Reflux monitoring: role of combined multichannel intraluminal impedance and pH

Combined multichannel intraluminal impedance and pH (MII-pH) is a promising technique that identifies liquid, gas, and mixed gastroesophageal reflux and categorizes it into acid and nonacid types. Gastroesophageal monitoring using combined MII-pH reconfirms previously reported data that there is a difference between refluxate volume presence time in the esophagus and time pH less than 4. Only one in five patients with persistent symptoms on acid-suppressive therapy have symptoms associated with persistent acid reflux, whereas two of five patients have symptoms associated with nonacid reflux; the remaining patients do not have any type of GER related to their symptoms. Combined MII-pH is a useful tool in evaluating patients with persistent symptoms on acid-suppressive therapy, patients with atypical symptoms, and infants.     

Wireless pH capsule--yield in clinical practice

Wireless pH monitoring is one of the recent technologies that focus on improving the diagnosis of gastroesophageal reflux disease (GERD). The capsule, which is fixed within the esophagus, transmits data via telemetry to an external receiver. The capsule is usually inserted 6 cm above the squamocolumnar junction during an upper endoscopy. The standard recording duration is 48 hours but this can be extended to 96 hours. The wireless capsule has been shown to be at least as accurate as the conventional catheter for the monitoring of esophageal pH. Normal pH values have been established in three different series. The use of a wireless capsule provides an increased diagnostic yield for GERD compared with the conventional catheter. The increased yield is the result of higher sensitivity to detect both abnormal acid esophageal exposure and positive symptom-reflux association. This may be related both to the prolonged recording duration and to fewer dietary modifications and restrictions on activities. Several studies have shown that the pH capsule was better tolerated by patients than the conventional pH catheter. Mild-to-moderate chest pain represents the main side effect of the pH capsule: severe chest pain requiring endoscopic removal of the capsule is rare. The main indication for wireless capsule application is monitoring of distal esophageal pH for diagnostic purpose, particularly in patients with a normal endoscopic examination. The capsule technique has some limitations: costs are higher than conventional pH monitoring, misplacement may occur, and the sampling rate is lower. Finally, compared with pH-impedance monitoring, only acid reflux events can be evaluated.     

Gastroesophageal scintigraphy

The technique of gastroesophageal scintigraphy was developed in order to quantitatively detect reflux from the stomach into the esophagus. The scintigraphic technique was compared to previous diagnostic tests including barium esophagography, fluoroscopy, endoscopy, esophageal biopsy, the acid perfusion test, esophageal manometry, and the acid reflux test. None of the other techniques is as sensitive as gastroesophageal scintigraphy for the detection of reflux, in comparison to the acid reflux test. Gastroesophageal scintigraphy is able to detect gastroesophageal reflux accurately, rapidly, noninvasively, and more sensitively than other diagnostic techniques. In addition, it is able to be employed to quantitate reflux and is suitable for studying the effects of various therapeutic modalities.     

Gastroesophageal reflux in children: Is there a place for the upper gastrointestinal study?

Objective tests for gastroesophageal reflux in children have shown only fair correlation with clinical symptoms. Thirty-four children referred to the pediatric surgery service for evaluation of gastroesophageal reflux had both 24-hour pH probe monitoring and standardized upper gastrointestinal examinations. A total of 16 children (47%) had documented significant or pathologic gastroesophageal reflux, 11 on pH monitors and 9 on contrast examinations. There were 4 in whom both tests were positive. None of the pH monitoring criteria correlated with the radiographic studies. The patient population documented by contrast study did not differ from the general testpositive population by age or associated clinical findings. The 2 studies probably measure different aspects of significant gastroesophageal reflux, are confirmatory and complementary, and must be correlated with the clinical symptoms.     

Ultrasound diagnosis of gastroesophageal reflux and hiatal hernia in infants and young children

In 30 young children suspected of gastroesophageal reflux (GER), the G-E junction was examined with ultrasonography directly after a feeding while these children were on overnight extended esophageal pH monitoring (EEpHM) (32 simultaneous ultrasound/EEpHM studies). The two tests showed 81% to 84% agreement in the detection of the presence or absence of GER, depending on whether the whole period of EEpHM or only the part of it covering the ultrasound observation period were used as the standard. The discrepancies between the two tests were explained by the much longer monitoring period of EEpHM compared to ultrasonography and the inability of EEpHM to show reflux of neutralized gastric contents directly after milk feedings. The two studies probably measure different aspects of clinically significant reflux and must be correlated with the clinical symptoms. Morphological findings associated with significant reflux were (1) a short intra-abdominal part of the esophagus, (2) a rounded gastroesophageal angle, and (3) a "beak" at the gastroesophageal junction. Barium meal findings confirmed these sonographic signs, indicating a sliding hiatal hernia of the distal esophagus, either fixed or intermittent. Ultrasonography can be recommended as a useful and physiological screening test to demonstrate clinically significant GER and a predisposing hiatal hernia of the esophagus in symptomatic children.     

支气管哮喘患者24小时食管pH监测的分析

目的　许多研究发现支气管哮喘和胃食管酸反流有关 ,但是有关胃食管酸反流引起支气管哮喘的机制还并不是十分清楚 ,用 pH监测仪对支气管哮喘患者的胃食管酸反流进行监测 ,以进一步探讨哮喘病的发病机制。 方法　将 84例患者分为 3组 ,单纯反流组 (30例 ) ,哮喘组 (2 8例 ) ,哮喘伴反流组 (2 6例 )。应用敏感的 2 4小时食管 pH监测仪监测食管 pH的变化。 结果　伴有酸反流的哮喘患者的 2 4小时酸反流次数、超过 5分钟的反流次数和 pH <4的时间均明显高于无胃食管反流的支气管哮喘患者 ,但超过 5分钟的反流次数、最长反流时间和 pH <4的时间明显低于单纯有胃食管反流的患者。结论　伴有酸反流的支气管哮喘患者 ,其哮喘的发作与酸反流有密切的关系 ,但是其酸反流程度小于单纯有胃食管反流的患者。这说明此类患者的哮喘发作除与胃食管酸反流对食管下段的刺激有关外 ,对酸反应的高敏感性也是其发病的重要因素 ,因此与胃食管反流相关的支气管哮喘发作是这两方面作用的结果     

Catheter-based pH monitoring: use in evaluation of gastroesophageal reflux disease symptoms (on and off therapy)

Tube-based ambulatory pH testing has rapidly evolved in the past 3 decades to become the standard by which other diagnostic approaches to gastroesophageal reflux disease are judged. Acid exposure 5 cm above the manometrically determined lower esophageal sphincter is the standard for documentation of pathologic acid exposure of the distal esophagus. Proximal esophageal or hypopharyngeal monitoring is an evolving technique that may shed light on patients with supraesophageal symptoms. The ability to simultaneously monitor esophageal and gastric acidity (usually in patients with persistent symptoms despite therapy) is another advantage of this technique. Whether the new system that allows simultaneous pH and impedance monitoring and the system that uses an implantable tubeless monitoring capsule will supplant this older but well-established technology remains to be determined.     

Test of refractory gastroesophageal reflux disease

It should be considered that the causes of refractory gastroesophageal reflux disease (GERD) are multifactorial. Esophageal manometry study is useful when we make distinguish patients with esophageal motility disorders from those with refractory GERD. Endoscopic ultrasonography is also performed to observe the thickness of esophageal wall which represents the disturbance of esophageal motor function. Esophageal pH monitoring is useful to detect the acid clearance disturbance and phenomenon of nocturnal acid breakthrough. Both are occurred at night, and are recently considered to be responsible for refractory GERD. Catheter-free pH monitoring system, Bravo, makes it possible to measure esophageal pH under quite physiological conditions. Genotype of CYP2C19 is sometimes checked in patients with PPI resistance GERD. Intra-gastric pH with omeprazole and lansoprazole depends on patient's genotype of CYP2C19. Monitoring of 24-hour bilirubin, Bilitec, is also useful to detect duodeno-gastro-esophageal reflux.     

Results of simultaneous 24 hour pH and ECG monitoring in patients with cardialgias

Simultaneous 24-hour pH and ECG monitoring is suggested as a method for differential diagnosis of cardialgias. Fifty-four patients were examined, complaining of retrosternal and precardial pain, retrosternal burning, heartburn, and belching of unknown origin. Four groups were distinguished. Relationships between gastroesophageal reflux disease (GERD) and coronary disease were evaluated. Reflux in GERD was hypothesized to be the mechanism triggering anginal episodes.     

Techniques in performing continuous distal esophageal pH monitoring in infants

Clinically significant gastroesophageal reflux in infants can be diagnosed accurately by using sophisticated recording equipment and standardized procedure methods. Consistency in the performance of continuous distal esophageal pH monitoring will provide precise, reliable and accurate results.     

Gastroesophageal reflux and respiratory diseases

There is a relationship between gastroesophageal reflux and respiratory diseases. Reflux may trigger and aggravate respiratory diseases especially bronchial asthma. Both clinical and experimental observations suggest that the pathogenic mechanisms may be a vagal reflex and/or microaspiration of gastric acid into the trachea. General measures to avoid reflux and proton pomp inhibitor together with inhaled corticosteroid are the choice for treatment of asthma associated with gastroesophageal reflux. Xanthine derivatives and beta 2 adrenergic agonist might be withheld in these patients. A laparoscopic surgical treatment may be an option for patients with persistent symptoms.     

三种不同检查方法在胃食管反流病诊断中的应用比较

目的：探讨电子胃镜、24 h食管pH值监测及胃食管反流病（GERD）Q评分三种方法在GERD诊断中的临床应用价值。方法：将于2011年4月—2012年6月因烧心、反酸等症状就诊于消化科门诊的120例患者随机分为胃镜组、24 h食管pH值监测组及GERD Q评分组,每组40例,分别接受电子胃镜、24 h食管pH值监测及GERD Q问卷评分,比较分析各种方法对GERD的检出情况。结果：24 h食管pH值监测组40例患者中病理性反流者19例,生理性反流者5例,GERD阳性率显著高于胃镜组及GERD Q评分组,差异具有统计学意义（P〈0.05）;胃镜组与GERD Q评分组之间差异无统计学意义（P〉0.05）。结论：24 h食道pH值监测可以对食管内反流情况进行实时、动态监测,为GERD的临床诊断及不同类型的反流治疗方案提供客观、准确的依据。     

Correlation of color Doppler sonographic findings with pH measurements in gastroesophageal reflux in children

PURPOSE: We conducted a prospective study of color Doppler sonography in children with suspected gastroesophageal reflux (GER). The purpose of this study was to compare the accuracy of color Doppler sonography with that of continuous 24-hour pH monitoring of the esophagus in diagnosing GER and to determine how to interpret the reflux episodes detected on color Doppler sonography in children at high risk for reflux. METHODS: Color Doppler sonography and 24-hour esophageal pH monitoring were performed in 54 children ranging in age from 2 months to 10 years (mean, 3 years). The stomach of each patient was filled for adequate gastric distention just before the color Doppler sonographic examination. We counted the number of reflux episodes over a period of 15 minutes. One day after the sonographic examination, the reflux was evaluated with esophageal pH monitoring, and the resultant reflux index (ReI) was obtained. The ReI was considered to be pathologic when it was equal to or greater than 11.99%. The number of refluxes on color Doppler sonography and the ReI were correlated for each patient. RESULTS: The 2 tests showed an 81.5% agreement in the detection of GER. When pH monitoring was taken as the reference test, color Doppler sonography had a high sensitivity (95.5%) for diagnosing GER but a very low specificity (11.0%), with a positive predictive value of 84.3% and a negative predictive value of 33.3%. There was no statistically significant correlation between the frequencies of GER detected on color Doppler sonography and the ReIs on pH monitoring (p = 0.1103). There was no correlation between the reflux grades on sonography and the ReI grades on pH monitoring (p = 0.422). CONCLUSIONS: Color Doppler sonography is highly sensitive and easier to use than pH monitoring. Although there are no definite criteria for evaluating the severity of GER on color Doppler imaging, this modality may be useful in screening children for GER.     

Development for and results of the use of a gastroesophageal reflux disease activity index as an outcome variable in a clinical trial

Due to the significant expense of obtaining frequent endoscopy and pH monitoring measures as outcome variables available for use in a multihospital clinical trial of gastroesophageal reflux disease, and the lack of a suitable inexpensive index of disease activity, evaluated for both reliability and validity, the study planning committee decided to develop an index of gastroesophageal reflux disease activity in a pilot study—to precede the clinical trial. In particular, the purpose of the pilot study was to find a reliable, valid, and inexpensive index of gastroesophageal reflux disease which could be obtained independently of the treating physician and used as an outcome variable in the clinical trial. This paper describes the pilot study and the statistical methodology used to derive and evaluate a gastroesophageal reflux disease activity index model. In addition, the results of the activity index's use in the subsequent clinical trial's longitudinal analyses are presented. Comparisons with the more expensive, and thus less frequently obtained, endoscopy and pH monitoring outcome variables are described.     

Diagnosing gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common condition with a variety of clinical manifestations and potentially serious complications. This article reviews available methods for diagnosing GERD. A clinical history of the classic symptoms of GERD, heartburn or acid regurgitation, is sensitive enough to establish the diagnosis in patients without other complications. Esophagogastroduodenoscopy is the best way to evaluate suspected complications of GERD, but endoscopic findings are insensitive for the presence of pathological reflux, and therefore they cannot reliably exclude GERD. The "gold standard" study for confirming or excluding the presence of abnormal gastroesophageal reflux is the 24-hour ambulatory esophageal pH monitoring test, and this study should be used for the evaluation of refractory symptoms and extraesophageal manifestations of GERD. A formal acid-suppression test is helpful in the evaluation of the atypical GERD symptom of noncardiac chest pain. Optimal use of currently available tests for GERD may allow for more efficient diagnosis and better characterization of the pathological manifestations associated with GERD.     

肝硬化患者血清一氧化氮和食管动力关系的研究

目的: 探讨肝硬化患者血清一氧化氮(NO)与食管动力的关系。方法: 35 例肝硬化患者(HC)和30 例健康人(HS)采用硝酸还原酶法测定血清NO含量;核素法测定食管液体通过时间和胃食管反流。结果: HC组血浆NO含量显著高于HS组(P<0.01);HC组胃食管反流发生率显著高于HS组;HC组中胃食管反流患者的NO含量显著高于无胃食管反流的患者(P<0.01),HC组的食管液体通过时间较HS组显著延长(P<0.01),但NO含量与食管通过时间无相关性(P>0.05)。结论: 肝硬化患者血浆NO含量的升高可能使食管下括约肌(LES)松弛而产生胃食管反流,但不影响食管蠕动功能。     

Clinical significance of 24-hour intraesophageal pH monitoring in GERD patients

24-hour intraesophageal pH monitoring(24-pH-M) is a method of choice to measure the esophageal acid exposure, and evaluate a patient's lifestyle who has reflux symptoms. The 24-pH-M is indicated to the cases who have at least one of the following signs/symptoms; endoscopy negative GERD(gastroesophageal reflux disease), atypical clinical course for reflux disease, atypical symptoms of GERD, and those who are subjected to have surgical treatment. In the 24-pH-M, not only the duration of gastroesophageal reflux(GER), but also reflux and symptom association should be evaluated. The 24-pH-M is useful to investigate the diagnosis and treatment of GERD including reflux esophagitis.     

The Diagnosis and Treatment of Gastro-oesophageal Reflux Disease in Infants and Children

Gastro-oesophageal reflux is a common phenomenon in infants, and is an aspecific complaint. The balance between negligence and overconcern is therefore very difficult to make, and requires experienced physicians. The approach in infants with uncomplicated reflux consists of non-drug treatment and reassurance of the parents about the almost physiological nature of the regurgitations of the baby. If the parents persist in their complaints, the administration of prokinetics such as cisapride can be considered before performing investigations (oesophagel pH monitoring). The efficacy and the lack of side-effects of cisapride makes this the drug of choice. The frequency of side-effects of other drugs necessitates the diagnosis of reflux disease before their administration.

Upper gastrointestinal tract endoscopy is the investigation of choice in children suspected of reflux oesophagitis. In the majority of cases, the efficacy of cisapride, H₂-blockers and Na-K-ATP-ase-blockers should be given a chance. Unusual presentations, such as chronic respiratory disease, as a manifestation of reflux disease should be confirmed with oesophageal pH monitoring.     

Gastroesophageal reflux disease in diabetic patients

Esophageal dysfunctions occur frequently in patients with diabetic neuropathy, and the complication of gastroesophageal reflux disease(GERD) has also been reported. However, the characteristics of GERD complicated with diabetes mellitus are obscure because no detailed assessment was performed. We performed long-term ambulatory esophageal pH and motility monitoring in diabetic patients, and analyzed the data in detail. Esophageal dysfunctions including GERD were significantly related to diabetic neuropathy and duration. Although GERD was frequently complicated with diabetes mellitus, the symptoms were not apparent in diabetic patients. The average score of a questionnaire was extremely low, and no significant difference in score was observed between patients with and without gastroesophageal reflux. We should keep in mind that diabetic patients have the abnormal gastroesophageal reflux even when they do not complain of the related symptoms.