Article

Scintigraphy in laryngopharyngeal and gastroesophageal reflux disease: A definitive diagnostic test?

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Abstract

To investigate the utility of scintigraphic studies in predicting response to laparoscopic fundoplication (LF) for chronic laryngopharyngeal reflux symptoms. Patients with upper aero-digestive symptoms that remained undiagnosed after a period of 2 mo were studied with conventional pH and manometric studies. Patients mainly complained of cough, sore throat, dysphonia and globus. These patients were imaged after ingestion of 99m-technetium diethylene triamine pentaacetic acid. Studies were quantified with time activity curves over the pharynx, upper and lower oesophagus and background. Late studies of the lungs were obtained for aspiration. Patients underwent LF with post-operative review at 3 mo after surgery. Thirty four patients (20 F, 14 M) with an average age of 57 years and average duration of symptoms of 4.8 years were studied. Twenty four hour pH and manometry studies were abnormal in all patients. On scintigraphy, 27/34 patients demonstrated pharyngeal contamination and a rising or flat pharyngeal curve. Lung aspiration was evident in 50% of patients. There was evidence of pulmonary aspiration in 17 of 34 patients in the delayed study (50%). Pharyngeal contamination was found in 27 patients. All patients with aspiration showed pharyngeal contamination. In the 17 patients with aspiration, graphical time activity curve showed rising activity in the pharynx in 9 patients and a flat curve in 8 patients. In those 17 patients without pulmonary aspiration, 29% (5 patients) had either a rising or flat pharyngeal graph. A rising or flat curve predicted aspiration with a positive predictive value of 77% and a negative predictive value of 100%. Over 90% of patients reported a satisfactory symptomatic response to LF with an acceptable side-effect profile. Scintigraphic reflux studies offer a good screening tool for pharyngeal contamination and aspiration in patients with gastroesophageal reflux disease.

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... The scintigraphic technique has been extensively described in previous publications [19][20][21][22][23]. Briefly, patients were fasted for 4 hours prior to the scan. ...
... It is conceivable that pertussis may have transformed asymptomatic or lowgrade GORD (± hiatus hernia) into more florid symptomatic disease due to the altered thoracoabdominal dynamics. The patients were referred for reflux scintigraphy to evaluate atypical symptoms that raised the possibility of laryngopharyngeal reflux (LPR) or pulmonary micro-aspiration of refluxate [19,22,27]. The scintigraphic test utilised in the study has been validated against the current standards of oesophageal pH/ impedance and multi-channel dent-sleeve manometry in the oesophagus [21,22,27,28]. ...
... The patients were referred for reflux scintigraphy to evaluate atypical symptoms that raised the possibility of laryngopharyngeal reflux (LPR) or pulmonary micro-aspiration of refluxate [19,22,27]. The scintigraphic test utilised in the study has been validated against the current standards of oesophageal pH/ impedance and multi-channel dent-sleeve manometry in the oesophagus [21,22,27,28]. It has also shown significant difference in scan pattern between GORD and LPR [28] and a strong correlation with resolution of symptoms of LPR/ pulmonary-micro-aspiration after fundoplication [22,28]. ...
Article
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Background: Pertussis is an infectious disease of the respiratory tract with a changing epidemiology. An increasing incidence has been found in the adult population with recurrent infections possibly related to changes in the current vaccine. Is there an association between pertussis infection, refractory cough and atypical gastro-oesophageal reflux (GORD)? Does this magnify and compound respiratory complications? Methods: Observational study which compares post-pertussis (n=103) with non-pertussis patients (n=105) with established GORD. Patients were assessed for laryngopharyngeal reflux and aspiration of refluxate by a novel scintigraphic study. Results: Both groups showed severe GORD in association with high rates of laryngopharyngeal reflux (LPR) and pulmonary aspiration and lung disease. High rates of hiatus hernia and clinical diagnosis of "atypical" asthma showed correlations with pulmonary aspiration. Conclusions: A high level of new onset LPR and lung aspiration has been shown in patients with chronic cough after recent pertussis infection by a novel scintigraphic technique with fused hybrid x-ray computed tomography (SPECT/CT).
... 24-hour impedance study with two channel 24-hour pH was performed on all patients as has been described elsewhere [16]. Briefly, a trans-nasal catheter with 2 level impedance rings and 2 level pH electrodes connected to an external monitoring device was inserted into the oesophagus. ...
... Standard stationary manometry was obtained with a water perfused dent sleeve 8 channel catheter (Dent Sleeve International, Mississauga, Ontario, Canada) as described elsewhere [16]. Data was recorded with a multichannel recording system (PC polygraph HR Medtronics, Synectics Medical, Minneapolis, Minnesota, United States) and analysed using the PolyGram software program (Medtronics, Synectics Medical, Minneapolis, Minnesota, United States). ...
... The scintigraphic test integrates the diagnosis of oesophageal and extra-oesophageal disease by direct visualisation of refluxate at these sites. It has been validated against the current standards for detecting GORD [16,33,34], and is endorsed by Medicare. ...
Article
Introduction Chronic disease poses a major problem for the Australian healthcare system as the leading cost-burden and cause of death. Gastroesophageal reflux disease (GORD) typifies the problems with a growing prevalence and cost. We hypothesise that a scintigraphic test could optimise the diagnosis, especially in problematic extraoesophageal disease. Materials and Methods Data was collected from 2 groups of patients. Patients undergoing fundoplication for severe GORD (n = 30) and those with atypical symptoms (n = 30) were studied by scintigraphy and 24-hour oesophageal pH, impedance and manometry. Results Mean age of cohort was 55.8 years with 40 females and 20 males. Body mass index was a mean of 28.3. DeMeester score was normal in 12/60 with atypical symptoms and abnormal in the rest. Good correlation was shown between scintigraphy and impedance, manometry and distal pH readings. Pulmonary aspiration was shown in 25/60 (15 with atypical symptoms) and LPR in 20/30. Several impedance, manometric and scintigraphic finding were good predictors of lung aspiration of refluxate. Conclusion Scintigraphy provides a good tool for screening patients with typical and atypical symptoms of GORD. It is well correlated with the standard methods for the diagnosis and provides visual evidence of LPR and lung aspiration.
... There have however been multiple technical difficulties and a lack of standardisation between studies with variable and sometimes contradictory results (13,16,17,18). We have developed and validated a consistent scintigraphic technique for the detection of GERD and LPR with good correlations with pH monitoring and manometry (19,20). We hypothesised that scintigraphic reflux studies could provide additional information and complement 24-hour pH and impedance studies in patients with GERD and suspected LPR. ...
... Patients were studied with impedance/pH, manometry and scintigraphic reflux studies. The principal purpose of the studies was assessment for surgery, but these studies have enabled evaluation of the relative contributions of impedance monitoring and standard pH monitoring to predict LPR and lung aspiration of reflux detected by scintigraphic studies, which we have validated in previous work (19,20). ...
... A number of strategies have been advocated including agents that inhibit transient relaxation of the LOS (32) and experimental endoscopic therapies (26). Ultimately, surgical treatment with laparoscopic fundoplication has efficacy that has been established in numerous studies (19,33,34,35) on the basis of pH monitoring alone and more recently, impedance/ pH monitoring in patients with non-acid but symptomatic GERD (36,37). ...
Article
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Objectives: The role of gastroesophageal reflux disease (GERD) in the aetiology of laryngopharyngeal reflux (LPR) is poorly understood and remains a controversial issue. The 24-hour impedance monitoring has shown promise in the evaluation of LPR but is problematic in pharyngeal recording. We have shown the utility of scintigraphic studies in the detection of LPR and lung aspiration of refluxate. Correlative studies were obtained in patients with a strong history of LPR and severe GERD. Methods: A highly selected sequential cohort of patients with a high pre-test probability of LPR/severe GERD who had failed maximal medical therapy were evaluated with 24-hour impedance/pH, manometry and scintigraphic reflux studies. Results: The study group comprised 34 patients (15 M, 19 F) with a mean age of 56 years (range: 28-80 years). The majority had LPR symptoms (mainly cough) in 31 and severe GERD in 3. Impedance bolus clearance and pH studies were abnormal in all patients in the upright and supine position. A high rate of non-acid GERD was detected by impedance monitoring. LOS tone and ineffective oesophageal clearance were found in the majority of patients. Scintigraphic studies showed strong correlations with impedance, pH and manometric abnormalities, with 10 patients showing pulmonary aspiration. Conclusion: Scintigraphic studies appear to be a good screening test for LPR and pulmonary aspiration as there is direct visualisation of tracer at these sites. Impedance studies highlight the importance of non-acidic reflux and bolus clearance in the causation of cough and may allow the development of a risk profile for pulmonary aspiration of refluxate.
... [19][20][21][22][23] Nuclear scintigraphy has potential to address many of these limitations and has been used successfully to detect reflux and aspiration people. [24][25][26][27][28] This technique has been used to safely evaluate pulmonary aspiration in medically fragile human infants. 24,25 In dogs, this technique is postulated to be able to detect reflux events missed by owner observation and that might be missed by VFSS because of small volume, detect nonacidic reflux events, broaden effective time of data collection by looking at additive radio-nuclide activity in several anatomic regions, and help establish the normative data necessary to determine the significance of positive results obtained in clinical patients. ...
... [24][25][26][27][28] This technique has been used to safely evaluate pulmonary aspiration in medically fragile human infants. 24,25 In dogs, this technique is postulated to be able to detect reflux events missed by owner observation and that might be missed by VFSS because of small volume, detect nonacidic reflux events, broaden effective time of data collection by looking at additive radio-nuclide activity in several anatomic regions, and help establish the normative data necessary to determine the significance of positive results obtained in clinical patients. [24][25][26][27][28] Nuclear scintigraphy might therefore represent a novel and sensitive means to help in the diagnosis of elusive reflux and AARS in dogs. ...
... 24,25 In dogs, this technique is postulated to be able to detect reflux events missed by owner observation and that might be missed by VFSS because of small volume, detect nonacidic reflux events, broaden effective time of data collection by looking at additive radio-nuclide activity in several anatomic regions, and help establish the normative data necessary to determine the significance of positive results obtained in clinical patients. [24][25][26][27][28] Nuclear scintigraphy might therefore represent a novel and sensitive means to help in the diagnosis of elusive reflux and AARS in dogs. ...
Article
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Background Reflux and aspiration in people are associated with respiratory disease, whereas approximately 50% of healthy adults microaspirate without apparent consequence. In dogs, analogous information is lacking. Hypothesis Healthy dogs commonly have gastroesophageal reflux and a proportion of these dogs will have laryngopharyngeal reflux with silent aspiration. Animals Twelve healthy, client‐owned dogs. Methods Prospective study: Dogs were free‐fed a meal containing (111 MBq) colloidal ⁹⁹m‐technetium phytate. Dynamic‐scans were performed 5 and 30 minutes postingestion. Time‐activity curves, reflux margination, volume, frequency, and duration were evaluated over 7 regions of interest in dorsal ± left‐lateral recumbency. Static scans (dorsal recumbency) were performed 2 and 18 hours postfeeding to detect aspiration. Reflux and aspiration were defined as counts ≥200% background activity ± decreased gastric counts. Between‐group comparisons were performed by Wilcoxon rank‐sum test or one‐way ANOVA on ranks with significance of P < .05. Results In this study, reflux of variable magnitude was detected in 12/12 dogs. No significant differences in outcome parameters were detected with recumbency (P > .05). Margination to the pharynx and proximal, middle, and distal esophagus was identified in 5/12, 2/12, 3/12, and 2/12 dogs, respectively. Median (IQR) reflux frequency and duration were 2 events/5 minutes (1‐3.3 events/5 minutes) and 6 seconds (4‐9 seconds) respectively. No dog had detectable aspiration. Conclusions and Clinical Importance Nuclear scintigraphy can document reflux in dogs. Reflux, but not aspiration, is common in healthy dogs and must be considered when interpreting results in clinically affected dogs.
... Untreated LPR with recurrent upper airway contamination can have serious consequences which range from paradoxical vocal cord motion to laryngeal stenosis, asthma, recurrent pneumonia, pulmonary fibrosis, and laryngeal malignancy [5,6]. The current algorithms for work-up for GERD and LPR include history and physical examination, trans-nasal laryngoscopy and gastro-intestinal endoscopy, 24-h pH monitoring, esophageal impedance, esophageal manometry, barium swallow, and scintigraphy; none of which is definitive [7][8][9]. ...
... Scintigraphy was conducted using computer-generated isotope counting minimizing potential inter-observer bias. This particular method of scintigraphy in diagnosis of GERD and LPR has been previously described in detail and validated by this group, and control values have been published [8,9,15]. Patients were fasted overnight and then placed before Hawkeye 4 gamma camera (General Electric, Milwaukee, United States) with stomach, chest, and upper airway in the field of view. ...
... Pulmonary aspiration can be treated with laparoscopic fundoplication with improvement demonstrated by scintigraphy as well as clinical resolution of symptoms [8,21]. Previous work by this group found that over 90% of patients with clinical and scintigraphic evidence of LPR pre-operatively reported significant resolution of symptoms and scan improvement after surgery [8,21]. ...
Article
Background Gastro-esophageal reflux disease (GERD) can present with typical or atypical or laryngo-pharyngeal reflux (LPR) symptoms. Pulmonary aspiration of gastric refluxate is one of the most serious variants of reflux disease as its complications are difficult to diagnose and treat. The aim of this study was to establish predictors of pulmonary aspiration and LPR symptoms.Methods Records of 361 consecutive patient from a prospectively populated database were analyzed. Patients were categorized by symptom profile as predominantly LPR or GERD (98 GER and 263 LPR). Presenting symptom profile, pH studies, esophageal manometry and scintigraphy and the relationships were analyzed.ResultsSevere esophageal dysmotility was significantly more common in the LPR group (p = 0.037). Severe esophageal dysmotility was strongly associated with isotope aspiration in all patients (p = 0.001). Pulmonary aspiration on scintigraphy was present in 24% of patients. Significant correlation was established between total proximal acid on 24-h pH monitoring and isotope aspiration in both groups (p < 0.01). Rising pharyngeal curves on scintigraphy were the strongest predictors of isotope aspiration (p < 0.01).Conclusions Severe esophageal dysmotility correlates with LPR symptoms and reflux aspiration in LPR and GERD. Abnormal proximal acid score on 24-h pH monitoring associated with pulmonary aspiration in reflux patients. Pharyngeal contamination on scintigraphy was the strongest predictor of pulmonary aspiration.
... Falk et al. (Fig. 13; [86]) reported a tight correlation demonstrated by cluster analysis suggesting possible physiological causes of proximal reflux disease. Patients with a strong clinical likelihood of LPR were investigated by two channel impedance 24-h pH study and a standardised reflux scintigraphic study. ...
... Physiological factors associated with laryngopharyngeal reflux symptoms-a cohort study [86] ...
Article
Aim A review of the recent changes in understanding of laryngopharyngeal and extra-oesophageal reflux symptoms. Method Literature search over 7 years (2008–2015) and relevant historical cited articles. Results Modern investigation more clearly shows a subgroup of patients with intermittent full column oesophago-gastric-reflux-causing symptoms. Multiple other sites in the lung, head and neck may also be implicated in the reflux disease process. Conclusion Understanding of extra-oesophageal reflux symptomology is evolving. New equipment and techniques suggest further areas of research, and as yet effective therapy remains elusive for some.
... It also enables synchronous diagnosis of pulmonary aspiration and delayed liquid gastric emptying. This technique has been validated and reported, and is a reliable technique for detection of suspected LPR events [10,11]. We have previously shown that no healthy, asymptomatic volunteers had pharyngeal reflux or lung aspiration with reflux scintigraphy [13]. ...
... In the present cohort of symptomatic LPR patients, the majority had both early (90.4%) and delayed (96.2%) evidence of scintigraphic contamination of the pharynx. The present scintigraphic technique has been validated in a cohort with severe reflux disease who had undergone fundoplication [11,12]. The present yield is higher than that reported by Bestetti et al., who reported positive reflux scintigraphy in 67% of a cohort of patients with posterior laryngitis [26]. ...
Article
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Purpose No gold-standard investigation exists for laryngopharyngeal reflux (LPR). Multichannel intraluminal impedance (MII)-pH testing has uncertain utility in LPR. Meanwhile, reflux scintigraphy allows immediate and delayed visualisation of tracer reflux in the esophagus, pharynx, and lungs. The present study aimed to correlate MII-pH and scintigraphic reflux results in patients with primary LPR. Methods Consecutive patients with LPR underwent MII-pH and scintigraphic reflux studies. Abnormal values for MII-pH results were defined from existing literature. MII-pH and scintigraphic data were correlated. Results 105 patients with LPR [31 males (29.5%), median age 60 years (range 20–87)] were studied. Immediate scintigraphic reflux was seen in the pharynx in 94 (90.4%), and in the proximal esophagus in 94 (90.4%). Delayed scintigraphic contamination of the pharynx was seen in 101 patients (96.2%) and in the lungs of 56 patients (53.3%). For MII-pH, abnormally frequent reflux was seen in the distal esophagus in 12.4%, proximal esophagus in 25.7%, and in the pharynx in 82.9%. Patients with poor scintigraphic clearance had higher Demeester scores (p = 0.043), more proximal reflux episodes (p = 0.046), more distal acid reflux episodes (p = 0.023), and more prolonged bolus clearance times (p = 0.002). Conclusion Reflux scintigraphy has a high yield in LPR patients. Scintigraphic time-activity curves correlated with validated MII-pH results. A high rate of pulmonary microaspiration was found in LPR patients. This study demonstrated a high level of pharyngeal contamination by scintigraphy and MII-pH, which supports the use of digital reflux scintigraphy in diagnosing LPR.
... Pulmonary aspiration of gastric refluxate is a feared complication of gastro-oesophageal reflux disease (GORD). Patients presenting with typical symptoms of GORD and those with symptoms of extraoesophageal reflux are at risk of pulmonary aspiration [1][2][3]. Scintigraphy is currently the only available test to objectively demonstrate pulmonary aspiration in GORD [2]. ...
... Patients presenting with typical symptoms of GORD and those with symptoms of extraoesophageal reflux are at risk of pulmonary aspiration [1][2][3]. Scintigraphy is currently the only available test to objectively demonstrate pulmonary aspiration in GORD [2]. ...
Article
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Purpose: Pulmonary aspiration of gastric refluxate is one of the indications for anti-reflux surgery. Effectiveness of surgery in preventing pulmonary aspiration post-operatively has not been previously tested. The aim of this project is to assess effectiveness of anti-reflux surgery on preventing pulmonary aspiration of gastric refluxate. Methods: Retrospective analysis of prospectively populated database of patients with confirmed aspiration of gastric refluxate on scintigraphy. Patients that have undergone anti-reflux surgery between 01/01/2014 and 31/12/2015 and had scintigraphy post-operatively were included. Objective data such as resolution of aspiration, degree of proximal aero-digestive contamination, surgical complications and oesophageal dysmotility as well as patient quality of life data were analysed. Results: Inclusion criteria were satisfied by 39 patients (11 male and 28 female). Pulmonary aspiration was prevented in 24 out of 39 patients (61.5%) post-operatively. Significant reduction of isotope contamination of upper oesophagus supine and upright (p = 0.002) and pharynx supine and upright (p = 0.027) was confirmed on scintigraphy post-operatively. Severe oesophageal dysmotility was strongly associated with continued aspiration post-operatively OR 15.3 (95% CI 2.459-95.194; p = 0.02). Majority (24/31, 77%) of patients were satisfied or very satisfied with surgery, whilst 7/31 (23%) were dissatisfied. Pre-operative GIQLI scores were low (mean 89.77, SD 20.5), modest improvements at 6 months (mean 98.4, SD 21.97) and deterioration at 12 months (mean 88.41, SD 28.07) were not significant (p = 0.07). Conclusion: Surgery is partially effective in reversing pulmonary aspiration of gastric refluxate on short-term follow-up. Severe oesophageal dysmotility is a predictor of inferior control of aspiration with surgery.
... While there have been a number of scintigraphic reflux studies in the past (6,7,8), there has been no general acceptance of the technique due to the variability in technique and inconsistent results. We have validated (9) and present a simple modification of the existing scintigraphic reflux testing and benchmark the findings against the current reference standards such as 24-hour pH monitoring and manometry. The comparison with impedance will be reported separately. ...
... Clinical history distinguished the patients clinically as predominantly GORD in 72 Scintigraphic studies were acquired within a 3-week period of the standard tests in all patients. A subset of 33 patients underwent laparoscopic fundoplication and these results have been reported elsewhere (9). Two channel 24-hour pH monitoring. ...
Article
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Objectives: Gastro-oesophageal reflux disease (GORD) is both common and troubling with a prevalence of 20-40%. We assessed the utility of a scintigraphic reflux study to evaluate the oesophageal and extra-oesophageal manifestation of disease compared to the standard tests such as pH monitoring and manometry. Methods: Patients were recruited into a prospective database of referrals to a tertiary referral center for either resistance to maximal medical therapy or extra-oesophageal symptoms of GORD. Data included 2 channel 24-hour pH monitoring and manometry results, as well as scintigraphic reflux data with late images assessing pulmonary aspiration of refluxate. Results: Study population included 250 patients (155 F, 95 M) with an average age of 60 years. Patients were clinically classified as either GORD (n=72) or laryngopharyngeal reflux (LPR) (n=178). Pulmonary aspiration of the refluxate was detected significantly more commonly in LPR patients (58/178 compared with GORD 10/72). Strong correlations were found between the scintigraphic time-activity curves in the upper oesophagus and pharynx, and ineffective oesophageal motility and pulmonary aspiration. pH studies correlated with the scintigraphic studies but did not predict aspiration similar to other modalities when evaluated by ROC analysis. Conclusion: Scintigraphic reflux studies offer a viable alternative test for GORD and extra-oesophageal manifestations of reflux disease. Strong correlations were found between measurable scintigraphic parameters and oesophageal motility and lung aspiration of refluxate. This may provide a more confident decision analysis in patients being considered for fundoplication for troubling extra-oesophageal symptoms.
... Several of these patients had undergone lobectomy to eradicate the primary infection of the lungs with subsequent recurrence elsewhere in the lungs. All patients gave a history of symptomatic gastroesophageal reflux disease (GERD), and were tested with a scintigraphic reflux study (5,6) to evaluate the presence of disease within the oesophagus, paranasal sinuses and the possibility of aspiration of refluxate into the lungs. The findings led to exploration of a possible connection between these conditions and surgical intervention, supporting the conclusions. ...
... The scintigraphic reflux study assesses patients for lung aspiration after a sampling period of 2 hours, during which the patient is supine for only 30 minutes. Previous work has shown that rising time activity curves for the pharynx/laryngopharynx and upper oesophagus have a positive predictive value of 90% for lung aspiration of refluxate (5). The only patient who did not show aspiration in the 2-hour study had this pattern of activity for the laryngopharynx and upper oesophagus. ...
Article
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Objectives: Fungal pneumonia in the immune competent host is a rarity with few reported cases in the literature. We present a series of 7 cases of recurrent fungal pneumonia in association with allergic fungal rhinosinusitis and gastroesophageal reflux disease (GERD). We hypothesised that recurrent infection may have been transported from the infected paranasal sinuses into the lung by GERD as the process was terminated by surgical fundoplication in 2 of these patients. Methods: Patients were recruited into the study if they were immune competent and had recurrent fungal pneumonia and GERD. Allergic fungal rhinosinusitis was proven by biopsy. GERD was investigated by a scintigraphic test that assessed local oesophageal disease, lung aspiration and head and neck involvement with a hybrid gamma camera and X-ray computed tomography. Results: All patients were shown to have GERD with 5/7 showing paranasal sinus contamination and 7/7 showing laryngopharyngeal involvement and 6/7 lung aspiration. One patient had characteristics strongly predictive of aspiration. Fundoplication led to cessation of fungal lung infection in two patients. Conclusion: Recurrent fungal pneumonia in the immune competent host should raise the possibility of re-infection from the paranasal sinuses, especially in patients with GERD.
... the level of the esophagus and in the extraesophageal structures such as the laryngopharynx and lungs has been developed and validated [12,13]. As sulfur colloid is no longer available in Australia, the replacement agent, 99m Tc Phytate is currently in use for gastroesophageal studies such as reflux and gastric emptying. ...
Article
Gastroesophageal reflux disease (GERD) is a common and growing problem in most western countries. It may present with the typical symptoms of heartburn and regurgitation or with the effects of extra-esophageal disease. We have developed and validated a scintigraphic test that evaluates reflux at both sites in patients at high risk of laryngopharyngeal reflux and lung aspiration. We hypothesized that the test may be able to separate physiologic reflux from pathological reflux and examined this possibility in normal asymptomatic volunteers. Asymptomatic volunteers were screened with the Belafsky reflux symptom index (RSI) and entered into the trial if scores were less than 13. 99mTc Phytate was ingested orally and dynamic studies from the pharynx to the stomach were obtained while upright and supine. A delayed study of the thorax was also obtained for lung aspiration of refluxate. Studies were semi-quantitated graphically as time-activity curves. A total of 25 volunteers were studied (13 M, 12 F) with a mean age of 57.5 yr (Range 40-85 yr). None gave a history of heartburn or regurgitation. Mean RSI was 4.1 (range 0-10). Testing showed upright gastroesophageal reflux to the mid-upper esophagus without pharyngeal contamination in 32%. None of the subjects showed supine reflux or lung aspiration. This result corresponds well with intraluminal impedance/pH monitoring in normal volunteers. The scintigraphic reflux test gives similar results to standard intraluminal impedance/pH studies in normal volunteers. A significant proportion of asymptomatic volunteers demonstrate upright reflux only.
... Radionuclide scintigraphy has been widely used to evaluate various gastrointestinal conditions such as gastric emptying, gastrointestinal bleeding, gastrointestinal motility, and gastroesophageal and laryngopharyngeal reflux. [10][11][12][13] In head and neck oncology, Humphrey et al. was the first to report the application of radionuclide scintigraphy to detect and quantify food transit and stasis in the oropharyngo-esophageal region as well as pulmonary aspiration in patients which provided an important reference for future application and research. 14 Oro-pharyngo-esophageal radionuclide scintigraphy (OPERS) is an investigation that is currently done using a radionuclide salivagram to evaluate swallowing and pulmonary aspiration in children and adults. ...
Article
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Objective To demonstrate that oro-pharyngo-esophageal radionuclide scintigraphy (OPERS) not only detects tracheobronchial aspiration after swallowing, but also quantifies the amount of aspiration and subsequent clearance. Methods Data collected between 2014 and 2019 were reviewed for aspiration pneumonia at 12 and 24-months after OPERS. The predictive value for aspiration pneumonia on flexible endoscopic evaluation of swallowing (FEES), videofluoroscopic swallowing study (VFSS), and OPERS, and the overall survival of patients with or without aspiration were determined. Results Thirty-seven patients treated with radiotherapy for nasopharyngeal carcinoma (NPC) were reviewed. The incidence of aspiration detected on FEES, VFSS, and OPERS was 78.4%, 66.7%, and 44.4%, respectively. Using VFSS as a gold standard, the sensitivity and specificity of OPERS for aspiration was 73.7% and 100%. The positive and negative predictive values for aspiration were 100% and 66.7%, respectively, with an overall accuracy of 82.8%. A history of aspiration pneumonia was one factor associated with a higher chance of subsequent aspiration pneumonia within 12 months (odds ratio: 15.5, 95% CI 1.67–145.8, p < .05) and 24 months (odds ratio: 23.8, 95% CI 3.69–152.89, p < .01) of the swallowing assessment. Aspiration detected by OPERS was a significant risk factor for future aspiration pneumonia at 12 and 24 months respectively. Significantly, better survival was associated with an absence of aspiration on OPERS only, but not on FEES or VFSS. Conclusion OPERS predicts the safety of swallowing, the incidence of subsequent aspiration pneumonia, and the survival prognosis in post-irradiated NPC dysphagia patients. Level of Evidence 3.
... It also has some disadvantages as the performance and interpretation of the test can show some variations between centers as the standards of the test are poorly established. Showing only postprandial refluxes independently of pH lowers its diagnostic value as it is already known that GER occurs mostly in the postprandial period [15][16][17][18][19][20][21][22] . The European (ESPGHAN) and North American (NASPGHAN) Societies for Pediatric Gastroenterology, Hepatology and Nutrition do not recommend GES in the routine diagnosis and management of GER in infants and children because of the low sensitivity of the test [1] . ...
Article
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AIM To evaluate the agreement of multichannel intraluminal impedance-pH monitoring (MII-pHM) and gastroesophageal reflux scintigraphy (GES) for the diagnosis of gastroesophageal reflux disease. METHODS Seventy-five consecutive patients with suspected gastroesophageal reflux disease (GERD) underwent 24-h combined MII-pHM recording and one hour radionuclide scintigraphy during the course of the MII-pHM study. Catheters with 6 impedance channels and 1 pH sensor were placed transnasally. Impedance and pH data analysis were performed automatically and manually. For impedance monitoring, reflux was defined as a retrograde 50% drop in impedance, starting distally and propagating retrogradely to at least the next two more proximal measuring channels. Reflux index (RI, percentage of the entire record that esophageal pH is < 4.0) greater than 4.2% for pHM and number of refluxes more than 50 for 24 h for MII were accepted as positive test results. At scintigraphy, 240 frames of 15 seconds duration were acquired in the supine position. Gastroesophageal reflux was defined as at least one reflux episode in the esophagus. After scintigraphic evaluation, impedance-pH recordings and scintigraphic images were evaluated together and agreement between tests were evaluated with Cohen’s kappa. RESULTS Sufficient data was obtained from 60 (80%) patients (34 male, 56.7%) with a mean age of 8.7 ± 3.7 years (range: 2.5-17.3 years; median: 8.5 years). Chronic cough, nausea, regurgitation and vomiting were the most frequent symptoms. The mean time for recording of MII-pHM was 22.8 ± 2.4 h (range: 16-30 h; median: 22.7 h). At least one test was positive in 57 (95%) patients. According to diagnostic criteria, GERD was diagnosed in 34 (57.7%), 44 (73.3%), 47 (78.3%) and 51 (85%) patients by means of pHM, MII, GES and MII-pHM, respectively. The observed percentage agreements/κ values for GES and pHM, GES and MII, GES and MII-pHM, and MII and pHM are 48.3%/-0.118; 61.7%/-0.042; 73.3%/0.116 and 60%/0.147, respectively. There was no or slight agreement between GES and pHM alone, MII alone or MII-pHM. pH monitoring alone missed 17 patients compared to combined MII-pHM. The addition of MII to pH monitoring increased the diagnosis rate by 50%. CONCLUSION No or slight agreement was found among pH monitoring, MII monitoring, MII-pH monitoring and GES for the diagnosis of gastroesophageal reflux disease.
... Standardized novel reflux-aspirate technetium scans were used for patient with atypical or upper respiratory symptoms. 12 ...
Article
Antireflux and paraesophageal hernia repair surgery is increasingly performed and there is an increased requirement for revision hiatus hernia surgery. There are no reports on the changes in types of failures and/or the variations in location of crural defects over time following primary surgery and limited reports on the outcomes of revision surgery. The aim of this study is to report the changes in types of hernia recurrence and location of crural defects following primary surgery, to test our hypothesis of the temporal events leading to hiatal recurrence and aid prevention. Quality of life scores following revision surgery are also reported, in one of the largest and longest follow-up series in revision hiatus surgery. Review of a single-surgeon database of all revision hiatal surgery between 1992 and 2015. The type of recurrence and the location of crural defect were noted intraoperatively. Recurrence was diagnosed on gastroscopy and/or contrast study. Quality of life outcomes were measured using Visick, dysphagia, atypical reflux symptoms, satisfaction scores, and Gastrointestinal Quality of Life Index (GIQLI). Two-hundred eighty four patients (126 male, 158 female), median age 60.8(48.2–69.1), underwent revision hiatal surgery. Median follow-up following primary surgery was 122.8(75.3–180.3) and 91.6(40.5–152.5) months after revision surgery. The most common type of hernia recurrence in the early period after primary surgery was ‘telescope’(42.9%), but overall, fundoplication apparatus transhiatal migration was consistently the predominant type of recurrence at 1–3 years (54.3%), 3–5 years (42.5%), 5–10 years (45.1%), and >10 years (44.1%). The location of crural defects changed over duration following primary surgery as anteroposterior defects was most common in the early period (45.5% in <1 year) but decreased over time (30.3% at 1–3 years) while anterior defects increased in the long term with 35.9%, 40%, and 42.2% at 3–5 years, 5–10 years, and >10 years, respectively. Revision surgery intraoperative morbidity was 19.7%, mainly gastric (9.5%) and esophageal (2.1%) perforation. There was a 75% follow-up rate and recurrence following revision surgery was 15.4%(44/284) in unscreened population and 21%(44/212) in screened population. There was no difference in recurrence rate based on size of hiatus hernia at primary surgery, or at revision surgery. There were significant improvements in the Visick score (3.3 vs. 2.4), the modified Dakkak score (23.2 vs. 15.4), the atypical reflux symptom score (23.7 vs. 15.4), and satisfaction scores (0.9 vs. 2.2), but no difference in the various domains (symptom, physical, social, and medical) of the GIQLI scores following revision surgery. Revision hiatal surgery has higher intraoperative morbidity but may achieve adequate long-term satisfaction and quality of life. The most common type of early recurrence following primary surgery is telescoping, and overall is wrap herniation. Anterior crural defects may be strong contributor to late hiatus hernia recurrence. Symptom-specific components of GIQLI, but not the overall GIQLI score, may be required to detect improvements in QOL.
... Fluoroscopic barium swallow testing can detect GER and microaspiration, but this also suffers from poor sensitivity (99,100). Gastro-esophageal scintigraphy can detect GER with 80% sensitivity but is not a widely available (101). Esophageal pH monitoring remains the gold standard for diagnosing acid GER, with a reported sensitivity and specificity of over 80% (102,103). ...
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Idiopathic pulmonary fibrosis (IPF), a fibrosing interstitial pneumonia of unknown etiology, primarily affects older adults and leads to a progressive decline in lung function and quality of life. With a median survival of 3–5 years, IPF is the most common and deadly of the idiopathic interstitial pneumonias. Despite the poor survivorship, there exists substantial variation in disease progression, making accurate prognostication difficult. Lung transplantation remains the sole curative intervention in IPF, but two anti-fibrotic therapies were recently shown to slow pulmonary function decline and are now approved for the treatment of IPF in many countries around the world. While the approval of these therapies represents an important first step in combatting of this devastating disease, a comprehensive approach to diagnosing and treating patients with IPF remains critically important. Included in this comprehensive assessment is the recognition and appropriate management of comorbid conditions. Though IPF is characterized by single organ involvement, many comorbid conditions occur within other organ systems. Common cardiovascular processes include coronary artery disease and pulmonary hypertension (PH), while gastroesophageal reflux and hiatal hernia are the most commonly encountered gastrointestinal disorders. Hematologic abnormalities appear to place patients with IPF at increased risk of venous thromboembolism, while diabetes mellitus (DM) and hypothyroidism are prevalent metabolic disorders. Several pulmonary comorbidities have also been linked to IPF, and include emphysema, lung cancer, and obstructive sleep apnea. While the treatment of some comorbid conditions, such as CAD, DM, and hypothyroidism is recommended irrespective of IPF, the benefit of treating others, such as gastroesophageal reflux and PH, remains unclear. In this review, we highlight common comorbid conditions encountered in IPF, discuss disease-specific diagnostic modalities, and review the current state of treatment data for several key comorbidities.
... The pathophysiology of laryngopharyngeal reflux (LPR) is less well understood, but recent studies combining oesophageal manometry, pH/impedance monitoring and reflux scintigraphy have shed more light on this subject 2,3 . It has been welldocumented that LPR patients presenting with predominantly respiratory symptoms such as cough and throat irritation, not associated with typical reflux symptoms of heartburn and acid regurgitation, often respond poorly to acid suppression therapy alone 4,5 . ...
Article
Laryngopharyngeal reflux (LPR) has been linked with irritable bowel syndrome (IBS). Functional colonic, upper gastrointestinal (GI) and LPR symptoms often co‐exist and all improve with osmotic laxative therapy. Reflux scintigraphy demonstrates direct contamination of the airway by refluxate. 1)Evaluate the clinical utility of reflux scintigraphy in managing LPR. 2)Assess the effect of osmotic laxatives combined with acid suppression on both functional GI and LPR symptoms. Forty consecutive patients referred over 6 months with functional colonic symptoms and significant LPR with a reflux symptom index (RSI) > 13 were followed prospectively. All patients underwent pre‐treatment reflux scintigraphy and gastroscopy with assessment of their reflux finding score (RFS). RSI and RFS were reassessed at ENT follow up at a median of 5 months. Functional GI symptoms and RSI were reassessed at a median of 17 months. Thirty‐nine of 40 (97.5%) demonstrated reflux into their oropharynx on reflux scintigraphy. The majority had minimal typical reflux symptoms (55%) and their LPR was refractory to acid suppression alone (62.5%). Short term combination therapy reduced both the RSI (22.6 to 17.2, p < 0.01) and RFS (12.3 to 7.7, p < 0.01). Longer term treatment reduced the RSI further (22.6 to 9.2, p < 0.01) correlating strongly with improvement in functional GI symptoms. LPR occurs frequently amongst IBS patients without typical reflux symptoms. Reflux scintigraphy is useful to both diagnose and optimise treatment of LPR. Reducing colonic distension with osmotic laxatives improves both functional GI and LPR symptoms. This article is protected by copyright. All rights reserved.
... 14 The same concept can be applied to detect reflux to the pharynx after ingestion of a radiolabeled drink, with late studies of the lungs obtained to detect aspiration. 15 Both these investigations are well-tolerated and require less expertise to interpret than pH impedance studies; however, neither provides insight into the mechanism of disease. ...
... The present protocol for quantitative reflux scintigraphy has previously been described and validated [8,9,11]. Patients were fasted for 12 h and proton pump inhibitors ceased 24 h prior to reflux scintigraphy. ...
Article
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IntroductionPreviously described methodologies for detecting laryngopharyngeal reflux (LPR) have limitations. Symptoms alone are non-diagnostic, and pH-impedance studies have poor sensitivity. Pulmonary micro-aspiration is under-recognised in LPR and gastro-esophageal reflux disease (GERD). The present study aimed to describe the results of a modified technique for scintigraphic reflux studies in two groups with severe reflux: those with typical reflux symptoms and those with laryngopharyngeal manifestations of reflux.MethodsA prospective database of severely symptomatic, treatment-resistant reflux patients was grouped based upon predominant symptom profile of typical GERD or LPR. All patients underwent reflux scintigraphy. Results were obtained for early scintigraphic reflux contamination of the pharynx and proximal esophagus, and delayed contamination of the pharynx and lungs after 2 h.Results187 patients were studied (82 GERD, 105 LPR). The LPR patients were predominantly female (70.5% vs. 56.1%; p = 0.042) and older than the GERD group (median age 60 years vs. 55.5 years; p = 0.002). Early scintigraphic reflux was seen at the pharynx in 89.2% (GERD 87.7%, LPR 90.4%; p = 0.133), and at the proximal esophagus in 89.7% (GERD 88.9%, LPR 90.4%; p = 0.147). Delayed contamination of the pharynx was seen in 95.2% (GERD 93.9%, LPR 96.2%; p = 0.468). Delayed pulmonary aspiration was seen in 46% (GERD 36.6%, LPR 53.3%; p = 0.023).Conclusion Reflux scintigraphy demonstrated a high rate of reflux-related pulmonary aspiration. Contamination of the proximal esophagus and pharynx was observed frequently in both groups of severe disease. The likelihood of pulmonary aspiration and potential pulmonary disease needs to be entertained in severe GERD and LPR.
... A strong association has been found be- Patient satisfaction with surgery, as measured by the response to "Would you have surgery again?" (*p < 0.01). GOR gastroesophageal reflux, LPR laryngopharyngeal reflux tween esophageal physiological abnormalities of peristalsis, lower esophageal sphincter pressure, and proximal 24-hpH abnormality but less so for distal 24-h pH abnormality [12]. Other groups have also demonstrated the association between proximal reflux events and esophageal body dysfunction [13]. ...
Article
The diagnosis and management of laryngopharyngeal reflux (LPR) symptoms are made difficult by the lack of good standard tests for diagnosis and for assessment of responsiveness to medical therapy. Proximal esophageal 24‑h pH reading may help identify a group of patients likely to benefit from surgery. A consecutive cohort of patients from a prospective populated database were identified. Further review was undertaken by an independent investigator for symptomatic evaluation following fundoplication 24 months after surgery. There were 90 patients (70% female) treated by fundoplication. The 24‑h pH study was successful in 68 patients; abnormal test results were found in 62 patients. Two clinical groups of patients were identified (GORD predominant/LPR predominant) with better control of LPR symptoms in the mixed GOR/LPR cohort but improved overall (p < 0.01). Symptom control was incomplete. In selected patients with elevated proximal pH readings, symptom improvement of LPR can be achieved by fundoplication.
... shown to induce changes in the laryngopharyngeal mucosa [5,8,9]. Pepsin is a critical digestive enzyme found in gastric acid [10]. ...
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Background: Although laryngopharyngeal reflux (LPR) has been implicated in various upper aerodigestive tract and laryngeal diseases, the underlying mechanisms remain elusive. In this study, we investigated the role of gastric acidified pepsin in laryngeal precancerosis. Methods: The in vitro and in vivo effects of acidified pepsin on H⁺/K⁺-ATPase expression and autophagy/mitophagy induction in mouse laryngeal epithelial cells were assessed by hematoxylin and eosin staining, immunohistochemistry, CCK-8 assay, flow cytometry, Western blotting, and quantitative real-time PCR. Additionally, the levels of pepsin and H+/K+-ATPase α and β subunits in 31 human laryngeal mucosal specimens were assessed by immunohistochemical staining. Results: Acidified pepsin (pH=3) enhanced the growth and survival of mouse laryngeal epithelial cells in vitro and promoted laryngeal mucosal thickening and laryngeal epithelial cell growth in vivo. Furthermore, acidified pepsin promoted autophagy/mitophagy induction, accompanied by a significant decrease in mitochondrial membrane potential (MMP). Inhibition of autophagy by chloroquine abolished the ability of acidified pepsin to promote mitophagy and cell growth in laryngeal epithelial cells. Additionally, chloroquine promoted cell apoptosis and further reduced MMP in laryngeal epithelial cells treated with acidified pepsin. The expression levels of pepsin and H⁺/K⁺-ATPase α and β subunits in 31 human laryngeal mucosa specimens were 51.6%, 48.4%, and 48.4%, respectively. Importantly, the pepsin level was correlated with the H⁺/K⁺-ATPase β subunit level. H⁺/K⁺-ATPase upregulation in laryngeal epithelial cells in response to acidified pepsin was essential for the mitophagy-promoting effect of acidified pepsin. H⁺/K⁺-ATPase knockout or inhibition further reduced MMP in the presence of acidified pepsin. Conclusions: Our findings suggest that in an acidic environment, pepsin promotes laryngeal epithelial cell growth and survival by upregulating H+/K+-ATPase and activating mitophagy, potentially leading to laryngeal precancerosis.
Article
Objective: Reflux scintigraphy is often used to diagnose gastro-esophageal reflux disease (GERD). However, the efficacy of this study remains controversial. Our aim was to determine the role of reflux scintigraphy in diagnosing GERD by comparing it to 24 h combined pH-impedance study as the gold standard. Materials and methods: Adult patients who presented for investigations of reflux symptoms were prospectively recruited into the study. All patients underwent high resolution esophageal manometry and those with major motor disorders of the esophagus were excluded. Eligible patients immediately underwent reflux scintigraphy following insertion of the pH-impedance catheter. Results: Thirty patients were included in the study. Using a total acid exposure time (AET) of >4.2% as the reference for abnormal acid reflux, reflux scintigraphy had a sensitivity and specificity of 62.5 and 68.2%, respectively, in detecting acid reflux. When compared to AET >6%, reflux scintigraphy had a sensitivity and specificity of 66.7 and 62.5%, respectively, and a positive predictive value of 30.8% and a negative predictive value of 88.2%. There were no associations between outcomes of reflux scintigraphy and total AET (p = .46), total (acid or non-acid) reflux events (p = 0.11), proximal AET (p = .33) or the number of proximal reflux episodes (p = .75) on 24 h pH-impedance study. Conclusions: Reflux scintigraphy has limited role in diagnosing GERD when compared to 24 h combined pH-impedance monitoring.
Article
Introduction: Severe oesophageal dysmotility is associated with treatment-resistant reflux and pulmonary reflux aspiration. Delayed solid gastric emptying has been associated with oesophageal dysmotility; however, the role of delayed liquid gastric emptying (LGE) in the pathophysiology of severe reflux disease remains unknown. The purpose of this study is to examine the relationship between delayed LGE, reflux aspiration, and oesophageal dysmotility. Methods: Data were extracted from a prospectively populated database of patients with severe treatment-resistant gastro-oesophageal reflux disease. All patients with validated reflux aspiration scintigraphy and oesophageal manometry were included in the analysis. Patients were classified by predominant clinical subtype as gastro-oesophageal reflux (GOR) or laryngopharyngeal reflux. LGE time of 22 min or longer was considered delayed. Results: Inclusion criteria were met by 631 patients. Normal LGE time was found in 450 patients, whilst 181 had evidence of delayed LGE. Mean liquid half-clearance was 22.81 min. Reflux aspiration was evident in 240 patients (38%). Difference in the aspiration rates between delayed LGE (42%) and normal LGE (36%) was not significant (p = 0.16). Severe ineffective oesophageal motility (IOM) was found in 70 patients (35%) and was independent of LGE time. Severe IOM was strongly associated with reflux aspiration (p < 0.001). GOR dominant symptoms were more common in patients with delayed LGE (p = 0.03). Conclusion: Severe IOM was strongly associated with reflux aspiration. Delayed LGE is not associated with reflux aspiration or severe IOM. Delayed LGE is more prevalent in patients presenting with GOR dominant symptoms.
Thesis
Internet est une source majeure d‟informations en santé pour la population générale introduisant un tiers dans la relation médecin-patient. La qualité de l‟information médicale disponible sur le Web est largement remise en question par les études qui s‟y sont intéressées. L‟objectif de notre travail était de rechercher sur Internet les différents sites de conseils à propos du reflux gastro-oesophagien du nourrisson, qui est un motif fréquent de consultation de médecine générale, et de comparer la qualité de l‟information présentée par ces sites. Une étude qualitative portant sur dix-huit sites Internet a été menée en mars-avril 2016.Elle a cherché à évaluer la qualité de leur structure grâce à trois outils d‟évaluation : le Discern, le Netscoring et le Honcode. La qualité du contenu qu‟ils délivraient a été ensuite comparée à un référentiel de recommandations françaises. L‟étude a cherché à montrer leurs pertinences et leurs insuffisances. Pour 14 des 18 sites analysés, la qualité de l‟information en santé disponible variait de pauvre à très pauvre. Les sites certifiés par la fondation Health On the Net avaient un score Discern et Netscoring significativement plus élevé (p=0.027) que les sites non certifiés. L‟accréditation des sites peut améliorer leur qualité mais ne garantit pas la validité de l‟information. L‟analyse du contenu des sites a montré que 72 % des sites avaient plus de la moyenne aux items de qualité du contenu mais un seul site sur dix-huit citait les dix mesures hygiéno-diététiques recommandées aux parents d‟enfants souffrant d‟un RGO. Aucune corrélation n‟a été observée entre le référencement des sites analysés et les notes obtenues avec les deux outils. Ce fait sociétal est à prendre en compte lors de la consultation de médecine générale ou pédiatrique en 2017. Les autorités devraient réfléchir à un outil pratique permettant de repérer l‟information en santé fiable quel que soit le site consulté.
Article
Intraoperative aspiration is a common pulmonary complication in the surgery, anesthesia and position were main factors leading to the operative aspiration. In recent years, perioperative lung protection has attracted wide attention of thoracic surgeons and anesthetist; how to accelerate the process of postoperative rehabilitation, reduce the incidence of related complications and significantly improve the prognosis of patients, these have become a chief goal of surgical treatment. This article will center on operative aspiration and summarize it from anatomy, pathophysiology, manifestation, diagnosis, treatment and prevention.
Chapter
Diagnostic imaging methods allow evaluating morphology and function of the upper gastrointestinal tract and have been used to evaluate reflux and its complications. In this chapter the main whole-body imaging techniques used to image reflux are described briefly, including their advantages and limitations. X-ray and video fluoroscopy in conjunction with oral barium contrast media can document reflux and a range of morphological changes such as hiatal hernia. Whist X-ray methods are well established, generally available and relatively cheap, they involve giving a dose of ionizing radiation to the patients. Nuclear medicine techniques exploit the sensitivity to small amounts of radiolabels to form images that can evaluate gastroesophageal reflux disease. This sensitivity allows demonstrating postprandial pulmonary aspiration of the ingested radiolabel by showing increased counts in the lung fields. Two and three dimensional nuclear medicine techniques used to image lung delivery of inhaled pharmacological agents could provide a promising technology to investigate airway reflux. More recently a role for MRI has emerged. MRI fluoroscopy is capable to image directly reflux, swallowing and bolus passage in the esophagus. MRI has the advantages of using non ionizing radiation, multi-planar capability, good spatial resolution and good soft tissue contrast. Sensitivity however is low.
Article
Smooth muscle dysfunction in Duchenne muscular dystrophy (DMD) has been rarely studied. A cross‐sectional study was conducted to estimate the prevalence of smooth muscle dysfunction (vascular, upper gastrointestinal, and bladder smooth muscle) in children with DMD using questionnaires (Pediatric Bleeding Questionnaire, Pediatric Gastroesophageal Symptom Questionnaire, and Dysfunctional Voiding Symptom Score). Investigations included bleeding time estimation, nuclear scintigraphy for gastroesophageal reflux, and uroflowmetry for urodynamic abnormalities. Ninety‐nine subjects were included in the study. The prevalence of vascular, upper gastrointestinal, and bladder smooth muscle dysfunction was 27.2%. Mean bleeding time was prolonged by 117.5 seconds. The prevalence of gastroesophageal reflux was 21%. Voided volume/estimated bladder capacity over 15% and abnormal flow curves on uroflowmetry were seen in 18.2% and 9.7% of the subjects, respectively. Our study highlights the need for addressing issues related to smooth muscle dysfunction in the routine clinical care of patients with DMD.
Article
INTRODUCTION Fundoplication for laryngopharyngeal disease with oesophageal dysmotility has led to mixed outcomes. In the presence of preoperative dysphagia and oesophageal dysmotility, this procedure has engendered concern in certain regards. METHODS This paper describes a consecutive series of laryngopharyngeal reflux (LPR) patients with a high frequency of dysmotility. Patients were selected for surgery with 24-hour dual channel pH monitoring, oesophageal manometry and standardised reflux scintigraphy. RESULTS Following careful patient selection, 33 patients underwent fundoplication by laparoscopy. Surgery had high efficacy in symptom control and there was no adverse dysphagia. CONCLUSIONS Evidence of proximal reflux can select a group of patients for good results of fundoplication for atypical symptoms.
Article
Background The inclusion of scintigraphy in the diagnostic algorithm for gastroesophageal reflux is controversial due to variability in methodology and reporting. A novel scintigraphic reflux study has been developed and validated against the current standards for the diagnosis of gastroesophageal reflux disease (GORD). Objective To compare a new scintigraphic reflux test against historic techniques and standardised diagnostic reference tests for gastroesophageal reflux disease. Methods Paired scintigraphic studies were conducted in seventeen patients. All patients underwent at least one other standardised diagnostic reflux test such as 24‐ hour oesophageal impedance/ pH, and oesophageal manometry, barium swallow, gastroscopy or the Peptest. Patients inadvertently presented at sites B for scintigraphic reflux testing rather than at Site A which was part of an approved study. The findings from sites B did not correlate with clinical symptoms and other diagnostic reference tests from GORD. These studies were then repeated at Site A with approval from the patients. A second reflux study was performed at site A, utilising a novel technique with the capability of assessing oesophageal and extra‐oesophageal disease. Results The Site A technique shows good concordance with the reference diagnostic tests with an accuracy of 82.4% and kappa of 0.64 (SE: 0.16, p = 0.00). Site B had an overall accuracy of 47.1% and kappa of 0.066 (SE: 0.068, p = 0.45). Conclusion The Site A technique shows higher accuracy than either site B or the historic reflux techniques. It has characteristics that make it an effective screening tool for assessment of local oesophageal disease and its extraoesophageal manifestations.
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Background: Although laryngopharyngeal reflux (LPR) has been implicated in various upper aerodigestive tract and laryngeal diseases, the underlying mechanisms remain elusive. In this study, we investigated the role of gastric acidified pepsin in laryngeal precancerosis. Results: Acidified pepsin (pH=3) enhanced the growth and survival of mouse laryngeal epithelial cells in vitro and promoted laryngeal mucosal thickening and laryngeal epithelial cell growth in vivo. Furthermore, acidified pepsin promoted autophagy/mitophagy induction, accompanied by a significant decrease in mitochondrial membrane potential (MMP). Inhibition of autophagy by chloroquine abolished the ability of acidified pepsin to promote mitophagy and cell growth in laryngeal epithelial cells. Additionally, chloroquine promoted cell apoptosis and further reduced MMP in laryngeal epithelial cells treated with acidified pepsin. The expression levels of pepsin and H⁺/K⁺-ATPase α and β subunits in 31 human laryngeal mucosa specimens were 51.6%, 48.4%, and 48.4%, respectively. Importantly, the pepsin level was correlated with the H⁺/K⁺-ATPase β subunit level. H⁺/K⁺-ATPase upregulation in laryngeal epithelial cells in response to acidified pepsin was essential for the mitophagy-promoting effect of acidified pepsin. H⁺/K⁺-ATPase knockout or inhibition further reduced MMP in the presence of acidified pepsin. Conclusions: Our findings suggest that in an acidic environment, pepsin promotes laryngeal epithelial cell growth and survival by upregulating H+/K+-ATPase and activating mitophagy, potentially leading to laryngeal precancerosis.
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Introduction: Drug-related problems are frequent in almost all therapeutic areas. Aims: The aim of this paper was to detect drug - related problems in patients with gastroesophageal reflux and to analyze their possible association with the patient characteristics. Material and methods: The study was designed as descriptive, retrospective, crosssectional study aiming to determine the most common drug - related problems in patients with gastro-esophageal reflux disease treated with proton-pump inhibitors. The survey was conducted at the Department of Gastroenterology, Clinical Centre in Kragujevac. The study enrolled all patients treated from gastroesophageal reflux disease with proton pump inhibitors during the time period from 1.1.2014 until 1.1.2015. The study used descriptive statistics (percentage distribution, mean and standard deviation). The correlation between the number of adverse events and patient characteristics was also calculated. Results: The average age of the patients was 55.97±15.811 years, and 43 of the patients (60.6 %) were male. The average hospitalization duration was 12.30±8.89 days. Based on the Pharmaceutical Care Network Europe classification, there were 182 Drug-Related Problems which was, on average, 2.56 problems per patient. Only 5 patients (7%) did not report any problem while 11 patients (15.49%) had over 10 possible drug-drug interactions. The most common problems which occurred were erroneous drug choice, inappropriate administration and possible interactions between medications. Conclusions: Based on the results of this study, one must pay attention to possible drug interactions and other problems which may occur with proton-pump inhibitors. Recognition of different sub-types of drug-related problems and of factors associated with drug related problems may reduce risk from adverse outcomes of gastro-esophageal reflux disease treatment with proton pump inhibitors.
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Background The purpose of this study was to determine whether magnetic sphincter augmentation (MSA) could effectively treat patients with gastroesophageal reflux disease (GERD) who suffer primarily from atypical symptoms due to laryngopharyngeal reflux (LPR). MSA has been shown to treat typical symptoms of GERD with good success, but its effect on atypical symptoms is unknown. Methods A retrospective review of a prospectively maintained institutional review board-approved database was conducted for all patients who underwent MSA between January 2015 and December 2018. All patients had objective confirmation of GERD from ambulatory pH monitoring off anti-reflux medications (DeMeester score > 14.7). Symptoms were assessed preoperatively and at 1 year postoperatively using GERD Health-Related Quality of Life (GERD–HRQL) and Reflux Symptom Index (RSI) questionnaires. Results There were 86 patients (38 males; 48 females) with a median age of 51.5 years. Total GERD HRQL scores improved from a mean of 38.79 to 6.53 (p < 0.01) and RSI scores improved from a mean of 20.9 to 8.1 (p < 0.01). Atypical symptoms evaluated from the RSI questionnaire include hoarseness, throat clearing, postnasal drip, breathing difficulties, and cough. All atypical symptoms were significantly improved at 1 year following MSA (p < 0.01). All three typical symptoms of heartburn, dysphagia, and regurgitation were significantly improved based on pre and postoperative GERD HRQL questionnaires (p < 0.02). Ninety-one percent of patients were off their PPI and dissatisfaction with their current therapy decreased from 95% preoperatively to 13% postoperatively. Conclusion MSA is an effective treatment for typical and atypical GERD symptoms.
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Background Airway reflux is a common cause of chronic cough and this is often refractory to medical therapy. Surgery in the form of Nissen fundoplication has been highly successful in the treatment of the classic reflux symptoms of heartburn and dyspepsia. There is a paucity of data regarding response to fundoplication in patients presenting with chronic cough. Methods We retrospectively reviewed the case notes of patients from the Hull Cough Clinic who had undergone Nissen fundoplication over the past 6 years. Demographic details, duration of symptoms, presence of other symptoms, results of oesophageal studies, outcome and complications were recorded. Patients were contacted by post and asked to complete a questionnaire detailing current symptoms. In a subgroup with continued troublesome cough 24 hour pharyngeal pH measurements were undertaken. Results Forty seven patients underwent fundoplication. The average duration of pre-operative cough was 8 years. Gastro intestinal symptoms were present in the majority. In 30 (64%) patients a positive response to treatment was recorded. Mild dysphagia or bloating was seen in 18 patients following surgery. Four patients needed repeat surgical intervention for modification of fundoplication. One patient developed aspiration pneumonia eight weeks following surgery and died of a myocardial infarction. Two thirds of patients with persisting cough had evidence of airway reflux on pharyngeal pH monitoring. Conclusion In these patients with intractable cough a long term response rate of 63% represents a useful therapeutic option. Treatment failure is more frequent than for classic peptic symptoms and may be related to persistent gaseous reflux.
Article
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Scintigraphic imaging is a useful screening tool for patients with suspected gastroesophageal reflux. New scintigraphic interpretation methods have recently been introduced. This study was undertaken to evaluate the efficiency of various scintigraphic interpretation methods in the detection of gastroesophageal reflux and to measure their influence on inter-reader agreement. Scintigraphic images of 49 children with suspected gastroesophageal reflux were interpreted by three different methods: visual interpretation, time activity curves, and condensed images. The readings were performed by three specialists and a resident. The discordant results were resolved by a consensus reading done together by all interpreters based on the three different methods. The gastroesophageal refluxes were grouped according to their number, location and intensity. Gastroesophageal reflux scintigraphy revealed 22 patients with negative results and 27 with positive results. The sensitivity, positive predictive value and specificity for each of the three specialists vs. the resident were 96%, 96% and 81% vs. 96%; 93%, 90% and 96% vs. 81%; and 90%, 86%, and 95% vs. 73%, respectively. The mean inter-observer reproducibility (κ value) was 0.910 for visual interpretation, 0.652 for time activity curves and 0.789 for condensed images. Twenty-seven percent of the results were discordant and most of these refluxes were of low grade (92%), low intensity (77%) and localization in the distal esophagus (54%). Gastroesophageal scintigraphy is a useful tool for detecting patients with suspected reflux, and visual interpretation is better than the other two methods in terms of accuracy and inter-observer reproducibility.
Article
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We illustrate the importance of short imaging times during gastroesophageal (GE) scintigraphy to better image GE reflux while still obtaining clinically useful gastric emptying data. While most reflux scans are comprised of 30- or 60-sec sequential images, we advocate the use of 10-sec images to maximize the signal-to-noise ratio of any radionuclide present in the esophagus. In the current case, clinically documented reflux of significant magnitude was missed during a study inadvertently performed using 60-sec frames, but subsequently detected using a 10-sec imaging protocol.
Article
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Acid reflux may aggravate airway disease including asthma and chronic cough. One postulated mechanism concerns a vagally-mediated oesophageal-tracheobronchial reflex with airway sensory nerve activation and tachykinin release. To test the hypothesis that patients with airways disease and reflux have higher airway tachykinin levels than those without reflux. Thirty-two patients with airways disease (16 with mild asthma and 16 non-asthmatic subjects with chronic cough) underwent 24 h oesophageal pH monitoring. Acid reflux was defined as increased total oesophageal acid exposure (% total time pH<4 of >4.9% at the distal probe). All subjects underwent sputum induction. Differential cell counts and concentrations of substance P (SP), neurokinin A (NKA), albumin and alpha2-macroglobulin were determined. SP and NKA levels were significantly higher in patients with reflux than in those without (SP: 1434 (680) pg/ml vs 906 (593) pg/ml, p=0.026; NKA: 81 (33) pg/ml vs 52 (36) pg/ml, p=0.03). Significantly higher tachykinin levels were also found in asthmatic patients with reflux than in asthmatic patients without reflux (SP: 1508 (781) pg/ml vs 737 (512) pg/ml, p=0.035; NKA: median (interquartile range 108 (85-120) pg/ml vs 75 (2-98) pg/ml, p=0.02). In patients with asthma there was a significant positive correlation between distal oesophageal acid exposure and SP levels (r=0.59, p=0.01) and NKA levels (r=0.56, p=0.02). Non-significant increases in SP and NKA were measured in patients with cough with reflux (SP: 1534.71 (711) pg/ml vs 1089 (606) pg/ml, p=0.20; NKA: 56 (43) pg/ml vs 49 (17) pg/ml, p=0.71). No significant difference in differential cell counts or any other biochemical parameter was noted between study groups. This study demonstrates increased airway tachykinin levels in patients with asthma and cough patients with coexistent acid reflux. This suggests airway sensory nerve activation in this population.
Article
Nuclear medicine offers a variety of studies for evaluating motility throughout the gastrointestinal tract. Gastric emptying remains the "gold standard" for studying gastric motor function, but its application in most centers remains limited to measuring only total gastric emptying in spite of data that show assessment of both fundal and antal function is of clinical value for evaluating patients with dyspepsia. Similarly, newer methods to study small bowel and colon transit have not gained widespread use. This review summarizes the state-of-the-art of prior established and newer scintigraphic studies with an emphasis on their clinical applications.
Article
GORD has been defined by international consensus based on symptoms of heartburn and regurgitation.1 While this definition is useful for patients with the typical reflux syndrome, these symptoms may not be present in patients with extra-oesophageal GORD. The limitations of pH testing and endoscopy were highlighted in a recent study that demonstrated that each failed to identify approximately 30% of patients with proven GORD.2 A test that establishes a diagnosis of GORD at low cost with minimal intervention would have great utility. The presence of pepsin in saliva or sputum has been proposed as a surrogate marker for reflux disease, albeit one that tells us nothing about a causal relationship between reflux and symptoms. Pepsin may be detected in sputum or saliva by enzymatic or immunological tests.3 Enzymatic tests have several limitations and are difficult to obtain and standardise in practice settings. Attention has therefore focused on immunologic assays with polyclonal and monoclonal antibodies that have been patented and commercialised.3 The question for the clinician is whether salivary pepsin determination is a diagnostic tool that is helpful in clinical practice. For a diagnostic test to be useful in clinical practice, we should be able to demonstrate that the test not only improves our accuracy but that it results in a treatment decision that changes patient outcomes.4 Tests that improve accuracy modestly but don't change management or outcomes have little … [Full text of this article]
Article
Background & Aims Combined pH and impedance monitoring can detect all types of reflux episodes within the esophageal lumen and the pharynx. We performed a multicenter study to establish normal values of pharyngeal and esophageal pH-impedance monitoring in individuals on and off therapy and to determine the interobserver reproducibility of this technique. Methods We collected ambulatory 24-hour pH-impedance recordings from 46 healthy subjects by using a bifurcated probe that allowed for detection of reflux events in the distal and proximal esophagus and pharynx. Data were collected when subjects had not received any medicine (off therapy) and after receiving 40 mg esomeprazole twice daily for 14 days (on therapy). The interobserver agreement for the detection of reflux events was determined in 20 subjects off and on therapy. Results were expressed as median (interquartile range). Results Off therapy, subjects had a median of 32 reflux events (17–45) in the distal esophagus and 3 (1–6) in the proximal esophagus; they had none in the pharynx. On therapy, subjects had a median number of 21 reflux events (6–37) in the distal esophagus and 2 (0–5) in the proximal esophagus; again, there were none in the pharynx. Interobserver agreement was good for esophageal reflux events but poor for pharyngeal events. Conclusions We determined normal values of pharyngeal and gastroesophageal reflux events by 24-hour pH-impedance monitoring of subjects receiving or not receiving esomeprazole therapy. Analyses of esophageal events were reproducible, but analyses of pharyngeal events were not; this limitation should be taken into account in further studies. Eudract.ema.europa.eu, Number: 2010-022845-48.
Article
Gastroesophageal reflux (GER) is frequently found in association with asthma. Successful control of GER in these patients may improve in their asthma symptoms. The present retrospective analysis was undertaken to find out the incidence of GER in asthmatic children not responding to routine antiasthmatic medications and to find out if there is a clinical correlation between the symptoms of GER and scintigraphic evidence of GER in these patients. A total of 126 children with a mean age of 2.31 years and range 6 months to 6 years were evaluated. The children were divided into two groups. Group I (n=100) consisted of children with asthma but no clinical symptoms of GER. Group II (n=26) consisted of those children with asthma and clinical symptoms of GER. Radionuclide scintigraphy was performed with 100–200 μCi (3.7–7.4 MBq) of Tc99m-sulphur colloid. All 33 out of 126 (26%) children had GER on scintigraphy. In Group I, only 23 (23%) had reflux while in Group II, 10 (38.5%) had reflux. In conclusion, esophageal scintiscanning can be used to detect GER in asthmatic children refractory to routine antiasthmatic medication irrespective of the presence or absence of symptoms suggestive of GER.
Article
Gastroesophageal reflux disease is increasingly associated with ear, nose, and throat symptoms, including laryngitis. Many patients are unaware of the gastroesophageal etiology of their symptoms. A variety of criteria are used to diagnose this condition, including laryngoscopy, esophagogastroduodenoscopy, and the use of ambulatory pH and impedance monitoring. However, no test serves as the gold standard for the diagnosis given their lack of sensitivity and specificity for reflux disease. Numerous trials have assessed the role of proton pump inhibitor therapy in patients with laryngopharyngeal reflux and most have revealed no benefit to acid suppression over placebo. Despite many uncertainties there has been some progress regarding the role of acid-suppressive therapy as well as other agents in this unique group of patients. In this review we explore therapeutic options and their rationale for patients with laryngeal signs and symptoms.
Article
Placebos have doubtless been used for centuries by wise physicians as well as by quacks, but it is only recently that recognition of an enquiring kind has been given the clinical circumstance where the use of this tool is essential "... to distinguish pharmacological effects from the effects of suggestion, and... to obtain an unbiased assessment of the result of experiment." It is interesting that Pepper could say as recently as 10 years ago "apparently there has never been a paper published discussing [primarily] the important subject of the placebo." In 1953 Gaddum1 said: Such tablets are sometimes called placebos, but it is better to call them dummies. According to the Shorter Oxford Dictionary the word placebo has been used since 1811 to mean a medicine given more to please than to benefit the patient. Dummy tablets are not particularly noted for the pleasure which they give to their recipients.
Although symptoms of laryngopharyngeal reflux (LPR) symptoms are commonly seen in the ENT clinic, their aetiology and prevalence in the population remain unknown. Lifestyle changes have been seen to be effective in symptom relief. We aimed to establish the prevalence of these symptoms and identify any associated factors. Pseudo-random sampling was performed on 2,000 adults that were sent a validated questionnaire containing the Reflux Symptom Index (RSI) and questions on their health and lifestyle. 45.8 % of the 378 responders were male. The mean RSI was 8.3. 30 % had an RSI of more than 10, of which 75 % had symptoms of gastro-oesophageal reflux disease (r = 0.646 at p = 0.01). Patients with depression and irritable bowel syndrome are more likely to have LPR symptoms. LPR symptoms are highly prevalent in the community and may be influenced significantly by the presence of gastro-oesophageal reflux, depression and irritable bowel syndrome.
Article
A procedure for forming hierarchical groups of mutually exclusive subsets, each of which has members that are maximally similar with respect to specified characteristics, is suggested for use in large-scale (n > 100) studies when a precise optimal solution for a specified number of groups is not practical. Given n sets, this procedure permits their reduction to n − 1 mutually exclusive sets by considering the union of all possible n(n − 1)/2 pairs and selecting a union having a maximal value for the functional relation, or objective function, that reflects the criterion chosen by the investigator. By repeating this process until only one group remains, the complete hierarchical structure and a quantitative estimate of the loss associated with each stage in the grouping can be obtained. A general flowchart helpful in computer programming and a numerical example are included.
Article
Chronic cough is a common problem resulting in significant impairment of quality of life. Along with cough variant asthma and nasal disease, gastroesophageal reflux is considered one of three main causes of cough. Despite this, acid suppression therapy is often far from effective. This review aims to explore whether reflux can lead to cough, the circumstances in which this is most likely to occur, and the potential mechanisms linking these processes. Particular mechanisms to be explored include laryngopharyngeal reflux, microaspiration, and neuronal cross-organ sensitization. Finally, diagnostic approaches are considered.
Article
The aim of this study was to explore the pathogenesis of chronic cough caused by non-acid reflux. Seven patients with chronic cough due to non-acid reflux, 12 patients with chronic cough due to acid reflux, 10 patients with gastro-oesophageal reflux disease without cough and 12 healthy volunteers were recruited for the study. All subjects underwent oesophageal multi-channel intraluminal impedance measurements combined with pH monitoring, and assessment of cough reflex sensitivity to capsaicin and induced sputum cytology. The concentrations of substance P, mast cell tryptase, prostaglandin D2 and histamine in induced sputum were measured by ELISA. Cough threshold C2 and C5 did not differ between patients with chronic cough due to non-acid or acid reflux, but the values were significantly lower than those for patients with gastro-oesophageal reflux disease without cough and healthy volunteers. Weakly acidic reflux episodes were obviously more frequent in patients with chronic cough due to non-acid reflux than in the other three groups. Sputum substance P and mast cell tryptase concentrations were remarkably increased in patients with chronic cough, but were similar for those with cough due to non-acid or acid reflux. There were significant inverse correlations between substance P levels and cough threshold C2 or C5 in patients with cough due to non-acid or acid reflux, and between mast cell tryptase levels and cough threshold C2 in patients with cough due to acid reflux. Chronic cough due to non-acid reflux may be related to cough reflex hypersensitivity caused by neurogenic airway inflammation and mast cell activation, in which weakly acidic reflux is possibly a major factor.
Article
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.
Article
Gastroesophageal reflux disease typically manifests as heartburn and regurgitation, but it may also present with atypical or extraesophageal symptoms, including asthma, chronic cough, laryngitis, hoarseness, chronic sore throat, dental erosions, and noncardiac chest pain. Diagnosing atypical manifestations of gastroesophageal reflux disease is often a challenge because heartburn and regurgitation may be absent, making it difficult to prove a cause-and-effect relationship. Upper endoscopy and 24-hour pH monitoring are insensitive and not useful for many patients as initial diagnostic modalities for evaluation of atypical symptoms. In patients with gastroesophageal reflux disease who have atypical or extraesophageal symptoms, aggressive acid suppression using proton pump inhibitors twice daily before meals for three to four months is the standard treatment, although some studies have failed to show a significant benefit in symptomatic improvement. If these symptoms improve or resolve, patients may step down to a minimal dose of antisecretory therapy over the following three to six months. Surgical intervention via Nissen fundoplication is an option for patients who are unresponsive to aggressive antisecretory therapy. However, long-term studies have shown that some patients still require antisecretory therapy and are more likely to develop dysphagia, rectal flatulence, and the inability to belch or vomit.
Article
Despite the new gold standard oesophageal impedance monitoring, pH monitoring is still used frequently for detection of gastro-oesophageal reflux (GOR). Besides drops in pH from above to below pH4, drops of > or =1 unit are also used as a marker for GOR. In this study the objective was to investigate the accuracy of drops in pH for detection of GOR, using impedance monitoring as the gold standard. Nineteen GORD patients (9 M, 55+/-11 years) underwent combined 24-h pH-impedance recording off acid-suppressive therapy. All drops in pH > or =0.5 pH units, with a duration > or =4 s, reaching the nadir pH within 5 s after onset were included. Reflux events detected with impedance monitoring were taken as the reference. In total, 2221 drops in pH were found; 47% were acid (nadir pH <4), 47% weakly acidic (nadir pH between pH7 and 4) and 5% were superimposed (pH drop starting below pH4). The sensitivities of acid, weakly acidic and superimposed pH drops > or =1 were 91%, 28%, 24%, respectively, and the percentages of false-positive reflux episodes were 20, 56 and 54, respectively. Acid reflux with a cut-off > or =0.5 and < or =3.3 had a moderate-to-good sensitivity (94-70%) and low false-positive percentages (23-13%). In contrast, weakly acidic and superimposed reflux showed greater false-positive than true-positive percentages for all cut-off values. Compared to impedance monitoring, detection of reflux with pH monitoring is clearly inferior. When drops in pH > or =1 are used irrespective of nadir pH as an indicator of reflux episodes, the number of reflux episodes is overestimated. Decreases from above to below 4 with cut-offs between > or =0.5 and < or =3.3 are the most indicative of true reflux episodes.
Article
We compared scintigraphy to other reflux tests in 45 symptomatic patients. Sensitivity of 24-h pH score was 82%, endoscopy 64%, and LESp 33%. Scintigraphy was insensitive (36%), although 50% of patients with esophagitis had a positive test. Specificity and positive predictive value were good (all greater than or equal to 88%) in discerning patients with an abnormal 24-h pH score and esophagitis. We suggest scintigraphy as the first diagnostic test to confirm frequent reflux events (REs) and normal clearance in the subgroup of patients with severe endoscopic esophagitis, and manometry and 24-h pH monitoring when scintigraphy is negative. We also compared scintigraphy to simultaneously performed pH monitoring in detecting individual postprandial REs and their clearance. The two methods agreed in only 25% of total reflux events. Scintigraphy was superior at detection of reflux of buffered gastric contents and detection of additional REs during acid clearing intervals, whereas only the pH probe detected REs after gastric emptying. We conclude that scintigraphy has a limited role as a diagnostic test in gastroesophageal reflux disease, and much potential as a research tool, especially in combination with the pH probe.
Article
One hundred and ten patients with suspected oesophageal symptoms were investigated by means of oesophageal endoscopy (OE), 24-h pH-metry, and oesophageal scintigraphy (ES). When 24-h pH-metry formed the basis for diagnosis of gastrooesophageal reflux disease (GERD), the sensitivity for ES at abdominal compression was 64%, but no statistically significant differences were found among erect refluxers (ER), supine refluxers (SR), and combined refluxers (CR). Only 4% of the GERD patients had pathologic oesophageal clearing at ES. The more severe the macroscopic oesophagitis found by OE, the more pronounced were the abnormal findings at 24-h pH-metry and at ES with abdominal compression. Increased postprandial reflux was associated with gastro-oesophageal reflux and hiatal hernia at ES with abdominal compression and the most severe form of oesophagitis, respectively. It was concluded that ES had too low sensitivity to be recommended as a screening test for GERD. Nevertheless, the specificity of 76% can to some extent help us to rule out GERD in patients.
Article
Esophageal exposure to acid is a major determinant in the pathogenesis of reflux esophagitis. In this study, we analyzed the esophageal peristaltic function of 177 patients and asymptomatic volunteers for abnormalities that could lead to prolonged esophageal acid clearance. The subjects were divided into five groups: normal volunteers, patient controls, patients with noninflammatory gastroesophageal reflux disease, patients with mild esophagitis, and ones with severe esophagitis. Manometric data were analyzed for the occurrence of failed primary peristalsis, for the occurrence of feeble peristalsis in the distal esophagus, and for hypotensive lower esophageal sphincter pressure. From an analysis of the data on control patients, peristaltic dysfunction was defined as the occurrence of either failed primary peristalsis or hypotensive peristalsis in the distal esophagus for over half of the test swallows. Peristaltic dysfunction was increasingly prevalent with increasing severity of peptic esophagitis, occurring in 25% of patients with mild esophagitis and 48% of patients with severe esophagitis. A correlation did not exist between the occurrence of peristaltic dysfunction and hypotensive lower esophageal sphincter pressure (less than or equal to 10 mmHg). We conclude that peristaltic dysfunction occurs in a substantial minority of patients with peptic esophagitis and could contribute to increased esophageal exposure to refluxed acid material.
Article
We tested a manometric assembly employing a sleeve sensor that is able to monitor anterior or posterior pressure in the human upper esophageal sphincter (UES) for prolonged intervals. When compared to rapid pull-through measurement of UES pressure obtained with conventional manometric assemblies, the sleeve sensor measured significantly lower UES pressures with less variability between subjects, thereby suggesting that the rapid pull-through maneuver stimulates the UES to contract. Concurrent recordings of UES pressure with a sleeve sensor and a side-hole sensor during a slow station pull-through yielded almost equal pressure values at the peak of the high-pressure zone (station zero), but the side-hole site recorded significantly lower pressures than the sleeve at stations 0.5 cm or more from the peak of the high-pressure zone. During 10 min of recording at station zero, the sleeve sensor recorded greater pressures than the side-hole sensor. This finding demonstrated the suceptibility of the side-hole sensor to axial movement relative to peak UES pressure. When stationary, both the sleeve sensor and the side-hole sensor recorded significantly lower UES pressure after 1-2 min of recording, again suggesting that movement of the recording assembly stimulates the UES to contract. Sleeve recordings of swallow-induced UES relaxations showed that UES relaxations induced by water swallows were slightly longer than those induced by dry swallows. Augmentations of UES pressure induced by balloon distension of the esophageal body were also recorded. We conclude that the sleeve sensor is a suitable method for investigating the normal physiology and pathophysiology of the UES in human subjects.
Article
The scintigraphic detection of small nocturnal aspirations of radio-labelled gastric contents is difficult in the presence of high remaining activity in the abdomen, causing a non-uniform background activity. This problem was examined in phantom experiments and a technique for interpolative background correction was further developed. The accuracy of this technique was found to be influenced by the distance between the lung and the abdominal source of activity, and the minimum detectable ‘aspirated’ activity was determined as 0.1 MBq at a distance of 15 cm and 1 MBq at 5 cm. The interpolative technique for background correction was evaluated on healthy volunteers and laryngectomized patients, examined 10 h after intragastric instillation of 200 MBq of 99Tcm-pertechnetate. After background subtraction, their calculated pulmonary mean net count value was comparable to that registered before the radioactive tracer was administered. No localized accumulation of activity was found in any of these controls. The technique was then applied clinically to 55 patients with chronic respiratory disorders and symptoms of gastroesophageal reflux. Aspiration was detected in 11 patients (20%). Five aspirators had asthma, two a chronic cough of unknown origin, two recurrent pulmonary infections, and one chronic bronchitis and chronic laryngitis respectively. Aspiration was detected among patients with and without demonstrated pathological gastroesophageal reflux.
Article
Ambulatory esophageal pH monitoring was performed in 26 normal volunteers, 20 patients with normal distal acid exposure, and 23 patients with abnormal distal acid exposure in an attempt to define normal values for proximal esophageal acid exposure using a standardized technique. We used a dual pH sensor with antimony electrodes spaced at 15 cm. The distal electrode was placed manometrically at 5 cm above the lower esophageal sphincter. Proximal electrode thus was located below the upper esophageal sphincter in the esophageal inlet. The patients underwent 24-h ambulatory pH monitoring and were told to pursue normal daily activities. The percentage of acid exposure time and number of episodes per 24 h at both pH < 4.0 and 5.0 were measured for the total, upright, and supine periods. Since the pH values were not normally distributed, the medians and 95th percentiles were used to define normal values. Minimal acid exposure occurred in the proximal esophagus (< 1% total; 0% supine) in volunteers and patients with normal distal reflux. Patients with abnormal distal acid exposure had significantly greater proximal reflux.
Article
Gastroesophageal reflux disease (GERD) is a common disease with many typical and atypical forms of presentation. In the classic presentations of GERD with heartburn and regurgitation, esophageal testing, except for endoscopy, is only required for poorly responding patients or prior to surgical therapy. The atypical presentations of GERD, including chest pain, asthma, and ear, nose, and throat complaints, frequently are not associated with heartburn or regurgitation. Esophageal testing, particularly 24-hour pH monitoring is key to making the diagnosis and ensuring adequate acid suppression.
Article
To define the role of ambulatory pH monitoring in evaluating chronic cough, we studied esophageal pH values of patients referred to a gastroenterology laboratory. Chronic cough was evaluated in 31 patients, who were grouped based on response to treatments; 11 patients (35.5%) had gastroesophageal reflux (GER)-related cough, 11 (35.5%) had pulmonary/otorhinolaryngologic-related cough (1 bronchitis, 6 asthma, 2 postnasal drip, 1 pneumonia), and 9 patients (29%) had cough of unknown etiology. Esophageal pH values of groups were compared. Excessive acid reflux distally (upright and supine) and proximally (upright) and cough symptom frequency related to acid reflux were significantly higher in patients with GER. Esophageal pH monitoring had good sensitivity (91%), specificity (82%), and positive (83%) and negative (90%) predictive values in identifying GER-related cough. In summary, ambulatory pH monitoring is an excellent test for identifying patients with GER-related cough.
Article
The aim of this study was to use gastroesophageal and pulmonary scintigraphy to evaluate the prevalence of gastroesophageal reflux and airway involvement among patients with posterior laryngitis. The study included a total of 201 patients (131 females, 70 males; age range, 15-77 y; mean age +/- SD, 49 +/- 16 y). All patients had posterior laryngitis documented by laryngoscopy and symptoms such as a dry cough, painful swallowing, and hoarseness. A control population of 20 healthy volunteers (13 females, 7 males; age range, 19-74 y; mean age, 53 +/- 13 y) was also evaluated. After a 12-h fast, all subjects underwent gastroesophageal scintigraphy through administration of 300 mL orange juice labeled with 185 MBq 99mTc-sulfur colloid. After 18 h, planar anteroposterior thoracic images were acquired with the subjects supine. Sixty-seven percent of patients (134/201) had scans positive for gastroesophageal reflux; of these, 30 (22%) had distal reflux and 104 (78%) had proximal reflux. In addition, the scans of 31 patients were positive for proximal reflux-associated pulmonary uptake. The frequency, duration, and degree of reflux episodes were significantly greater in patients with proximal reflux than in patients with distal reflux (P < 0.001). The 67 patients in whom reflux was not detected had diseases or reflux-associated cofactors that could account for laryngeal symptoms. No statistically significant difference in symptoms or esophageal motility parameters could be identified among the patient groups, but patients with proximal reflux had significantly prolonged gastric emptying times compared with healthy volunteers. Most patients with posterior laryngitis had detectable proximal gastroesophageal reflux. Exposure of the proximal part of the esophagus to acid, by setting the stage for microaspiration of gastric material into the larynx, remains a major cause of damage to the laryngeal mucosa. Slowed gastric emptying may be a predisposing factor. Moreover, symptoms such as a dry cough, painful swallowing, or hoarseness may not be reliable predictors of the presence of gastroesophageal reflux or of associated airway involvement.
Article
Placebo treatment has been reported to improve subjective and objective measures of disease in up to 30-40% of patients with a wide range of clinical conditions. A review of 8 clinical trials on the effects of antitussive medicines on cough associated with acute upper respiratory tract infection shows that 85% of the reduction in cough is related to treatment with placebo, and only 15% attributable to the active ingredient Treatment with a cough medicine can be viewed as consisting of three components: pharmacological, physiological (demulcent) and placebo. The placebo effect is related to belief in the effectiveness of the treatment and this idea must in some way influence the central control of cough. Studies on the placebo effect of analgesics indicate that the placebo effect may be mediated by endogenous opioid neurotransmitters and this may explain the analgesic potency of opioid medicines such as morphine. In the present paper a model is proposed to explain the antitussive effects of placebo treatment on the basis of endogenous opioid neurotransmitters. With active pharmacological ingredients contributing only 15% to the effects of cough treatment it seems reasonable to conduct more research on the other components of treatment such as placebo.
Article
Radionuclide studies have gained wide acceptance in the evaluation of infants and children with gastroesophageal reflux (GER). For correct interpretation of scan results, knowledge of inter-observer and intra-observer variability and minimum detectable reflux volume is essential. In this study, we evaluated the methodological issues underlying the visual assessment of GER and time activity curve analysis. An in vitro model of stomach and oesophagus was established to determine the minimum detectable reflux by placing various volumes and concentrations representing the diluted activity in the stomach. In the clinical part 99 patients were imaged for 1 h after oral administration of 99mTc sulfur colloid. Eleven patients were excluded from the study either due to incomplete clinical data or suboptimal image quality. Frames of 16 s each, and time-activity curves which were generated after drawing regions of interest from the oesophagus, were read three times by an experienced nuclear medicine physician and a resident in training. On the phantom study, the concentration, volume and duration were the determining factor for the visualization of reflux. In the clinical part, the overall incidence of GER in 88 patients was 69%. The mean intra- and inter-observer reproducibility (kappa values) was 0.76 and 0.7065, respectively. Agreement was slightly higher in the analysis of time-activity curves (0.767 and 0.731). Our results indicate that GER may be reproducibly analysed on scintigraphy by the same and different observers with varying levels of training. Its visualization is associated with reflux duration, volume and dilution factor of radioactivity.
Article
Gastroesophageal reflux (GER) is frequently found in association with asthma. Successful control of GER in these patients may improve in their asthma symptoms. The present retrospective analysis was undertaken to find out the incidence of GER in asthmatic children not responding to routine antiasthmatic medications and to find out if there is a clinical correlation between the symptoms of GER and scintigraphic evidence of GER in these patients. A total of 126 children with a mean age of 2.31 years and range 6 months to 6 years were evaluated. The children were divided into two groups. Group I (n = 100) consisted of children with asthma but no clinical symptoms of GER. Group II (n = 26) consisted of those children with asthma and clinical symptoms of GER. Radionuclide scintigraphy was performed with 100-200 microCi (3.7-7.4 MBq) of Tc99m-sulphur colloid. All 33 out of 126 (26%) children had GER on scintigraphy. In Group I, only 23 (23%) had reflux while in Group II, 10 (38.5%) had reflux. In conclusion, esophageal scintiscanning can be used to detect GER in asthmatic children refractory to routine antiasthmatic medication irrespective of the presence or absence of symptoms suggestive of GER.
Article
Laryngeal signs and symptoms are often associated with gastroesophageal reflux disease (GERD). However, such diagnoses presume that laryngeal findings may be specific for GERD. However, neither laryngoscopy, EGD or pH monitoring are specific tests for identifying GERD related laryngitis. Non-placebo controlled trials often show clinical benefit from proton pump inhibitor therapy; however, suffer from lack of controls. GERD may be one cause of laryngeal signs and symptoms in a subgroup of patients but not in all those currently so suspected. Future, studies are needed in this area to better delineate this association.
Article
It is widely believed that placebo interventions induce powerful effects. We could not confirm this in a systematic review of 114 randomized trials that compared placebo-treated with untreated patients. To study whether a new sample of trials would reproduce our earlier findings, and to update the review. Systematic review of trials that were published since our last search (or not previously identified), and of all available trials. Data was available in 42 out of 52 new trials (3212 patients). The results were similar to our previous findings. The updated review summarizes data from 156 trials (11 737 patients). We found no statistically significant pooled effect in 38 trials with binary outcomes, relative risk 0.95 (95% confidence interval 0.89-1.01). The effect on continuous outcomes decreased with increasing sample size, and there was considerable variation in effect also between large trials; the effect estimates should therefore be interpreted cautiously. If this bias is disregarded, the pooled standardized mean difference in 118 trials with continuous outcomes was -0.24 (-0.31 to -0.17). For trials with patient-reported outcomes the effect was -0.30 (-0.38 to -0.21), but only -0.10 (-0.20 to 0.01) for trials with observer-reported outcomes. Of 10 clinical conditions investigated in three trials or more, placebo had a statistically significant pooled effect only on pain or phobia on continuous scales. We found no evidence of a generally large effect of placebo interventions. A possible small effect on patient-reported continuous outcomes, especially pain, could not be clearly distinguished from bias.
Article
To evaluate the role of oropharyngoesophageal scintigraphy in the diagnostic approach to patients with laryngopharyngeal reflux (LPR). Forty-one patients with chronic laryngopharyngeal symptoms and a control group of 15 healthy volunteers were examined. All subjects underwent standard oropharyngoesophageal scintigraphy. The following parameters were considered: activity-time curves, presence of double peaks and reduced slope in oropharyngeal phase, presence of accelerated or slowed esophagogastric transit, persistence of radioactive material on the pharyngeal or esophageal mucosa, and presence of gastroesophageal reflux (GER) under exercise. There were objective signs of laryngeal reflux in 80.5% of the patients. In 82.9%, scintigraphy documented several associated morphofunctional pathologic patterns: positive GER test (61.0%), presence of double peaks (36.6%), indirect signs of pharyngoesophageal inflammation (31.7%), hypotonic lower esophageal sphincter (17.1%), and slowed esophageal clearance (9.8%). Oropharyngoesophageal scintigraphy may be used as preliminary examination in outpatients with signs and symptoms of LPR. Cases of classic gastroesophageal reflux disease could be separated from those of LPR disease and therefore submitted to more invasive instrumental examinations.
Article
Gastro-oesophageal reflux disease is known to be a frequent cause of patients' referral to hospital gastroenterologists. To increase knowledge on referral for reflux disease, in an Italian academic setting. The impact of gastro-oesophageal reflux disease on 1 year's workload, comprising upper endoscopy, outpatients' consultations in the general clinic, oesophageal pH monitoring and oesophageal manometry was retrospectively assessed. Appropriateness of oesophageal pH monitoring and oesophageal manometry was also evaluated. Endoscopy: Out of 2269 upper endoscopies reflux symptoms comprised 16.9% (n=386) of referrals; 19.1% only of these 386 patients had erosive oesophagitis at endoscopy and none had oesophagogastric malignancies (68% of the patients were >45 years). Consultations: Thirty-three percent out of 553 patients were referred for reflux symptoms. Upper endoscopy had already been performed before consultation in 64% of them. pH monitoring and oesophageal manometry: Two hundred and sixteen oesophageal pH monitorings and 160 oesophageal manometries were performed and 29% and 28%, respectively, were inappropriate, being performed in the diagnostic work-up of patients with typical reflux symptoms. At an academic Gastroenterology Unit, (a) gastro-oesophageal reflux disease is a frequent referral for upper endoscopy and consultations, (b) prevalence of oesophagitis is low, (c) consultation is preceded by endoscopy in the majority of patients and (d) oesophageal pH monitoring and oesophageal manometry are often inappropriately used.
Article
Although the long-term results of open fundoplication for gastroesophageal reflux disease are well documented, few reports exist on the long-term results of laparoscopic fundoplication. Retrospective study with clinical evaluation or mailed survey for patients unable to return to the hospital center. Multicenter studies (ie, private medical centers, institutional hospitals, and university hospitals). Between January 1992 and December 1998, 2684 patients with gastroesophageal reflux disease underwent laparoscopic fundoplication in 31 hospital centers. Outcome data covering a period of 5 or more years after surgery were available for 1340 patients: 711 who underwent complete fundoplication, 559 who underwent partial posterior fundoplication, and 70 who underwent partial anterior fundoplication. Evaluation of clinical and quality-of-life actions used to treat the symptoms of gastroesophageal reflux disease. The overall residual severe dysphagia rate was 5.1% (n = 68). A further surgical procedure was required for 59 patients (4.4%) for a total of 63 interventions. Subsequent operation was performed laparoscopically in 32 cases (50.8%). Twelve of these procedures were for the repair of a paraesophageal hiatus hernia, 11 were for dysphagia (4 because of a tight esophageal hiatus and 7 for conversion of Nissen fundoplication to a posterior partial fundoplication procedure), 31 were for recurrent reflux (wrap undone), 2 were for intestinal obstruction (adhesiolysis), 1 was for incisional hernia, 1 was for abdominal abscess (drainage), and 1 was for gastroparesis (pyloroplasty). The recurrence rate was 10.1% (n = 136), and 122 patients (9.1%) resumed taking antisecretory medication. Gas bloat syndrome was present in 101 patients (7.5%). A total of 93.1% of the patients were satisfied (Visick classification, grades 1 and 2) and 6.9% were unsatisfied, with no difference among the 3 procedures. After 5 years of experience, laparoscopic fundoplication remains an effective antireflux procedure.
Article
To critically review and summarize the literature on cough and gastroesophageal reflux disease (GERD), and to make evidence-based recommendations regarding the diagnosis and treatment of chronic cough due to GERD. Ovid MEDLINE literature review (through March 2004) for all studies published in the English language and selected articles published in other languages such as French since 1963 using the medical subject heading terms "cough," "gastroesophageal reflux," and "gastroesophageal reflux disease." GERD, singly or in combination with other conditions, is one of the most common causes of chronic cough. In patients with normal chest radiographic findings, GERD most likely causes cough by stimulation of an esophageal-bronchial reflex. When GERD causes cough, there may be no GI symptoms up to 75% of the time. While 24-h esophageal pH monitoring is the most sensitive and specific test in linking GERD and cough in a cause-effect relationship, it has its limitations. In addition, there is no general agreement on how to best interpret the test, and it cannot detect non-acid reflux events. Therefore, when patients fit the clinical profile that has a high likelihood of predicting that GERD is the cause of cough, antireflux medical therapy should be empirically instituted. While some patients improve with minimal medical therapy, others require more intensive regimens. When empiric treatment fails, it cannot be assumed that GERD has been ruled out as a cause of chronic cough. Rather, an objective investigation for GERD is then recommended because the empiric therapy may not have been intensive enough or medical therapy may have failed. Surgery may be efficacious when intensive medical therapy has failed in selected patients who have undergone an extensive objective GERD evaluation. Accurately diagnosing and successfully treating chronic cough due to GERD can be a major challenge.
Article
Nuclear medicine offers a variety of studies for evaluating motility throughout the gastrointestinal tract. Gastric emptying remains the "gold standard" for studying gastric motor function, but its application in most centers remains limited to measuring only total gastric emptying in spite of data that show assessment of both fundal and antal function is of clinical value for evaluating patients with dyspepsia. Similarly, newer methods to study small bowel and colon transit have not gained widespread use. This review summarizes the state-of-the-art of prior established and newer scintigraphic studies with an emphasis on their clinical applications.
Article
Silent gastroesophageal reflux disease (GERD) is a very common phenomenon that involves the incidental finding of erosive esophagitis, Barrett's esophagus, and the evolution of esophageal adenocarcinoma in asymptomatic patients. The reasons for having advanced GERD without clearly identifiable symptoms are poorly understood, primarily due to lack of recognition of this important phenomenon. The clinical implications of silent GERD are vast and should provide the impetus for further research into this group of patients. Recent studies have suggested that sleep disturbances and poor quality of sleep could be the needed clues to identify individuals with silent GERD.
Article
Thus far, there has been a paucity of studies that have assessed the value of the different gastroesophageal reflux disease (GERD) symptom characteristics in identifying patients with long-segment Barrett's esophagus versus those with short-segment Barrett's esophagus. To determine if any of the symptom characteristics of GERD correlates with long-segment Barrett's esophagus versus short-segment Barrett's esophagus. Patients seen in our Barrett's clinic were prospectively approached and recruited into the study. All patients underwent an endoscopy, validated GERD symptoms questionnaire and a personal interview. Of the 88 Barrett's esophagus patients enrolled into the study, 47 had short-segment Barrett's esophagus and 41 long-segment Barrett's esophagus. Patients with short-segment Barrett's esophagus reported significantly more daily heartburn symptoms (84.1%) than patients with long-segment Barrett's esophagus (63.2%, P = 0.02). There was a significant difference in reports of severe to very severe dysphagia in patients with long-segment Barrett's esophagus versus those with short-segment Barrett's esophagus (76.9%vs. 38.1%, P = 0.02). Longer duration in years of chest pain was the only symptom characteristic of gastroesophageal reflux disease associated with longer lengths of Barrett's mucosa. Reports of severe or very severe dysphagia were more common in long-segment Barrett's esophagus patients. Only longer duration of chest pain was correlated with longer lengths of Barrett's esophagus.
Article
Gastroesophageal reflux (GER) may underlie respiratory manifestations via vagally mediated airway hyperresponsiveness or microaspiration, and intraesophageal pH monitoring is generally used to identify GER in patients with such manifestations. We aimed to establish the frequency of retrograde pulmonary aspiration in patients with unexplained respiratory manifestations. Fifty-one patients with refractory respiratory symptoms (cough, n = 18; pneumonia, n = 14; apnea, n = 8; asthma, n = 7; and laryngitis, n = 4) were prospectively evaluated. They underwent 24-h intraesophageal pH monitoring and gastroesophageal 99Tc scintigraphy with lung scan 18 to 20 h after the test meal. Thirteen of 51 patients (25.5%) had abnormal intraesophageal pH study results (mean reflux index, 11.3%; range, 6.5 to 50%); and in 25 of 51 patients (49%), overnight scintigraphy showed pulmonary aspiration. Nineteen of these 25 patients had entirely normal pH study results, whereas 6 of 13 patients with abnormal pH study results had aspiration. Pulmonary aspiration was demonstrated in all patients with apnea and 61.5% of patients with recurrent pneumonia. Nine of 25 patients (36%) with aspiration had histologic evidence of esophagitis, whereas histologic esophagitis was present in 5 of 13 patients (38.4%) with pathologic GER as shown by intraesophageal pH monitoring. Pulmonary aspiration as demonstrated by overnight scintigraphy is common in children with unexplained and refractory respiratory manifestations, suggesting that GER could be the underlying cause of these manifestations. Since only a few children with chronic or recurrent respiratory symptoms have a pathologic gastroesophageal acid reflux, a normal intraesophageal pH study result does not rule out GER in these children.
Laryngitis and gastroesophageal reflux disease: increa sing prevalence or poor diagnostic tests?
  • M F Vaezi
Vaezi MF. Laryngitis and gastroesophageal reflux disease: increa sing prevalence or poor diagnostic tests? Am J Gastroenterol 2004; 99: 786-788 [PMID: 15128337 DOI: 10.1111/j.1572-0241.2004.40290.x] 6
GERD-related cough: pathophysiology and diagnostic approach
  • J A Smith
  • R Abdulqawi
  • L A Houghton
Smith JA, Abdulqawi R, Houghton LA. GERD-related cough: pathophysiology and diagnostic approach. Curr Gastroenterol Rep 2011; 13: 247-256 [PMID: 21465223 DOI: 10.1007/s11894-011-0192-x]
Functional evaluation of the esophagus. The Esophagus Medical and surgical management Philadelphia: WB Saunders
  • C Russell