The association of gastroesophageal reflux with bronchial asthma. Can asthma also trigger reflux?

BACKGROUND/AIMS: The frequency of gastroesophageal reflux (GER) among asthmatic patients was found to range from 34% to 89% at different locations. The aims of this study have been to determine the frequency of GER in patients with asthma in the Saudi environment, to ascertain the main mechanism whereby GER triggers asthma, and to seek any evidence whether asthma can also trigger GER. METHODOLOGY: Fifty asthmatic patients were consecutively recruited as they reported to King Fahd Hospital of the University (KFHU), Al-Khobar, Saudi Arabia, in the period from February 2000 to February 2001; their mean age +/- SD was 38.0 +/- 9.8 years. Twenty-two subjects without asthma or GER served as controls; their mean age +/- SD was 29.4 +/- 8.6. Both groups were subjected to a questionnaire, esophageal manometry, dual probe ambulatory 24-hour pH monitoring, and pulmonary function tests. RESULTS: Among the asthmatic group 22 patients (44%) had GER. Accordingly, the asthmatic patients were divided into two groups: asthmatic with GER (n=22), and asthmatic without GER (n=28). Hoarseness of voice and nocturnal symptoms were found to be significant predictors for the presence of GER in asthmatics. Manometry revealed that asthmatic patients with GER had higher gastric pressure (11.4 +/- 4.0 mmHg vs. 8.4 +/- 2.8 mmHg; p=0.006) and lower resting pressure at the lower esophageal sphincter (LES) (21.2 +/- 8.7 mmHg vs. 28.2 +/- 9.3 mmHg; p=0.013) when compared with controls, both factors favoring the occurrence of reflux. With regard to pH data, acid reflux occurred both at the distal and proximal esophagus but the percent total acid exposure time was about 7 times longer at the distal than at the proximal esophagus (5.80 vs. 0.9). In addition, gastric pressure was positively and significantly correlated with distal esophageal acid exposure time and the DeMeester score, negatively correlated with spirometric parameters in asthmatic patients, as well as found to be a significant predictor of the severity of asthma (p=0.006). CONCLUSIONS: Forty-four percent of the sample of asthmatic patients reporting to KFHU had GER. Since distal esophageal total acid exposure time was nearly 7 times longer than at the proximal esophagus, the main mechanism for GER triggering asthma is the vagally mediated reflex initiated by acid in the distal esophagus. In addition, the positive correlation of increased gastric pressure with the distal esophageal acid exposure time and the DeMeester score, its negative correlation with spirometric parameters and being a significant predictor of asthma severity suggest that severe asthma may trigger or aggravate GER.     

Paroxysmal Laryngospasm: A Typical but Underrecognized Supraesophageal Manifestation of Gastroesophageal Reflux?

Thirty-five consecutive adult patients with paroxysmal laryngospasm (LS) and with unimpaired vocal fold mobility were prospectively studied for coexisting gastroesophageal reflux disease (GERD). Nineteen patients reported frequent (>3 episodes a week) LS episodes (FLS patients) and 16 patients reported occasional LS episodes (OLS patients). All patients underwent an extensive otorhinolaryngological (ORL) examination, upper gastrointestinal (GI) endoscopy, ambulatory 24-hr dual-channel esophageal pH monitoring, and esophageal manometry. In addition, a subset of LS patients also underwent ambulatory duodenogastroesophageal reflux (DGER) monitoring. Patients with daily LS used the symptom marker during pH monitoring indicating separate LS episodes. All FLS patients and 14 OLS patients (87%) had a diagnosis of GERD. Only 10 patients (29%) experienced heartburn and/or regurgitation. Compared to OLS patients, FLS patients generally had more severe GERD as indicated by a higher prevalence of a hiatus hernia, higher distal and proximal esophageal acid exposure times, and higher values of DGER. In six FLS patients, 21 LS episodes (91%) occurred simultaneously with acid reflux, indicating a causal association between LS and GER. On antireflux therapy consisting of omeprazole, 20 mg bid, or lansoprazole, 30 mg oid, and lifestyle measures, LS ceased completely in all patients within 6 weeks. The present study not only demonstrates the role of GER in the pathogenesis of LS and the effectiveness of antireflux therapy, but also suggests that LS in adult patients with unimpaired vocal fold mobility might be considered a typical, although most frequently unrecognized, supraesophageal manifestation of GER.     

The Symptom Index: A Clinically Important Parameter of Ambulatory 24-Hour Esophageal pH Monitoring

Ambulatory 24-h esophageal pH monitoring is an accurate quantitative test of gastroesophageal reflux (GER). However, it does not answer the question: are the patients' symptoms due to GER? We developed a numerical scale to quantify the percent association between symptoms and pH less than 4--the symptom index (SI). In 100 consecutive patients with heartburn or chest pain, the SI for the chief complaint was either high (greater than 75%) or low (less than 25%) in 77% of cases. A similar bimodal distribution was seen when heartburn or chest pain symptoms were individually evaluated. There was a good association between high SI and the presence of GER (97.5%), as well as low SI and a normal 24-h pH study (81.1%). Endoscopy was normal in 89.5% of patients with low SI, but patients with high SI had esophagitis in only 69.7% of cases. The Bernstein test showed a poor association with the SI. Therefore, the SI gives clinically relevant information regarding the role of acid reflux and patient's symptoms. We believe this simple calculated index should be included in the analysis of 24-h esophageal pH studies.     

Evaluation of gastroesophageal reflux as a cause of idiopathic hoarseness

Eleven patients presenting to an ear, nose, and throat specialist were diagnosed as having idiopathic hoarseness and prospectively evaluated for evidence of gastroesophageal reflux (GER) to determine if an association existed. Testing for GER included voice analysis, EGD, esophageal manometry, Bernstein test, and ambulatory 24-hr pH monitoring. Six of the 11 (55%) hoarse patients studied had GER by pH monitoring (mean score 105 +/- 23), and most reflux episodes were supine and prolonged (20.9 +/- 8.2% supine pH less than 4.0, longest 129 min). All patients with abnormal pH monitoring had endoscopic esophagitis (Barrett's esophagus in two, peptic stricture in one, and erosive esophagitis in three), while none of the patients with normal scores had esophagitis. Symptoms of throat pain or nocturnal heartburn were more common in the GER-positive patients (6 of 6 vs 1 of 5), and clinically helpful in discriminating which hoarse patients had pathologic GER. Treatment with ranitidine 150 mg per os twice a day for 12 weeks improved esophagitis in all patients, but the voice improved in only one of the two patients with completely healed esophagitis. This study suggests that (1) GER is frequently seen in patients with idiopathic hoarseness (55%), (2) hoarse patients with throat pain or nocturnal heartburn are likely to have severe esophagitis and should be evaluated by EGD, and (3) additional antireflux and voice therapy may be necessary to heal esophagitis and improve the voice.     

Lack of significant proximal esophageal acid reflux in infants presenting with respiratory symptoms

The effects of proximal esophageal acid reflux on upper and lower respiratory tract symptoms in infants with gastroesophageal reflux (GER) remain controversial. We studied 116 infants with either respiratory or gastrointestinal symptoms to determine whether acid reflux in the proximal esophagus plays an etiologic role in the elicitation of respiratory symptoms in comparison to causing gastrointestinal (GI) symptoms only. Sixty-two infants (age range, 1-12 months) with respiratory symptoms suggestive of GER and 54 infants with gastrointestinal symptoms only (age range, 1-10 months) were evaluated with dual level esophageal pH monitoring. Mean duration of dual-level pH monitoring in infants with respiratory symptoms was 20.4 h, and in those with GI symptoms was 20.7 h. Seventeen of 54 infants with GI symptoms only and 16 of 63 infants with respiratory symptoms had abnormal distal esophageal acid reflux indices (i.e., pH <4.0 for >5% of the duration of study). In infants with abnormal distal pH monitoring, the median proximal acid reflux index in the GI group was 4.0% in comparison to 0.95% in the respiratory group (P < 0.01 by Wilcoxon rank sum W test). Values for other reflux parameters were also higher in the GI than in the respiratory group. We conclude that reflux-associated respiratory symptoms are more likely due to mechanisms other than the mere presence of refluxed acid in the proximal esophagus.     

Reflux episode reaching the proximal esophagus are associated with chronic cough

Background/Aims

Gastroesophageal reflux (GER) has been implicated in the pathogenesis of chronic cough. The aims of this study were to evaluate the diagnostic usefulness of multichannel intraluminal impedance combined with pH monitoring (MII/pH monitoring) in patients with suspected symptoms of gastroesophageal reflux disease (GERD) and to assess the correlation between GER symptoms and reflux nature.

Methods

Seventy patients with suspected symptoms of GERD (such as heartburn, acid regurgitation, non-cardiac chest pain, globus and chronic cough) were enrolled. All patients were asked to discontinue medications that would influence esophageal motor function and gastric acid secretion at least one week ago. All subjects underwent MII/pH monitoring.

Results

Forty-five patients (64.3%) were diagnosed with GERD. Among these patients, eleven patients (15.7%) had pathologic acid reflux by pH data and thirty-four patients (48.6%) had pathologic bolus exposure by impedance. Subjects with chronic cough had a higher DeMeester score (p=0.009), percentage of acid exposure time (p=0.007), acid bolus exposure % time (p=0.027), distal acid reflux episodes (p=0.015) and proximal acid reflux episodes (p=0.030) than subjects without chronic cough.

Conclusions

The results of this study showed that the impedance monitoring enhanced diagnostic sensitivity than pH-monitoring alone by 48.6%. In addition, reflux episodes at the distal and proximal esophagus were noted to be important factors associated with chronic cough.     

Nonpropulsive Esophageal Contractions and Gastroesophageal Reflux

Nonpropulsive esophageal contractions radiologically described as tertiary contractions or "corkscrew" esophagus suggest the presence of an underlying motility disorder and may lead to impaired acid clearance. The goals of this study were to determine the prevalence and role of gastroesophageal reflux (GER) in patients with tertiary contractions. Thirty-five consecutive patients with spontaneous, repetitive, nonpropulsive esophageal contractions noted on esophagography were studied with endoscopy, infusion esophageal manometry, and 24-h ambulatory pH monitoring. All patients had esophageal symptoms, mainly dysphagia, heartburn, and chest pain, but only three were found to have esophagitis by endoscopy and biopsy. Nineteen patients had repetitive, nonlumen-obliterating, nonperistaltic (tertiary) contractions, six had corkscrew esophagus, and 10 had forceful, lumen-obliterating simultaneous contractions (rosary bead esophagus). Twenty patients (58%) had GER by pH criteria with mean values: % time pH less than 4, 40.9; %upright pH less than 4, 41; %supine pH less than 4, 44.3%; number of episodes with greater than 5 min of pH less than 4, 12. Esophageal motility revealed "nutcracker" esophagus in eight, low LESP in two, and nonspecific esophageal motility disorder in 10. Symptoms or severity of nonperistaltic contractions did not correlate with GER. Radiologically demonstrable free reflux or the presence of heartburn did not predict GER. We conclude that 1) GER occurs in up to 58% of patients with nonpropulsive (tertiary) esophageal contractions on esophagography, and may play a role in the induction of abnormal peristaltic activity of the esophageal body; 2) GER is usually not associated with endoscopic evidence of esophagitis or characteristic symptoms, and is recognized by 24-h pH monitoring. We speculate that detection and treatment of GER may improve the symptomatic management of patients with nonpropulsive esophageal contractions.     

Comparison of Simultaneous Esophageal pH Monitoring and Scintigraphy in Infants with Gastroesophageal Reflux

Twenty-nine infants under 1 yr of age were studied by simultaneous esophageal pH monitoring and scintigraphy for evaluation of gastroesophageal reflux (GER). Scintigraphy and pH monitoring were performed for 120 min after infants ingested their usual volume of formula. The number of reflux episodes during six 20-min intervals, as determined by both tests, were recorded. Esophageal pH monitoring was continued for 18–24 h. Sixteen of 29 patients exhibited GER by pH monitoring during the 2-h study. Gastroesophageal reflux occurred in seven of 29 during the first hour and 13 of 29 during the second hour. The mean time of first reflux episode detected by pH monitoring following the feeding was 82.4 ± 49.3 min. In comparison, 28 of 29 patients had GER by scintigraphy during the 2 h. All 28 exhibited GER during the first hour, whereas only 22 of 29 patients exhibited GER during the second hour. The mean time of first episode of reflux by scintigraphy was 3.1 ± 2.7 min. Forty-five percent of all reflux episodes detected by scintigraphy occurred during the first 20 min and 80% were detected during the first hour. In contrast, only 17% of reflux episodes were seen by pH monitoring during the first 20 min and 35% during the first hour; 65% of reflux episodes detected by pH monitoring were during the second hour. There was no correlation between the total number of reflux episodes detected by scintigraphy and 2-h esophageal pH monitoring during the 2-h study period ( r = 0.326; p > 0.1). Overall, to detect reflux, scintigraphy was a more sensitive method than esophageal pH monitoring under the conditions of this study. Scintigraphy selectively detected reflux during the first 60 min postprandially whereas pH monitoring was more likely to detect reflux beyond the first postprandial hour. These observations help to explain the lack of correlation between the two tests.     

High prevalence of proximal and distal gastroesophageal reflux disease in advanced COPD

BACKGROUND: Gastroesophageal reflux disease (GERD) is common in a variety of chronic respiratory diseases, but little is known about GERD in the setting of COPD. The aims of this study were to determine the prevalence, presentation, and predictors of GERD based on proximal and distal esophageal pH monitoring in patients with severe COPD. METHODS: Forty-one COPD patients with a mean FEV1 of 24% of predicted underwent dual-probe 24-h esophageal pH monitoring, and 1 patient underwent esophagogastroduodenoscopy. RESULTS: The prevalence of GERD was 57%. Elevated distal and proximal reflux were present in 41% and 46% of patients undergoing esophageal pH studies, respectively. Fifteen percent of these patients had abnormal proximal reflux despite having normal distal probe results. Most patients with GERD were not receiving acid blockers at the time of their referral, and only one third reported heartburn and/or acid regurgitation during the pH study. Only higher body mass index was predictive of reflux on regression analysis (odds ratio, 1.2; 95% confidence interval, 1.0 to 1.5; p = 0.05). CONCLUSIONS: GERD is common in advanced COPD. Patients are often asymptomatic and have a relatively high prevalence of isolated abnormal proximal reflux. Dual-probe monitoring is therefore well suited for detecting GERD in patients with advanced COPD.     

Esophageal Function and Sjögren's Syndrome

The frequency and characteristics of esophageal dysmotility in Sjögren's syndrome (SS) are as controversial as their related symptoms. We evaluated esophageal function and gastroesophageal reflux (GER) in 21 SS patients using manometry and 24-hr esophageal pH monitoring. All patients complained of xerostomia, 33% of dysphagia, and 62% of heartburn. Compared to controls, the mean percentage abdominal length of their lower esophageal sphincters (LES) and resting LES pressures were significantly lower, with no difference in primary esophageal peristalsis. Tertiary waves without swallowing were detected in 29% of them and pathological GER in 67%. Symptoms, esophageal motor abnormalities, and reflux features were similar in primary and secondary SS. ANOVA indicated that dysphagia was unrelated to the esophageal impairments and GER analysis results, while heartburn was significantly associated with GER severity. Esophageal acid-exposure time was significantly longer in SS patients with distal tertiary waves, while proximal esophagus wave velocity was significantly lower. While SS patients have nonspecific esophageal motility disorders and frequently GER disease, early and accurate diagnosis of GER is essential to identify SS patients at risk for acidic reflux, especially because the acid-clearance capacity of the esophagus is already diminished by the lack of saliva.     

Nasal CPAP reduces gastroesophageal reflux in obstructive sleep apnea syndrome.

Anecdotal reports suggest that obstructive sleep apnea syndrome (OSAS) patients may suffer from frequent nocturnal gastroesophageal reflux (GER) and that nasal continuous positive airway pressure may be an effective form of antireflux therapy in this population. To confirm these clinical impressions, we performed two consecutive days of 24-h esophageal pH monitoring, nocturnal esophageal pressure recording, and polysomnography on six OSAS patients complaining of regular nocturnal GER. On night one, the patients were untreated. Five of six subjects had abnormal amounts of nocturnal GER. Arousal, movement and swallowing were more frequent (p less than 0.043) and nadir intrathoracic pressure lower (p less than 0.005) in the 30 s prior to precipitous drops in esophageal pH (greater than or equal to 2 pH units) than during random control periods. A direct association between obstructive apneas and GER was not identified. On night two, nasal CPAP was administered and successfully treated apnea in five of six subjects. In these patients, there was also dramatic reduction in GER frequency and duration on CPAP. The mean percentage of time pH less than 4 dropped from 6.3 +/- 2.1 to 0.1 +/- 0.1 percent (p less than 0.025). We believe that OSAS may predispose to nocturnal GER by lowering intrathoracic pressure and increasing arousal and movement frequency. Nasal CPAP can correct these predisposing factors and reduce GER.     

Comparison of Omeprazole and Famotidine on Esophageal pH in Patients with Moderate to Severe Esophagitis: A Cross-over Study

Objective: This open cross-over study compared the effects on esophageal pH of omeprazole (O) (20 mg once a day) and famotidine (F) (40 mg b.i.d.) in 19 patients with proven acid gastroesophageal reflux (GER) complicated by erosive or ulcerated esophagitis. Methods: Each drug was taken for 7 days. A wash-out interval of at least 3 days separated the two treatment periods in each subject. Twenty-four-hour pH measurements were performed in similar standardized conditions at 7 ± 2 days, at the end of each period of treatment. Results: Compared with the pretreatment results, both O and F reduced the following pH parameters: percent of time with esophageal pH < 4, total number of GER episodes, number of nocturnal GER episodes, and duration of the longest GER episodes. O was more effective than F except for the percent of time esophageal pH < 4 and the number of nocturnal GER episodes, not different between the two treatments. With O, GER was reduced to physiological value in 19 of the 19 patients and abolished in 13. With F, GER was normalized in 13 and abolished in four. The effects of both drugs and grading of esophagitis were not correlated. Both treatments were well-tolerated. Conclusions: In patients with acid GER complicated by ulcerative esophagitis, O, 20 mg daily, and F, 40 mg b.i.d. significantly reduced acid exposure. O was superior to F, but the latter drug improved significantly two important prognostic variables: the total percent of time pH < 4 and the nocturnal GER.     

危重症患者胃食管反流的临床诊断研究

目的 分析危重症患者动态食管内pH及胆汁反流监测结果及用于临床诊断的可行性。方法观察组41例为我院危重症监护病房（1CU）的患者。对照组41例为同期具有反酸、烧心、胸痛后不适,咳嗽等反流症状,临床诊断为胃食管反流的普通患者,两组行24h动态食管内pH及胆汁反流监测。结果观察组单纯酸反流者4例（9．8％）,单纯胆汁反流者13例（31．7％）,混合反流者15例（36．5％）,无酸和胆汁反流者9例（21．9％）,胆汁反流者明显多于酸反流病人（x2=4．03,P〈0．05）。与对照组比较,观察组酸反流少,胆汁反流多,尽管反流次数少,但每次反流时间长,特别是最长反流时间明显增加,与对照组比较均有显著性差异（P均〈0．05）。结论动态食管内pH及胆汁监测适合于危重症患者的诊断,在结果分析时应充分考虑其反流特点。     

阻塞性睡眠呼吸暂停与胃食管反流的关系及对抗反流治疗的效果

目的 研究阻塞性睡眠呼吸暂停（ＯＳＡ）与胃食管反流（ＧＥＲ）的关系及西沙必利和奥美拉唑对两者的治疗效果。方法 １８例有睡眠打鼾和反流症状的患者接受了昼夜食管ｐＨ和压力监测,并在夜间睡眠时与多导睡眠图（ＰＳＧ）同步监测;对同时有ＧＥＲ和ＯＳＡ患者予以西沙必利（１０ｍｇ,４次／日）和奥美拉唑（２０ｍｇ,２次／日）治疗１周后重复以上检查。结果 ７例（３８．９％）同时合并有ＯＳＡ及重度ＧＥＲ,除１例外不仅     

Prevalence of upper respiratory symptoms in patients with symptomatic gastroesophageal reflux disease.

This study evaluated the prevalence of upper respiratory symptoms (URS) among patients with symptomatic gastroesophageal reflux disease (GERD). Seventy-four subjects with heartburn completed a URS questionnaire before dual-probe, 24-h esophageal pH monitoring. The URS questionnaire was also completed by 74 normal volunteers without previous or current symptoms of GERD. Esophageal pH monitoring results were classified as normal, distal, or proximal and distal gastroesophageal reflux using standardized criteria. Mean URS scores (+/- SD) were 8.31 +/- 3.98 in the 52 subjects with GERD and 4.57 +/- 3.57 in the 22 subjects with negative pH probe studies, p = 0.02. Subjects with negative pH probe studies and normal volunteers scored similarly on the URS questionnaire. Reflux episodes/24 h correlated with URS scores, r = 0.47, p = 0.0001. Seventy-five percent of subjects with upper reflux, 68% of subjects with lower reflux, 36% of subjects with normal esophageal pH studies, and 9% of normal volunteers reported laryngeal symptoms for at least 5 d/mo. Sixty-nine percent of subjects with upper reflux, 50% of subjects with lower reflux, 31% of subjects with normal pH studies, and 14% of normal volunteers reported nasal symptoms for at least 5 d/mo. URS are frequent among subjects with GERD. Keywords: rhinitis; upper airway; gastroesophageal reflux     

Esophageal mucosal acid sensitivity can coexist with normal pH recording in healthy adult volunteers

We aimed to determine whether healthy volunteers with normal pH monitoring study results experienced heartburn or discomfort during an esophageal acid perfusion test. We performed an esophageal acid perfusion test, followed by ambulatory esophageal pH monitoring, in 15 healthy and asymptomatic volunteers (aged 19 to 34 years). The results of the acid perfusion test were correlated with those of the pH monitoring. Three subjects (20%) reported chest discomfort during acid perfusion. The pH data in all subjects were within our laboratory reference ranges; the median (range) percent total time at pH < 4 being 1.7 (0.2–4.0)% [laboratory reference, median (range), 3.0 (0.2–4.0)%]. We concluded that direct infusion of acid onto the distal esophagus can produce discomfort akin to that of gastroesophageal reflux disease in asymptomatic adult volunteers, even in the absence of excessive esophageal acid exposure. Received: July 2, 1999 / Accepted: October 22, 1999     

Significantly Reduced Acid Detection at 10 Centimeters Compared to 5 Centimeters above Lower Esophageal Sphincter in Patients with Acid Reflux

Ambulatory pH monitoring of the esophagus is carried out by positioning a pH sensor 5 cm above the lower esophageal sphincter (LES). There are several techniques to locate the LES, and each method has a different margin of error. This work used dual pH sensors to monitor simultaneously at two different levels (5 and 10 cm above the LES) in order to establish the possible magnitude of error that could arise from inaccurate placement of a pH probe. Thirty-four patients with symptoms of gastroesophageal reflux (GER) were studied. They were grouped as 20 patients with pathological reflux (GER group) and 14 patients with physiological reflux, based on a reflux score derived by Johnson and DeMeester for distal esophageal pH monitoring. When the reflux scores were compared, the difference between the two monitoring levels was statistically significant in the GER group ( p < 0.001) but not in the physiological reflux group ( p = 0.09). In the GER group, the difference in the Johnson and DeMeester score accounted for a change in clinical diagnosis in nine of the 20 patients if the pH probe was placed at 10 cm above the upper margin of LES. Proximal reflux episodes (10 cm above LES) were preceded by distal reflux episodes (5 cm above LES) in 97% (878/901) of cases. Accurate probe placement is essential in the diagnosis of GER.     

Characteristics of Distal Partial Gastrectomy Patients with Esophageal Symptoms of Duodenogastric Reflux

Objectives : Partial gastrectomy patients with anatomic alterations to the pylorus and acid secretion are excellent models for studying the controversial role of duodenogastric reflux in producing esophageal symptoms and esophagitis. Methods : We studied 13 partial gastrectomy patients who had recent upper gastrointestinal endoscopies and chronic duodenogastric reflux symptoms. Simultaneously, acid and duodenogastric reflux were assessed by ambulatory 24-h esophageal pH and bilirubin monitoring. Abnormal values for both acid and bilirubin reflux were defined by previous studies of healthy volunteers from our laboratory. Symptoms were recorded and correlated with acid and duodenogastric reflux episodes. Results : Mean percent time bilirubin reflux for the entire group was 26.8 ± 7.2% (range 0.4–91.2%), whereas mean percent total acid reflux was 4.6 ± 2.4% (range 0.0–26.1%). Ten (77%) patients had abnormal duodenogastric reflux, but three patients (23%) also had associated abnormal acid reflux. Only these three patients had esophagitis, two ulcerative and one Barrett's esophagus. A total of 75 symptoms (36 heartburn, 33 epigastric pains, three regurgitation, two nausea/vomiting, one abdominal distension) were reported; 65% were acid related. Of patients with heartburn and regurgitation, 97% were associated with acid reflux episodes. Conclusions : Although excessive amounts of duodenogastric reflux are common in partial gastrectomy patients, esophagitis and Barrett's esophagus are seen only in patients with concomitant acid reflux, and most esophageal symptoms are acid related. Therefore, acid rather than duodenogastric reflux is the main culprit in this syndrome and should be aggressively treated.     

Lower pH values of weakly acidic refluxes as determinants of heartburn perception in gastroesophageal reflux disease patients with normal esophageal acid exposure

Multichannel impedance pH monitoring has shown that weakly acidic refluxes are able to generate heartburn. However, data on the role of different pH values, ranging between 4 and 7, in the generation of them are lacking. The aim of this study was to evaluate whether different pH values of weakly acidic refluxes play a differential role in provoking reflux symptoms in endoscopy‐negative patients with physiological esophageal acid exposure time and positive symptom index and symptom association probability for weakly acidic refluxes. One hundred and forty‐three consecutive patients with gastroesophageal reflux disease, nonresponders to proton pump inhibitors (PPIs), were allowed a washout from PPIs before undergoing: upper endoscopy, esophageal manometry, and multichannel impedance pH monitoring. In patients with both symptom index and symptom association probability positive for weakly acidic reflux, each weakly acidic reflux was evaluated considering exact pH value, extension, physical characteristics, and correlation with heartburn. Forty‐five patients with normal acid exposure time and positive symptom association probability for weakly acidic reflux were identified. The number of refluxes not heartburn related was higher than those heartburn related. In all distal and proximal liquid refluxes, as well as in distal mixed refluxes, the mean pH value of reflux events associated with heartburn was significantly lower than that not associated. This condition was not confirmed for proximal mixed refluxes. Overall, a low pH of weakly acidic reflux represents a determinant factor in provoking heartburn. This observation contributes to better understand the pathophysiology of symptoms generated by weakly acidic refluxes, paving the way toward the search for different therapeutic approaches to this peculiar condition of esophageal hypersensitivity.     

Gastroesophageal reflux as a pathogenic factor in the development of symptomatic lower esophageal rings

Gastroesophageal reflux (GER) has been suggested as a cause of the lower esophageal (Schatzki) ring. We looked for the presence of GER and reflux injury in a series of 20 patients with lower esophageal ring and dysphagia, using a 24-hour esophageal pH monitoring and upper endoscopy with biopsy. Abnormal GER was documented in 13 of the patients (65%), 10 of whom had erosive reflux changes in the distal esophagus. Seven patients (35%) showed no evidence of pathologic GER or reflux esophagitis. All patients also underwent esophageal manometry. Nonspecific esophageal body motor dysfunction may have contributed to dysphagia in five patients, two of whom had no evidence of abnormal GER. We conclude that GER disease is a frequent cause of the gradually progressive ring stricturing and dysphagia seen in patients with lower esophageal ring. Antireflux therapy, as an adjunct to esophageal dilatation, may be appropriate for many symptomatic lower esophageal ring patients.