of PGA/pepsin A proteins. PGA gene expression was analyzed by reverse transcriptase sequencing methods for tissue samples. Specifically, 24 hour pH monitoring technique was conducted for patients who donated saliva samples.

RESULTS

Eight out of ten types of human tissue samples (stomach, esophagus, lung, kidney, colon, parotid gland, nasal turbinate and nasal polyps) were confirmed positive for PGA/pepsin A gene and protein by genetic and PRM technique, respectively. Two out of ten types of body fluid samples (gastric fluid, urine) were confirmed positive for PGA/pepsin A protein by PRM technique. The consistence rates of PGA/pepsin A positivity among three commercial antibody brands and Elisa kit were poor, and Elisa results of salivary did not match with 24-hour pH monitoring.

CONCLUSIONS

Multiple tissues and body fluid could be detected baseline expression levels of PGA/pepsin A gene and protein. However, those commercially available PGA/pepsin A antibodies achieved poor sensitivity and specificity, therefore, relying on the detection of PGA/pepsin A in UADT by single antibodies to diagnose extra-gastroesophageal reflux without a specific positive cut-off value is unreliable.

Role of Endoscopy in Motility Disorders of Upper Gastrointestinal Tract

Gastrointestinal motility disorders have a wide range of symptoms and affect patients' quality of life. With the advancement of endoscopy, the diagnostic and therapeutic roles of endoscopy in motility disorders is becoming more significant. Endoscopy is necessary to rule out possible organic diseases in patients with suspected motility disorders and provide significant clues for their diagnosis. Moreover, interventional endoscopy may be a primary or alternative treatment option for selected patients with motility disorders, and it is becoming a promising field as new therapeutic applications are developed and utilized for various motility disorders. This review may provide suitable indications for the use of endoscopy in diagnosing and treating motility disorders of the upper gastrointestinal tract.

Presence of pepsin in laryngeal tissue and saliva in benign and malignant neoplasms

Objectives: The current study was performed to determine the presence of pepsin in saliva and laryngeal tissue among participants with benign and malignant laryngeal neoplasms.

Study design: Case–control study included three groups of patients with: (1) benign laryngeal neoplasms, (2) malignant laryngeal neoplasms and (3) control subjects without symptoms or signs of laryngopharyngeal reflux (LPR).

Methods: Eighty-one voluntary participants were included into study. They were recruited from a group of patients with histologically proven benign and malignant laryngeal neoplasms and in case of control subjects among patients with nasal septum deformation without symptoms of LPR.

Morning saliva samples were collected preoperatively. Tumor biopsies were collected by directoscopy of larynx and the control samples from interarytenoid unit of larynx. All samples were analyzed by Enzyme-Linked Immunosorbent Assay (ELISA) and Immunohistochemistry.

Results: Pepsin was found in all samples of saliva and tissue biopsies in groups with malignant and benign neoplasms. The highest concentration of pepsin was found in a group of patients with malignant laryngeal neoplasms. Patients with benign laryngeal neoplasms had lower concentrations and the control subjects presented with the lowest concentration of pepsin measured from their saliva. Differences were not statistically significant. Immunohistochemical (IHC) analysis showed the largest number of high positive samples in the group of malignant lesions.

Conclusion: These results suggest that pepsin and LPR can contribute to the development of benign and malignant laryngeal neoplasms. Further prospective studies, with far more patients, are necessary to prove the role of pepsin in multifactorial etiology of laryngeal neoplasms.

A SIGE-SINGEM-AIGO technical review on the clinical use of esophageal reflux monitoring

Patients with esophageal symptoms potentially associated with gastroesophageal reflux disease such as heartburn, regurgitation, chest pain, or cough represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal reflux monitoring in clinical practice is: (1) to accurately define reflux burden, (2) to segregate patients according to reflux monitoring results as true GERD, reflux hypersensitivity and functional heartburn, and (3) to establish a treatment plan. With this in mind, in the last decade, investigations and technical advances, with the introduction of impedance-pH monitoring and wireless pH capsule, have enhanced our understanding and management of GERD. The following recommendations were discussed and approved after a comprehensive review of the medical literature pertaining to reflux testing techniques and their recent application. This review created under the auspices of the Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE), Società Italiana di Neuro-Gastro-Enterologia e Motilità (SINGEM) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying reflux studies in the most fruitful manner within the context of their patients with esophageal symptoms.

Efficacy evaluation of pepsin in laparoscopic antireflux surgery for gastroesophageal reflux disease

BACKGROUND

The false positive rate of the PPI test for the diagnosis of typical symptoms of gastroesophageal reflux disease (GERD) is extremely high.

OBJECTIVE

This study aims to investigate the effect of the pepsin test on GERD and laparoscopy-assisted anti-reflux surgery for GERD.

METHODS

A total of 30 GERD patients were enrolled into this study, and the pre-diagnosis of GERD was determined by symptom evaluation, impedance-pH examination, gastroscopy and pepsin test. All patients underwent surgery.

RESULTS

Among the 30 GERD patients, 18 patients were male and 12 were female, and their average age was 58.2 + 12.6 years old. The patients were treated with laparoscopic fundoplication and hiatus hernia repair after preoperative assessment. A total of 28 patients were followed up, one patient developed recurrent symptoms, and one patient developed postoperative dysphagia and received non-operative treatment. Furthermore, the symptom scores were significantly lower at postoperative pepsin detection when compared to the scores before the operation (pepsin: preoperative: 148.8 ± 82.6, postoperative: 30.7 ± 24.6; t= 4.848, P= 0.000).

CONCLUSIONS

Laparoscopic fundoplication and hiatus hernia repair may effectively control the symptoms of GERD. Furthermore, the detection of pepsin is non-invasive and easy to operate.

Pathophysiology, diagnosis, and pharmacological treatment of gastro-esophageal reflux disease

INTRODUCTION

Gastro-esophageal reflux disease (GERD) is a highly prevalent, chronic, relapsing disorder, whose knowledge has increased in last years thanks to the advent of new sophisticated techniques, such as 24-h impedance-pH monitoring and high-resolution manometry, for the study of esophageal functions.

AREAS COVERED

This review provides an overview of our advancements in understanding the complex pathophysiology, improving the diagnosis and defining the modern pharmacological therapeutic approach to GERD.

EXPERT OPINION

The growing clinical application of impedance-pH testing has allowed us to know the diversity of patients with non-erosive reflux disease (NERD), who nowadays represent about 70% of the whole population with reflux symptoms. We have realized that NERD has to be considered as an umbrella term covering various subgroups with different pathophysiologies. The development of new impedance metrics, in particular mean nocturnal baseline impedance, seems to be promising in the improvement of the diagnostic process of this disease. There are no particularly innovative features in the pharmacological therapy of GERD, unless the interest toward drugs is able to increase the defense properties of esophageal mucosa and/or its protection. These compounds can be of help in combination with proton pump inhibitors in NERD patients with partial response to antisecretory drugs alone.

Beer effects on postprandial digestive symptoms and gastroesophagic physiology

BACKGROUND

Beer has been related to gastroesophageal reflux (GER) and dyspepsia, based on its alcohol and gas content. The aim of this study is to evaluate the association between moderate consumption of traditional and alcohol-free beer and upper digestive symptoms, gastric accommodation and GER.

METHODS

Healthy adults without frequent gastrointestinal symptoms and GER disease were included. The intervention involved administration of traditional beer to 10 subjects (substudy 1) and alcohol-free beer to 20 (substudy 2); control intervention entailed administration of water. Study duration was 2 weeks (control/intervention). Postprandial gastric accommodation was assessed through the maximum tolerated volume during a nutrient drink test after the ingestion of water (day 1) and beer (day 8), in which symptoms of dyspepsia were evaluated every 5 minutes. An impedance-pH monitoring assessed 24 hours and post-NDT GER (days 1 and 8). Symptoms were evaluated daily during the study. The defined variables were compared between visits and weeks using a nonparametric test for paired data.

KEY RESULTS

Dyspepsia symptoms showed a progressive increase during the NDT for both interventions in the 2 substudies, though no significant differences were detected in the MTV analysis. No differences were detected in the sum of weekly symptoms. The analysis of impedance-pH monitoring did not show any differences between intervention and control visits for both interventions.

CONCLUSIONS AND INFERENCES

Moderate consumption of traditional and alcohol-free beer does not increase dyspeptic symptoms or GER in healthy subjects, whether in a controlled-intake or real-life situation. Neither gastric accommodation nor reflux episodes are modified in this context.

The diagnostic value of pepsin detection in saliva for gastro-esophageal reflux disease: a preliminary study from China

Background

None of current diagnostic methods has been proven to be a reliable tool for gastro-esophageal reflux disease (GERD). Pepsin in saliva has been proposed as a promising diagnostic biomarker for gastro-esophageal reflux. We aimed to determine the diagnostic value of salivary pepsin detection for GERD.

Methods

Two hundred and fifty patients with symptoms suggestive of GERD and 35 asymptomatic healthy volunteers provided saliva on morning waking, after lunch and dinner for pepsin determination using the Peptest lateral flow device. All patients underwent 24-h multichannel intraluminal impedance pH (24-h MII-pH) monitoring and upper gastrointestinal endoscopy. Based on 24-h MII-pH and endoscopy study, patients were defined as GERD (abnormal MII-pH results and/or reflux esophagitis) and non-GERD otherwise.

Results

Patients with GERD had a higher prevalence of pepsin in saliva and higher pepsin concentration than patients with non-GERD and healthy controls (P < 0.001 for all). The pepsin test had a sensitivity of 73% and a specificity of 88.3% for diagnosing GERD using the optimal cut-off value of 76 ng/mL. Postprandial saliva samples collected when the symptoms occurred had a more powerful ability to identify GERD.

Conclusions

Salivary pepsin test had moderate diagnostic value for GERD. It may be a promising tool to replace the use of currently invasive tools with advantages of non-invasive, easy to perform and cost effective.

Trial registration

ChiCTR-DDD-16009506 (date of registration: October 20, 2016).

New Approaches to Gastroesophageal Reflux Disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disorder of the esophagus. It is a chronic, progressive disorder that presents most typically with heartburn and regurgitation and atypically with chest pain, dysphagia, chronic cough, globus, or sore throat. The mainstay for diagnosis and characterization of the disorder is esophagoduodenoscopy (EGD), high-resolution esophageal manometry, and symptom-associated ambulatory esophageal pH impedance monitoring. Additional studies that can be useful in certain clinical presentations include gastric scintigraphy and oral contrast upper gastrointestinal radiographic series.

DISCUSSION

Refractory GERD can be surgically managed with various techniques. In obese individuals, laparoscopic Roux-en-Y gastric bypass should be considered due to significant symptom improvement and lower incidence of recurrent symptoms with weight loss. Otherwise, laparoscopic Nissen fundoplication is the preferred surgical technique for treatment of this disease with concomitant hiatal hernia repair when present for either procedure. The short-term risks associated with these procedures include esophageal or gastric injury, pneumothorax, wound infection, and dysphagia. Emerging techniques for treatment of this disease include the Linx Reflux Management System, EndoStim LES Stimulation System, Esophyx® and MUSE™ endoscopic fundoplication devices, and the Stretta endoscopic ablation system. Outcomes after surgical management of refractory GERD are highly dependent on adherence to strict surgical indications and appropriate patient-specific procedure selection.

A modification of Nissen fundoplication improves patients' outcome and may reduce procedure-related failure rate

BACKGROUND

Laparoscopic anti-reflux surgery has a failure rate of 10-20%. We aimed to investigate whether a modification of Nissen fundoplication (MNF) may improve patients' outcome and reduce failure rate.

MATERIALS & METHODS

We prospectively compared 40 consecutive patients with gastroesophageal reflux disease who underwent anti-reflux surgery: 20 Nissen fundoplication (NF) and 20 the MNF approach. Eight cases in the MNF group needed redo surgery. The MNF consisted in suturing the esophagus to the diaphragmatic crura on each side by means of 4 non-absorbable stitches and in fixing the upper stitch of the valve to diaphragm. In case of clearly weak crura, a reinforcement with Ultrapro mesh was used. All patients were assessed before and after surgery using validated symptoms and quality of life (GERD-HRQL) questionnaires, manometry and 24-h impedance-pH monitoring, endoscopy and barium-swallow.

RESULTS

Mortality and postoperative complications were nil. At a median follow-up of 36 months, no significant differences emerged between the MNF and NF group in terms of symptoms, GERD-HRQL scores, manometric findings, and impedance-pH features. Dysphagia was not reported by the MNF group, while it was quite common (20% vs.0%, p = ns) in the NF group. Anti-reflux surgery was successful in all patients in the MNF group, whereas two patients in the NF group presented a slipped wrap and one recurrent reflux; two of these cases required redo-surgery (10% vs. 0%, p = ns).

CONCLUSIONS

Our preliminary data demonstrated that the MNF is a safe and effective procedure. Further, it seems to reduce the failure rate associated to the surgical procedure.

Practice guidelines on the use of esophageal manometry - A GISMAD-SIGE-AIGO medical position statement

Patients with esophageal symptoms potentially associated to esophageal motor disorders such as dysphagia, chest pain, heartburn and regurgitation, represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal manometry in clinical practice is: (1) to accurately define esophageal motor function, (2) to identify abnormal motor function, and (3) to establish a treatment plan based on motor abnormalities. With this in mind, in the last decade, investigations and technical advances, with the introduction of high-resolution esophageal manometry, have enhanced our understanding and management of esophageal motility disorders. The following recommendations were developed to assist physicians in the appropriate use of esophageal manometry in modern patient care. They were discussed and approved after a comprehensive review of the medical literature pertaining to manometric techniques and their recent application. This position statement created under the auspices of the Gruppo Italiano di Studio per la Motilità dell'Apparato Digerente (GISMAD), Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying manometric studies in the most fruitful manner within the context of their patients with esophageal symptoms.