Combined multichannel intraluminal impedance and pH monitoring is helpful in managing children with suspected gastro-oesophageal reflux disease

BackgroundGastro-oesophageal reflux is very common in the paediatric age group. There is no single and reliable test to distinguish between physiologic and pathological gastro-oesophageal reflux, and this lack of clear distinction between disease and normal can have a negative impact on the management of children.AimsTo evaluate the usefulness of 24-h oesophageal pH-impedance study in infants and children with suspected gastro-oesophageal reflux disease.MethodsPatients were classified by age groups (A–C) and reflux-related symptoms (typical and atypical). All underwent pH-impedance study. If the latter suggested an abnormal reflux, patients received therapy in accordance with NASPGHAN/ESPGHAN recommendations, while those with normal study had an additional diagnostic work-up. The efficacy of therapy was evaluated with a specific standardized questionnaire for different ages.ResultsThe study was abnormal in 203/428 patients (47%) while normal in 225/428 (53%). Of those with abnormal study, 109 exhibited typical symptoms (54%), and 94 atypical (46%). The great majority of the patients with abnormal study were responsive to medical anti-reflux therapy.ConclusionsWe confirm the utility of prolonged oesophageal pH-impedance study in detecting gastro-oesophageal reflux disease in children and in guiding therapy. Performing oesophageal pH-impedance monitoring in children with suspected gastro-oesophageal reflux disease is helpful to establish the diagnosis and avoid unnecessary therapy.     

Multichannel intraluminal impedance and pH monitoring in gastroesophageal reflux disease

The role of acid is very well established in the pathogenesis of gastroesophageal reflux disease and acid suppression constitutes the main approach to its medical treatment. With the current frequent use of proton pump inhibitors, we are seeing increasing numbers of patients in whom symptoms persist despite pharmacological acid suppression. Reflux monitoring has been traditionally performed through esophageal pH measurement to detect acid reflux (i.e., drops in esophageal pH to below 4.0). Multichannel intraluminal impedance and pH measurement constitutes an important development in reflux monitoring because, in addition to detecting acid reflux, it enables measurement of nonacid reflux (i.e., with a pH > 4.0, also known as ‘weakly acidic’ for pH > 4 but < 7, or ‘weakly alkaline’ if pH > 7), which may be responsible for symptoms in some patients who are being treated with proton pump inhibitors. This review describes the approach to measuring nonacid reflux, the possible mechanisms responsible for symptoms due to this type of reflux, the clinical importance of this phenomenon and available treatment options; and the role of multichannel intraluminal impedance and pH monitoring in the evaluation of refractory gastroesophageal reflux disease.     

Small volume acid reflux in gastroesophageal reflux disease patients with hiatal hernia is only detectable by pH‐metry but not by multichannel intraluminal impedance

Until now, it is uncertain if the so‐called pH‐only reflux episodes that consist of a pH drop without evidence of retrograde bolus movement in multichannel intraluminal impedance (MII) represent reflux episodes or artifacts. Hiatal hernia (HH) may allow reflux of small volumes to occur that can be detected by pH‐metry but not by MII. The aim was to search for a mechanism that can explain pH‐only reflux, 20 patients (12 females and 8 males, median age 52 years, interquartile range [IQR]: 40.5–60.75 years) were investigated with MII–pH off PPI. Impedance and pH‐metry data were analyzed separately. The differences in detection rate of acid reflux between pH‐metry and MII were correlated with the presence of HH. In an in vitro experiment, MII–pH probes were flushed with citric acid in plastic tubes of different size with capillary diameter and diameters of 2.5 mm and 4.5 mm, while recording pH values and impedance. HH was present in six patients and absent in 14 patients. In patients with HH in comparison with patients with absent HH, the difference of acid reflux detection between pH‐metry and MII is significantly higher (70%, IQR: 15–88% and 3.6%, IQR: 0–31%, respectively). In vitro all simulated reflux lead to a fall in pH whereas a corresponding decrease in impedance was only recognizable in the 4.5‐mm plastic tubes. Acid reflux episodes in patients with HH are more frequently detected by pH‐metry than by MII. Small volume reflux that does not lead to a decrease in impedance is the likely explanation for this phenomenon.     

The sensitivity of multichannel intraluminal impedance and the pH probe in the evaluation of gastroesophageal reflux in children.

BACKGROUND & AIMS: Multichannel intraluminal impedance (MII) has been incorporated into gastroesophageal reflux evaluations in children despite a lack of evidence comparing it to the gold standard pH probe. The aim of this study was to compare these two technologies. METHODS: Twenty-five consecutive, untreated children undergoing pH-MII recording were studied. Sensitivities for the pH probe and MII were defined as: (acid+pH-only episodes)/(acid+non-acid+pH-only episodes) and (acid+non-acid episodes)/(acid+non-acid+pH-only episodes), respectively. Sensitivities were compared using paired t testing. After the analysis was performed, the pH-MII tracings of 25 age-matched children taking acid suppression therapy were compared and sensitivity calculations were performed. RESULTS: In untreated patients, 1845 reflux episodes were detected, and 1702 were detected in treated patients. The mean sensitivities of pH probe and MII in untreated patients were 80.6 +/- 18.2% and 76.1 +/- 13.5%, respectively (P = .41). The mean sensitivities of pH probe and MII in treated patients were 47.2 +/- 36.0% and 80.3 +/- 21.1%, respectively (P = .005). Twenty-five percent of reflux episodes were pH-only episodes. There were no differences in the mean number of acid or non-acid reflux episodes in patients with normal and abnormal pH probe studies. Instead, there were significantly more pH-only episodes in patients with abnormal probe studies. CONCLUSIONS: The sensitivity of MII equals that of the pH probe in untreated patients but is superior to the pH probe in treated patients. pH-only episodes are numerous in pediatrics and should be included in pH-MII analyses.     

贲门失驰缓症及滑动型食管裂孔疝患者食管多通道阻抗-压力测定分析

目的应用食管联合多通道阻抗-压力测定(MII-EM)技术研究贲门失驰缓症及滑动型食管裂孔疝患者的食管动力异常特点。 方法连续选取2013年4月至2014年6月到首都医科大学附属北京同仁医院就诊,入组内镜或食管造影诊断的贲门失驰缓症患者6名、滑动型食管裂孔疝患者10名以及健康志愿者10名行MII-EM检查,分析比较二个患病组与对照组间各检测指标差异。 结果与对照组相比,二个患病组的食团传送率均显著降低。贲门失驰缓症患者LES残余压显著升高,同步收缩及逆行收缩率明显增加,LES松弛率显著降低,食管中上段收缩压力也减低(P<0.05),但未发现其在LES静息压、LES长度、及UES各功能指标上的差异。滑动型食管裂孔疝患者LES静息压较对照组显著降低,UES舒张时间延长,食管近端收缩压力减低(P<0.05),但未发现食管中、下段收缩功能的异常。 结论MII-EM技术能够评估贲门失驰缓症及滑动型食管裂孔疝的食管功能障碍,具有一定的辅助诊断价值。     

滑动型食管裂孔疝患者高分辨率食管测压及阻抗-pH监测特点

目的应用高分辨率食管测压(HRM)及多通道腔内阻抗-pH监测技术(MII-pH)研究滑动型食管裂孔疝(HH)患者食管动力及胃食管反流的特点。方法将内镜诊断的滑动型食管裂孔疝患者连续入组,并进行HRM及MII-pH监测后分为短段HH不伴糜烂性食管炎组(HHs)、短段HH伴糜烂性食管炎组(HHs+EE)及长段HH伴糜烂性食管炎组(HHL+EE)。另外选取10名志愿者作为健康对照组(HC)。结果 8例HH患者及10例健康志愿者纳入研究(HHs:7,HHs+EE:15,HHL+EE:6,HC:10)。3组HH患者的LES长度、LES静息压、膈脚张力、有效蠕动比例均明显低于对照组,但长段与短段HH组间无显著性差异。HH患者各组食管酸暴露明显重于对照组,DeMeester评分HHL+EEHHs+EEHHs(P0.05)。HHL+EE组近端反流及卧位反流比例更高。结论滑动型食管裂孔疝患者食管动力障碍及病理性胃食管反流程度较对照组重,长段HH患者食管酸暴露、近端反流及卧位反流更重。     

多通道食管腔内阻抗-pH监测对胃食管反流性咳嗽的诊断价值

 目的 探讨多通道食管腔内阻抗-pH监测（MII-pH）对胃食管反流性咳嗽（GERC）的诊断价值和局限性。方法 选择2010年5月—2011年7月在同济大学附属同济医院呼吸内科门诊就诊的可疑GERC患者,进行MII-pH,并经药物抗反流治疗证实诊断。分析MII-pH对GERC诊断的灵敏度、特异度、假阳性率、假阴性率、总符合率、阳性预计值和阴性预计值,并计算AUC_ROC和Kappa值。结果 在接受MII-pH的56例患者中,35例结果阳性,30例（85.7%）确诊为GERC,其中酸反流引起者25例（83.3%）,非酸反流引起者5例（16.7%）。在21例MII-pH阴性结果患者中,有6例（28.6%）经药物抗反流治疗,GERC诊断得到证实。MII-pH对GERC的诊断灵敏度为83.3%,特异度75.0%,假阳性率25.0%,假阴性率16.7%,总符合率80.4%,阳性预测值85.7%,阴性预测值71.4%,AUC_ROC 0.792,Kappa值0.577。结论 MII-pH能识别包括非酸反流在内的所有GERC,是较灵敏可靠的GERC诊断手段。     

Reflux profile of Chinese gastroesophageal reflux disease patients with combined multichannel intraluminal impedance-pH monitoring

Background and Aims:  To investigate the reflux profile of Chinese gastroesophageal reflux disease (GERD) patients with the aid of combined multichannel intraluminal impedance-pH (MII-pH) monitoring technique.
Methods:  Consecutive patients presented with GERD symptoms were enrolled to erosive esophagitis (EE) group, non-erosive reflux disease (NERD) group and functional heartburn (FH) group after upper endoscopy, combined MII-pH monitoring and rabeprazole test. Another 20 healthy controls (HC) were recruited.
Results:  Sixty-four GERD patients (EE:20, NERD:22, FH:22, HC:20) were enrolled. There were more episodes of liquid reflux and proximal reflux in EE and NERD groups than that in FH and HC groups ( P  < 0.05). Patients in FH and HC groups had higher proportion of mixed reflux ( P  = 0.000). The percentage of acid reflux in EE and NERD was much higher, while there was a higher percentage of weakly acidic reflux in FH and HC ( P  = 0.000). No significant difference was found in MII-pH parameters between groups with and without response to rabeprazole test except recumbent percentage time of esophageal pH value below 4 and episodes of proximal reflux.
Conclusion:  Erosive esophagitis and NERD patients had more liquid and proximal reflux episodes than FH patients and healthy controls. Acid and liquid reflux was predominant in the former two groups, while weakly acidic and mixed reflux was predominant in the latter two groups.     

Characteristics of nighttime reflux assessed using multichannel intraluminal impedance pH monitoring and a portable electroencephalograph

Gastroesophageal reflux disease (GERD) is strongly associated with sleep disturbances. Although the mechanisms of this association have not been fully elucidated, nighttime reflux plays a central role. However, the detailed characteristics of nighttime reflux occurring during sleep are unknown. The aim of the present study was to examine the characteristics and prevalence of nighttime reflux in the natural sleep environment of GERD patients. Seventeen patients experiencing daily moderate‐to‐severe heartburn and/or regurgitation were studied using multichannel intraluminal impedance pH monitoring and electroencephalography off‐proton pump inhibitor treatment. Nighttime reflux was divided based on reflux type (liquid or gas), acidity (acidic, weakly acidic, or alkaline) and extent (distal only or proximal migration) according to the standard criteria. Nighttime phases were divided as follows: recumbent‐awake before falling asleep, nonrapid eye movement, rapid eye movement, awakening from sleep, and post‐awakening in the morning. Among 184 nighttime refluxes, 43 (23%) occurred during recumbent‐awake before falling asleep, 28 (15%) during nonrapid eye movement, 14 (8%) during rapid eye movement, 86 (46%) during awakening from sleep, and 13 (7%) during post‐awakening in the morning. Liquid reflux was more common in awakening during sleep (92%), nonrapid eye movement (100%), and rapid eye movement (100%) compared with awakening before falling asleep (68%). The prevalence of proximal migration was significantly lower in nonrapid eye movement and rapid eye movement than in the other phases. There were no differences in acidity and bolus clearance time among the phases. Thirteen (65%) of 20 events with GERD symptoms had nighttime reflux, suggesting that only 7.1% (13 of 184) of nighttime refluxes were symptomatic. Nighttime reflux was observed in 48 (11%) of 425 awakening episodes during sleep. Different reflux patterns at each phase during nighttime might explain the pathogenesis of GERD and its related sleep disturbances.     

Influence of laparoscopy-aided gastrostomy on gastroesophageal reflux in neurologically impaired patients using multichannel intraluminal impedance pH measurements

Esophagus - Development of gastroesophageal reflux disease (GERD) after gastrostomy remains debatable. Therefore, this study aimed to evaluate whether laparoscopy-aided gastrostomy (LAG) influence...     

Multichannel intraluminal impedance in esophageal function testing and gastroesophageal reflux monitoring

Multichannel intraluminal impedance (MII) is a new technique for evaluating esophageal function and gastroesophageal reflux. This technique depends on changes in resistance to alternating current between two metal electrodes produced by the presence of bolus inside the esophageal lumen. Combined MII and manometry (MII-EM) provides simultaneous information on intraluminal pressure changes and bolus movement, whereas combined MII and pH (MII-pH) allows detection of pH episodes irrespective of their pH values (ie, acid and non-acid reflux). Combined MII-EM studies are performed very similarly to standard manometry. Based on studies in healthy volunteers and patients, combined MII-EM challenges current existing criteria that define the effectiveness of esophageal body function. Combined MII-pH testing brings a shift in gastroesophageal reflux testing paradigm. In MII-pH studies, reflux events are no longer detected by pH. Refluxate presence, distribution, and clearing are primarily detected by MII and simply characterized as acid versus non-acid based on pH change and as liquid, gas, or mixed based on MII. MII determines refluxate clearance time, whereas pH measures acid clearance time. MII-pH shows promise to become an important clinical tool, particularly to assess gastroesophageal reflux in the postprandial period and in patients with persistent symptoms on therapy and with atypical symptoms.     

体质量指数、食管裂孔疝与胃食管反流的关系

目的:分析胃食管反流病(gastroesophageal reFLux disease,GERD)患者的体质量指数(body mass index,BMI)、食管裂孔疝(hiatal hernia,HH)与胃食管反流(包括症状、食管炎)的关系.方法:收集2008-06/2011-10期间我院就诊的GERD患者590例.反流性疾病问卷(reflux disease questionnaire,RDQ)评价患者的胃食管反流症状,胃镜诊断糜烂性食管炎(erosive esophagitis,EE)、非糜烂性反流病(non-erosive reflux disease,NERD)、HH.根据BMI将患者分为4组:体质量过轻(BMI<18.5kg/m2)、正常体质量(18.5-22.9kg/m2)、超质量(23.0-24.9kg/m2)、肥胖(≥25kg/m2).分析GERD患者的临床特点、HH与BMI的关系、BMI及HH与GERD症状及EE的关系.结果:(1)临床特征:590例患者RDQ积分13.33±5.66,EE占52.2%(308/590),平均BMI为(23.64±3.10)kg/m2,体质量过轻、正常、超质量及肥胖组患者所占的比例分别为3.7%(22/590)、37.0%(218/590)、23.7%(140/590)、35.6%(210/590);(2)BMI与HH:体质量过轻、正常、超质量及肥胖组HH的检出率分别为0、6.0%(13/218)、12.9%(18/140)、16.7%(35/210),差异有统计学意义(P=0.001);(3)BMI、HH与GERD症状:体质量过轻、正常、超质量、肥胖4组的RDQ积分依次为11.95±5.86、13.33±5.50、13.45±5.22、13.40±6.07(F=0.465,P=0.707);HH组RDQ积分平均值高于无HH组(17.36±6.66vs12.83±5.31,P=0.005),且多元线性回归分析后差异仍有统计学意义(P=0.000);(4)BMI、HH与EE:EE组超质量、肥胖患者的比例明显高于NERD组(P=0.000);HH组EE的检出率高于无HH组(P=0.000).多因素分析后发现BMI、HH是EE发生危险因素.结论:HH可能是肥胖患者发生EE的重要机制之一.GERD患者的症状严重程度与HH相关,而与BMI无关,BMI和HH均是EE发生的危险因素.     

Comparison of multichannel intraluminal impedance-p H monitoring and reflux scintigraphy in pediatric patients with suspected gastroesophageal reflux

AIM To evaluate the agreement of multichannel intraluminal impedance-p H monitoring(MII-p HM) and gastroesophageal reflux scintigraphy(GES) for the diagnosis of gastroesophageal reflux disease. METHODS Seventy-five consecutive patients with suspectedgastroesophageal reflux disease(GERD) underwent 24-h combined MII-p HM recording and one hour radionuclide scintigraphy during the course of the MIIpH M study. Catheters with 6 impedance channels and 1 p H sensor were placed transnasally. Impedance and p H 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 p H is 4.0) greater than 4.2% for p HM 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-pH M 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 p HM, MII, GES and MII-p HM, respectively. The observed percentage agreements/κ values for GES and p HM, GES and MII, GES and MII-p HM, and MII and p HM 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 p HM alone, MII alone or MII-p HM. p H monitoring alone missed 17 patients compared to combined MII-p HM. The addition of MII to pH monitoring increased the diagnosis rate by 50%.CONCLUSION No or slight agreement was found among p H monitoring, MII monitoring, MII-pH monitoring and GES for the diagnosis of gastroesophageal reflux disease.     

联合食管多通道腔内阻抗-pH监测在诊断胃食管反流病中的价值

目的 了解联合食管多通道腔内阻抗pH(MII-pH)监测诊断胃食管反流病(GERD)的价值.方法 纳入具有烧心症状且食管黏膜无损伤患者44例,首先行MII-pH监测,然后行14 d的雷贝拉唑试验(试验结束时烧心症状完全消失定义为雷贝拉唑试验阳性).70名健康志愿者行MII-pH监测的结果作为正常值进行参照.结果 根据食管pH监测存在异常食管酸暴露或酸反流症状指数(SI)阳性者20例(45.4%).MII-pH监测提示弱酸反流SI阳性者2例,据此检查诊断烧心患者GERD的比例增至50%(22/44).雷贝拉唑试验阳性4例,据此则将烧心患者诊断为GERD的比例增至54.5%(24/44).结论 联合食管MII-pH监测可增加GERD检出率.     

联合食管多通道腔内阻抗-pH监测在诊断胃食管反流病中的价值

目的 了解联合食管多通道腔内阻抗pH(MII-pH)监测诊断胃食管反流病(GERD)的价值.方法 纳入具有烧心症状且食管黏膜无损伤患者44例,首先行MII-pH监测,然后行14 d的雷贝拉唑试验(试验结束时烧心症状完全消失定义为雷贝拉唑试验阳性).70名健康志愿者行MII-pH监测的结果作为正常值进行参照.结果 根据食管pH监测存在异常食管酸暴露或酸反流症状指数(SI)阳性者20例(45.4%).MII-pH监测提示弱酸反流SI阳性者2例,据此检查诊断烧心患者GERD的比例增至50%(22/44).雷贝拉唑试验阳性4例,据此则将烧心患者诊断为GERD的比例增至54.5%(24/44).结论 联合食管MII-pH监测可增加GERD检出率.     

胃食管反流病合并食管裂孔疝动物实验手术配合体会

目的促使新一代的青年医师、器械护士能够更加熟练掌握胃食管反流病合并食管裂孔疝手术方式及术中能够紧密的配合。 方法新疆维吾尔自治区人民医院微创外科与科研技术部门合作,成功建立了腹腔镜下胃食管反流病合并食管裂孔疝手术小猪动物训练模型,通过动物模型手术训练熟悉手术操作要点及配合要点。 结果共完成腹腔镜食管裂孔疝修补术6次,Nissen胃底折叠术12次,Toupet胃底折叠术12次,Dor胃底折叠术12次,未发生麻醉意外、二氧化碳气栓、失血性休克等严重并发症。预期手术成功完成,没有发生因术中并发症导致实验动物死亡而终止训练等情况。 结论经过腹腔镜抗反流手术动物模型的手术训练可以使医护人员明显缩短学习时间、促进临床术中配合,可以减少手术相关并发症,是一种安全可行的最佳手术训练方法。