Alkaline gastroesophageal reflux
Tripler Army Medical Center, Honolulu, Hawaii, United StatesThe American Journal of Surgery (Impact Factor: 2.29). 03/1978; 135(2):177-84. DOI: 10.1016/0002-9610(78)90093-4
Twenty-four hour monitoring provides a continuous record of the pH of the lower esophagus in a near physiologic setting. The upper level of physiologic reflux was determined from the percentage of time and the number of episodes that the pH was less than 4 or more than 7 and the mean duration of each episode in fifteen asymptomatic subjects. One hundred patients with symptoms of gastroesophageal reflux were divided into four groups on the basis of twenty-four hour pH monitoring: those with abnormal acid but normal alkaline reflux, termed acid refluxers (51 patients); those with both abnormal acid and alkaline reflux, termed acid-alkaline refluxers (25); those with normal acid and abnormal alkaline reflux, termed alkaline refluxers (6); and those with both normal acid and alkaline reflux, termed nonrefluxers (18).Nonrefluxers had a similar incidence of heartburn, regurgitation, and dysphagia as acid and acid-alkaline refluxers, proving the inaccuracy of symptoms for detecting reflux. Alkaline refluxers had a lesser incidence of heartburn but a greater incidence of regurgitation, and four alkaline reflux patients presented with severe pulmonary disease secondary to aspiration. Similar incidence and degree of esophagitis was seen in acid, acid-alkaline, and alkaline refluxers. All three groups of symptomatic refluxers had a mean distal esophageal sphincter pressure significantly lower than that of the control asymptomatic subjects. There was no difference in the distal esophageal sphincter pressure between controls and symptomatic nonrefluxers.Nine of the patients with acid-alkaline reflux and one of the patients with alkaline reflux underwent an antireflux procedure and were restudied three months postoperatively. All ten patients had a 24 hour pH acid score within normal limits, but two had an abnormal 24 hour pH alkaline score. In both patients, reflux was demonstrated after placing an acid load in the stomach.It is concluded that symptomatic gastroesophageal reflux in patients with an intact gastrointestinal tract is a mixture of both acid and alkaline secretions, with one or both abnormal due to different degrees of acid production and pyloric regurgitation. Patients with alkaline reflux may develop serious complications of reflux in the absence of typical symptoms of heartburn. Twenty-four hour pH monitoring of the esophagus is useful in the identification of these patients and in evaluating the ability of an antireflux procedure to control both abnormal acid and alkaline reflux.
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ABSTRACT: Parole chiave LaringePatologia infiammatoria della laringeCarci- noma della laringeReflusso biliare Summary Laryngopharyngeal reflux is now of major interest as an aeti- ologic factor in chronic inflammatory and neoplastic lesions of upper digestive tract. However, reports in the literature refer only to the irritating action of the acid component of reflux, while possible damaging action of other reflux components re- mains unknown. Aim of this study was to verify the hypothe- sis that alkaline-bile reflux could also be involved in onset of inflammatory, precancerous and neoplastic laryngeal lesions. A total of 40 consecutive gastrectomized patients coming to our Clinic from Gastroenterology Outpatient Unit for an anamnestic and clinical evaluation with videolaryngoscopy of upper digestive airways, entered the study. All presented bile or alkaline reflux as a direct consequence of gastroduodenal anastomosis (Billroth I) and gastrojejunal anastomosis (Bill- roth II) performed over a time span >20 years. Oesophagogas- troduodenoscopy revealed the presence of bile in the residual gastric cavity in all operated patients objectively confirming duodenogastric reflux. Examination of data showed that 3 pa- tients (7.5%) had undergone CO2 laser cordectomy in the 3 years prior to the study for squamous cell laryngeal carcinoma, 3 patients (7.5%) had leukoplakia, 8 (20%) vocal cord chronic oedema with signs of chronic diffuse laryngitis, 6 (15%) pos- terior laryngitis, 8 (20%) interarytenoid oedema while only 12 (30%) showed no ENT lesions. Statistical analysis revealed a significant correlation between incidence of inflammatory and neoplastic laryngeal lesions and type of surgery (Billroth II and total gastrectomy) with respect to other types of gastric re- section. There was also a significant increase in presence and severity of laryngopharyngeal lesions in relation to time elapsed after surgery. These results, although preliminary, seem to confirm that some components of reflux (duodenal content), other than the acid component, play a damaging role involved in the onset of multiple clinical signs and symptoms of laryngopharyngeal reflux disease. It is concluded that sys- tematic use of bile measurement, together with 24-hour pH monitoring, is advisable in subjects with clinical signs and symptoms of laryngopharyngeal reflux, but unresponsive to classic medical treatment, and in gastrectomized patients in or- der to confirm, on larger series, this fascinating aetiopatho- genetic hypothesis. Riassunto Il reflusso faringo-laringeo (RFL) sembra ormai riscuotere grande interesse come fattore eziologico sia nella patologia flogistica cronica che in quella neoplastica delle VADS. Tutta- via i vari studi riportati in letteratura sono riferiti solo all'a- zione irritante della componente acida del reflusso, mentre non è nota, a tutt'oggi, la possibile azione lesiva di altre compo- nenti del refluito patologico. Scopo del presente lavoro è stato quello di verificare l'ipotesi che il reflusso alcalino-biliare, in analogia con quanto riportato per il distretto gastro-esofageo, possa essere anch'esso coinvolto nell'insorgenza di lesioni flo- gistiche, precancerose e neoplastiche laringee. Sono stati valu- tati pertanto 40 pazienti consecutivi gastrectomizzati inviati dall'Ambulatorio di gastroenterologia alla nostra Clinica per una valutazione anamnestico-clinica e videolaringoscopica delle vie aereo-digestive superiori, perché affetti da reflusso biliare o alcalino come diretta conseguenza degli interventi di