Is ineffective esophageal motility gastropharyngeal reflux disease？

AIM： TO evaluate the association between IEM and gastropharyngeal reflux disease （GPRD） in patients who underwent ambulatory 24-h dual-probe pH monitoring for the evaluation of supraesophageal symptoms.
METHODS： A total of 632 patients who underwent endoscopy, esophageal manometry and ambulatory 24-h dual-pH monitoring due to supraesophageal symptoms （e.g. globus, hoarseness, or cough） were enrolled. Of them, we selected the patients who had normal esophageal motility and IEM. The endoscopy and ambulatory pH monitoring findings were compared between the two groups.
RESULTS;： A total of 264 patients with normal esophageal motility and 195 patients with the diagnosis of IEM were included in this study. There was no difference in the frequency of reflux esophagitis and hiatal hernia between the two groups. All the variables showing gastroesophageal reflux and gastropharyngeal reflux were not different between the two groups. The frequency of GERD and GPRD, as defined by ambulatory pH monitoring, was not different between the two groups.
CONCLUSION： There was no association between IEM and GPRD as well as between IEM and GERD. IEM alone cannot be considered as a definitive marker for reflux disease.     

Diagnostic value of dilated intercellular space and histopathologic scores in gastroesophageal reflux disease

The aim of this paper is to investigate the diagnostic value of histopathologic score and the dilated intercellular space (DIS) in patients with gastroesophageal reflux disease (GERD) and functional heartburn (FH). Participants with GERD symptoms including reflux esophagitis, non‐erosive reflux disease (NERD), Barrett's esophagus (BE), functional heartburn (FH), along with a control group with atypical GERD‐like symptom (Sym‐C), and asymptomatic healthy volunteers (H‐C) were administered GERD questionnaire, and subjected to endoscopy and biopsies, as well as 24‐hour pH‐impedance monitoring. Biopsies were evaluated using standards from the 2011 Esohisto Project after Hematoxylin‐Eosin staining. DIS was measured quantitatively under light microscopy. Among the total of 565 participants with qualified biopsy specimens, the mean DIS of the reflux esophagitis (RE) group was significantly wider compared with the other five groups. DIS in patients with GERD‐like symptoms was significantly wider compared with the H‐C. No significant differences were observed between NERD and FH. Results from 24‐hour pH‐impedance monitoring indicated that only the DIS of patients with acid reflux or the amount of acid reflux episodes in patients with DIS was significantly wider compared with patients with nonacid reflux or patients without DIS (P < 0.001). With DIS = 0.9 μm as the cutoff value, the sensitivity and specificity were 62.6% and 54.1%, respectively. Using the total histopathologic score > 3 as the diagnostic criterion, the sensitivity and specificity were 71.7% and 47.4%. DIS is closely associated with GERD and acid reflux. The diagnostic value of histological scores in lower esophagus in GERD is very similar to that of the quantitative measurement of DIS.     

Esophageal pH and bile monitoring for detecting duodenogastroesophageal reflux and evaluating the effectiveness of treatment

OBJECTIVE: To study methods of diagnosing duo­denogastroesophageal reflux (DGER) and to evaluate the role of bile reflux in gastroesophageal reflux disease (GERD). METHODS: Simultaneous 24‐h esophageal mucosal bilirubin level and pH monitoring were performed in 20 healthy subjects and 52 patients with symptoms suggesting gastroesophageal reflux. Data were gathered by using an ambulatory duodenogastric reflux monitoring system (Bilitec 2000) and an ambulatory pH recorder (Digitrapper MKIII). An absorbance value of ≥0.14 was designated as the threshold value for the presence of bile reflux. Patients suffering from mixed pathological reflux of acid and bile were treated with hydrotalcite and cisapride for 4 weeks, then the monitoring was repeated. RESULTS: No pathological acid reflux was found in the 20 healthy subjects. Based on findings from 24‐h esophageal pH monitoring, 47 of 52 patients (including 12 with esophagitis) were found to have patho­logical reflux. The total fraction of time with bile reflux was greater in the patients (n = 52) than in the healthy subjects (n = 20; 2.67 ± 3.23%vs 0.47 ± 0.71%; P < 0.05) and was greater in the patients with esophagitis (n = 12) than in the patients without esophagitis (n = 35; 5.41 ± 4.93%vs 1.68 ± 1.76%; P < 0.05). Of the 47 patients with GERD, 15 (32%) had abnormal mixed acid and bile reflux. Eight of the 15 patients with esophagitis were found to have mixed reflux and only four of 32 had acid reflux only (P < 0.05). After treatment with hydrotalcite and cisapride, the total fraction of time with acid and bile reflux in the 15 patients with mixed reflux decreased significantly (P < 0.05). Esophagitis was cured in seven of eight patients. CONCLUSION: The ambulatory duodenogastric reflux monitoring system is a useful tool for detecting DGER and evaluating the efficacy of treatment. Approximately 32% (15/47 cases) of patients with GERD were found to have DGER. Bile reflux may play a significant role in causing esophageal mucosal damage in patients suffering from GERD.     

Non-erosive and uncomplicated erosive reflux diseases: Difference in physiopathological and symptom pattern

AIM:To investigate differences in the physiopathological findings(manometry and pH monitoring) and symptoms between cases of non-erosive reflux disease(NERD) and erosive reflux disease(ERD) found positive at 24 h pH monitoring. METHODS:For a total of 670 patients who underwent 24 h pH monitoring,esophageal manometry and upper endoscopy were retrospectively evaluated,assessing the reflux symptoms,manometric characteristics of the lower esophageal sphincter(LES) and esophageal body and the presence or absence of esophagitis and hiatal hernia. Typical and atypical symptoms were also evaluated. For inclusion in the study,patients had to have NERD or ERD and be found positive on pH monitoring(NERD+) . Patients with Gastroesophageal reflux disease(GERD) complicated by stenosis,ulcers or Barrett’s esophagus were ruled out. RESULTS:214 patients were involved in the study,i.e. 107 cases of NERD+ and 107 of ERD. There were no significant gender-or age-related differences between the two groups. The ERD group had more cases of hiatal hernia(P = 0.02) and more acid reflux,both in terms of number of reflux episodes(P = 0.01) and as a percentage of the total time with a pH < 4(P = 0.00) ,when upright(P = 0.007) and supine(P = 0.00) . The NERD+ cases had more reflux episodes while upright(P = 0.02) and the ERD cases while supine(P = 0.01) . The LES pressure was higher in cases of NERD+(P = 0.03) while the amplitude and duration of their esophageal peristaltic waves tended to be better than in the ERD group(P >0.05) . The NERD+ patients presented more often with atypical symptoms(P = 0.01) . CONCLUSION:The NERD+ patients’ fewer reflux episodes and the fact that they occurred mainly while in the upright position(unlike the cases of ERD) may be two factors that do not favor the onset of esophagitis. The frequently atypical symptoms seen in patients with NERD+ need to be accurately evaluated for therapeutic purposes because patients with GERD and atypical symptoms generally respond only partially to medical and surgical treatments.     

Laryngopharyngeal reflux in patients with symptoms of gastroesophageal reflux disease

Laryngopharyngeal reflux (LPR) has been extensively studied in patients with laryngeal signs and symptoms, gastroesophageal reflux being identified in approximately 50%. Few studies have investigated the incidence and significance of LPR in GERD patients. Two-hundred and seventy-six consecutive patients referred with symptoms of gastroesophageal reflux had dual probe 24 h pH, esophageal manometry, GERD and ENT questionnaires. LPR was defined as at least three pharyngeal reflux events less than pH 5.0 with corresponding esophageal reflux, but excluding meal periods. Fourty-two percent of patients were positive for LPR on 24 h pH monitoring and 91.3% corresponded with an abnormal esophageal acid score. Distal esophageal acid exposure was significantly greater (P < 0.001) in patients with LPR but symptoms of GERD and regurgitation scores showed no significant differences between patients with positive and negative LPR on 24 h pH. There was no significant difference between the incidence of LPR in patients with or without laryngeal symptoms. There is a high incidence of LPR in patients with GERD but its significance for laryngeal symptoms is tenuous. Fixed distance dual probe pH monitoring allows documentation of conventional esophageal reflux and LPR.     

Failure of Initial 24-Hour Esophageal pH Monitoring to Predict Refractoriness and Intractability in Reflux Esophagitis

Prolonged esophageal pH monitoring is considered to be the most sensitive and specific test for the diagnosis of gastroesophageal reflux disease (GERD). However, the role of pH monitoring in predicting the clinical and endoscopic response of reflux esophagitis is not well defined. In this study, 106 patients with moderate to severe symptoms of GERD and esophagitis (grades 0-IV) by endoscopy were initially studied by ambulatory esophageal pH monitoring, and their clinical response to standard H2 antagonist therapy was monitored at 8 wk. Refractory patients were defined as those who failed to heal and/or had intractable reflux symptoms after 8 wk of H2 antagonist therapy, and who required continuous therapy with higher doses of H2 antagonists, addition of prokinetic agents, or omeprazole. There was a positive correlation (r = 0.89) between endoscopic severity of esophagitis upon entry into the study and refractoriness to standard medical therapy. However, there were no differences in the various pH parameters analyzed between the 58 patients who responded and the 48 patients who were refractory to medical therapy, regardless of the endoscopic grading of their esophagitis. We conclude that 24-h ambulatory esophageal pH monitoring does not predict refractoriness of reflux esophagitis to standard therapy. The decision for more aggressive methods of treatment probably requires assessment of symptomatic and endoscopic response after 8 week standard H2 antagonist therapy.     

Comparison of central and intraesophageal factors between gastroesophageal reflux disease (GERD) patients and those with GERD‐related noncardiac chest pain

Gastroesophageal reflux disease (GERD) causes a wide range of symptoms. Some patients present with typical symptoms such as heartburn and regurgitation and others with atypical symptoms such as chest pain. The mechanism responsible for the varying clinical presentation of GERD is still not fully elucidated. The aim of this study was to prospectively evaluate differences in central and local intraesophageal factors between patients with typical GERD symptoms and those with noncardiac chest pain (NCCP). Patients presenting with typical and atypical symptoms suspicious of GERD underwent upper endoscopy and 24‐hour pH monitoring with four sensors, each positioned at a different esophageal level. All patients completed GERD symptom, Hospital Anxiety and Depression Scale, and Symptom Stress Rating questionnaires. From January 2006 to December 2009, 50 patients were recruited, 29 with typical symptoms, and 21 with NCCP. Patients with proven GERD and NCCP had higher proximal extension of acid during reflux episodes than patients with typical symptoms. They were found to be older, had a shorter history of symptom onset, worse anxiety scores, and more endoscopic findings compatible with gastritis. Proximal extension of acid during the reflux episodes in patients with GERD presenting with NCCP may play a role in symptom generation.     

REVIEW: Ambulatory Esophageal pH Monitoring: Technique, Interpretations, and Clinical Indications

Gastroesophageal reflux disease (GERD) is the most common esophageal disorder and perhaps among the most prevalent conditions seen in the primary care setting. The clinical manifestations of GERD, typical or atypical, such as noncardiac chest pain, respiratory or ear, nose, and throat symptoms, result from the reflux of gastric contents into the esophagus. Thus the clinical spectrum is wide and requires accurate diagnosis. Ambulatory 24-hr esophageal pH monitoring is not useful in all patients suspected to have GERD. This review describes the technique of ambulatory 24-hr esophageal pH monitoring, the interpretation of findings, and clinical applications of this test.     

The utility of ambulatory pH monitoring in patients presenting with chronic cough and asthma.

OBJECTIVE: To evaluate the prevalence of gastroesophageal reflux disease (GERD) in patients presenting with asthma and chronic cough. PATIENTS AND METHODS: The charts of 358 consecutive patients who were referred for ambulatory gastroesophageal pH monitoring to the Lung Centre in Vancouver, British Columbia, were reviewed, and the data of 108 (30%) patients with asthma and 134 (37%) patients with chronic cough were analyzed. The maintenance treatment for GERD was discontinued before patients underwent the pH monitoring study. One hundred eighteen (33%) patients were excluded. RESULTS: Reflux episodes identified reflux events as the percentage of time where the pH was less than four. For asthma patients, 70 (64.8%) had distal total reflux, 50 (46.3%) had distal upright reflux, 41 (38.3%) had distal supine reflux and 73 (67.6%) had other distal refluxes. Proximal total reflux in asthmatic patients was present in 56 (52%), proximal upright reflux in 55 (51%) and proximal supine reflux in 56 (52%) patients. For chronic cough patients, 70 (52.6%) had distal total reflux, 59 (44.4%) had distal upright reflux, 45 (34.4%) had distal supine reflux and 75 (56%) patients had other distal refluxes. In chronic cough patients, proximal total reflux was present in 70 (52%), proximal upright reflux in 80 (60%) and proximal supine reflux in 59 (44%). Presenting respiratory and/or reflux symptoms were absent in approximately 25% of patients with asthma and reflux, and in approximately 50% of patients with chronic cough and reflux. During pH monitoring, symptoms did not differ significantly between those with and without distal reflux in both study groups, except for more significant heartburn in patients with chronic cough and reflux (RR 2.0). CONCLUSIONS: The data of the present study support the observation that there is a high prevalence of GERD in patients with asthma or chronic cough. The use of different pH parameters for detecting acid reflux during 24 h ambulatory pH monitoring, such as proximal esophageal acid measurement, should be considered as part of the routine interpretation of such testing. A low threshold for diagnosing GERD in patients with asthma or chronic cough is essential, because respiratory and/or reflux symptoms can be absent or atypical in some of these patients.     

Females without reflux symptoms or gastroesophageal reflux disease have less distal esophageal acid exposure than males without reflux symptoms or gastroesophageal reflux disease

Ambulatory 24‐hour esophageal pH monitoring is the gold standard examination to assess esophageal acid exposure. Gender‐related variation is a well‐recognized physiologic phenomenon in health and disease. To date, limited gender‐specific 24‐hour esophageal pH monitoring data are available. The aim of this study was to obtain values of esophageal pH monitoring in males and females without reflux symptoms or gastroesophageal reflux disease (GERD) to determine if gender variation exists in esophageal acid exposure among individuals without these factors. Twenty‐four‐hour dual esophageal pH monitoring was performed in male and female volunteers without reflux symptoms or GERD. Values for total number of reflux episodes, episodes longer than 5 minutes, total reflux time in minutes, % time with pH below 4, and longest reflux episode in the proximal/distal esophagus were obtained and recorded for both groups. The distal channel was placed 5 cm and proximal channel 15 cm above the manometrically determined lower esophageal sphincter. Means were compared using an independent sample t‐test. Sixty‐seven males and 69 females were enrolled. All subjects completed esophageal 24‐hour pH monitoring without difficulty. There was no age or body mass difference between groups. Females had significantly fewer reflux episodes at both esophageal measuring sites and, significantly less total reflux time and % time with pH below 4 in the distal esophagus than males. All other parameters were similar. Significant gender‐related differences exist in esophageal acid exposure, especially in the distal esophagus in individuals without reflux symptoms or GERD. These differences underscore the need for gender‐specific reference values for 24‐hour pH monitoring, allowing for an accurate evaluation of esophageal acid exposure in symptomatic patients.     

Belching: dyspepsia or gastroesophageal reflux disease?

OBJECTIVES: Eructation (belching) is a common symptom seen in clinical practice. Because either belching or heartburn may result from transient lower esophageal sphincter relaxations, it has been proposed that belching may be a manifestation of gastroesophageal reflux disease (GERD). In this retrospective study we evaluated the prevalence of belching in dyspepsia and GERD and the relation of belching to acid reflux events documented by pH monitoring. METHODS: We examined the prevalence, frequency, and severity of belching and other GERD symptoms by use of standardized questionnaires in 180 GERD patients (group A) and 78 dyspeptic controls (group B) referred for evaluation at our institution. GERD was defined as either endoscopic esophagitis (or Barrett's esophagus) or positive DeMeester score (>14.2) on pH monitoring or both. Dyspeptic patients had normal endoscopy and pH studies. We also analyzed the relationship of belching to acid reflux events during the 24-h period of pH studies. RESULTS: Of 180 GERD patients, 132 (70%) reported belching during pH monitoring, versus 63 of 78 dyspeptic patients (80%) (p = ns). Similarly, 163 of 180 GERD patients (90%) reported heartburn versus 64 of 78 of dyspeptic patients (82%) (p = ns). Review of symptom questionnaires revealed no significant difference in belching severity between groups. However, heartburn and acid regurgitation were significantly more severe among GERD patients. There was a significantly higher correlation of both heartburn and belching with acid events in patients with GERD compared with patients with dyspepsia. In addition, although both belching and heartburn were significantly improved in patients with GERD, belching scores remained unchanged after proton pump inhibitor (PPI) therapy in patients with dyspepsia. CONCLUSIONS: Belching is as common and as severe in patients with dyspepsia as it is in patients with GERD. Belching and heartburn in GERD patients are more likely correlated with episodes of pathological acid reflux. Because belching cannot be clinically used as a discriminatory symptom, ambulatory pH monitoring should be considered to elucidate the relationship of belching to acid reflux in patients with dyspepsia or GERD.     

Is the Proton Pump Inhibitor Test Helpful in Patients with Laryngeal Symptoms?

Background and Objectives

The association of gastroesophageal reflux disease (GERD) and laryngeal symptoms is not clear. We aimed to examine the symptomatic and endoscopic relations between GERD and laryngeal symptoms and also to evaluate the response to a 2-week proton pump inhibitor (PPI) trial.

Methods

Seventy-two patients experiencing persistent laryngeal symptoms ≥2/week were enrolled. The laryngeal symptoms using the 1-week laryngeal symptom score (LSS) and the typical reflux symptoms including heartburn and acid regurgitation were assessed. Transnasal-esophagogastroduodenoscopy (TN-EGD) and ambulatory 24-h esophageal pH monitoring were performed. The patients were classified into a GERD group and a non-GERD group. The GERD group was defined as the cases of the presence of typical reflux symptoms and/or reflux esophagitis and/or pathologic acid exposure. Patients were treated with 30 mg of lansoprazole bid for 14 days.

Results

Thirty-nine patients (54 %) were diagnosed with GERD on the basis of typical reflux symptoms, EGD, and/or pH testing. There was no significant association between the LSS and the presence of typical reflux symptoms. Also, the presence of laryngitis was not significantly related to reflux esophagitis. The 2-week PPI trial showed no significant difference in the improvement in laryngeal symptoms between the GERD and non-GERD groups.

Conclusions

There was no significant symptomatic and endoscopic association between GERD and laryngeal symptoms. Therefore, GERD does not appear to be the sole cause of these symptoms. Additionally, a 2-week PPI trial is not long enough to be a diagnostic tool in patients with laryngeal symptoms.     

41例老年人胃食管反流病24小时食管pH测定结果分析

目的探讨老年人食管酸暴露频率强度与胃食管反流病的关系。方法应用食管ｐＨ测定方法，对４１例有胃食管反流症状者和１５例健康老年人进行２４小时食管ｐＨ监测。结果健康老年人ｐＨ＜４的总时间百分比＜３３％，立位ｐＨ＜４时间百分比＜５５％，反流＞５分钟次数＜２次，ｐＨ＜４反流次数＜６５次，但卧位ｐＨ＜４时间百分比为＜１４％。４１例有胃食管反流症状者中，３８例酸反流得分＞１４５，包括１５例内镜下无食管炎征象者，阳性率达９２５％。根据内镜下有无食管炎，比较食管粘膜损伤组与无食管粘膜损伤组之间各项ｐＨ指标的异同。可见ｐＨ＜４的总时间百分比、卧位ｐＨ＜４时间百分比和持续反流＞５分钟次数有明显不同。结论老年人食管粘膜暴露频率时间与胃食管反流病的严重程度有关。     

酸和胆汁反流与胃食管反流症状的关系

目的 分析酸反流及胆汁反流在引起胃食管反流症状中的作用。方法 对56例有典型反流症状的患者进行24小时食管内pH值及BiHtee胆汁同步监测。患者通过症状按键标记典型反流症状，对每一症状事件按症状发生前2分钟内食管最低pH值和最高胆红素光吸收值，分别计算症状与酸反流或胆汁反流事件的相关性，得出每一例患者的酸反流相关症状指数(Sla)及胆汁反流相关症状指数(SIb)。结果 56例患者中共发生典型症状事件357次。其中大部分症状(37．25％)与酸反流有关，仅7．56％的症状与单纯胆汁反流有关。反流性食管炎组(RE)亚组的243次症状事件中，105次(43．21％)事件与酸反流相关，而21次(8．64％)与胆汁反流有关。两种症状相关指数均值比较差异有显著性。结论 胃食管反流症状事件与酸反流的相关性明显高于胆汁反流，胆汁反流在引起典型食管症状方面似乎不起主要作用。     

Endoscopic reflux esophagitis in patients with upper abdominal pain-predominant dyspepsia

BACKGROUND: Reflux symptom assessment had reliable accuracy in the diagnosis of gastroesophageal reflux disease (GERD). However, patients may recognize heartburn or regurgitation as dyspepsia because of inaccurate understanding or atypical presentation. The aim of the present study was to estimate endoscopic reflux esophagitis in patients with upper abdominal pain as a predominant symptom in the absence of heartburn or regurgitation. METHODS: Two hundred and sixty-three consecutive patients presenting dyspepsia without heartburn or regurgitation were enrolled. Patients with heartburn or regurgitation were excluded using the symptom interviewer method. Dyspepsia was categorized into pain-predominant or dysmotility-predominant groups according to the Rome II proposal. Endoscopic reflux esophagitis was graded using the Los Angeles classification. RESULTS: One hundred and five patients were included in the pain-predominant group and 119 in the dysmotility-predominant group. Reflux esophagitis was found in 18.8% (42/224) of all dyspeptic patients. Grade A esophagitis was noted in 27.6% (29/105) of the pain-predominant group and in 7.6% (9/119) of the dysmotility-predominant group. Grade B was noted in two patients in each group. A total of 29.5% (31/105) and 9.3% (11/119) had reflux esophagitis, respectively (P < 0.001). Comparing patients with or without reflux esophagitis, there was no difference in body mass index, smoking habit, alcohol consumption, or Helicobacter pylori infection status. CONCLUSIONS: A significant proportion of patients presenting dyspepsia, especially pain-predominant dyspepsia, have endoscopic reflux esophagitis. In view of GERD, pain-predominant dyspepsia should be investigated and managed differently from dysmotility-predominant dyspepsia.     

Utilization of wireless pH monitoring technologies: a summary of the proceedings from the Esophageal Diagnostic Working Group

Gastroesophageal reflux disease (GERD) can be difficult to diagnose – symptoms alone are often not enough, and thus, objective testing is often required. GERD is a manifestation of pathologic levels of reflux into the esophagus of acidic, nonacidic, and/or bilious gastric content. However, in our current evidence‐based knowledge approach, we only have reasonable outcome data in regards to acid reflux, as this particular type of refluxate predictably causes symptoms and mucosal damage, which improves with medical or surgical therapy. While there are data suggesting that nonacid reflux may be responsible for ongoing symptoms despite acid suppression in some patients, outcome data about this issue are limited. Therefore, this working group believes that it is essential to confirm the presence of acid reflux in patients with ‘refractory’ GERD symptoms or extraesophageal symptoms thought to be caused by gastroesophageal reflux before an escalation of antireflux therapy is considered. If patients do not have pathologic acid reflux off antisecretory therapy, they are unlikely to have clinically significant nonacid or bile reflux. Patients who do not have pathologic acid gastroesophageal reflux parameters on ambulatory pH monitoring then: (i) could attempt to discontinue antisecretory medications like proton pump inhibitors and H2‐receptor antagonists (which are expensive and which carry risks – i.e. C. diff, etc.); (ii) may undergo further evaluation for other causes of their esophageal symptoms (e.g. functional heartburn or chest pain, eosinophilic esophagitis, gastroparesis, achalasia, other esophageal motor disorders); and (iii) can be referred to an ear, nose, and throat/pulmonary/allergy physician for assessment of non‐GERD causes of their extraesophageal symptoms.     

Gastroesophageal reflux disease poorly responsive to single-dose proton pump inhibitors in patients without Barrett's esophagus: acid reflux, bile reflux, or both?

OBJECTIVES:   Studies using ambulatory pH and esophageal bile reflux monitoring (Bilitec^®) have shown that both acid reflux and duodeno-gastro-esophageal reflux (DGER) frequently occur in patients with gastroesophageal reflux disease (GERD). A subset of patients with GERD has persistent reflux symptoms in spite of standard doses of proton pump inhibitors (PPIs). The aim of the present study was to investigate the role of acid and DGER in patients with reflux disease poorly responsive to PPIs.
METHODS:   Sixty-five patients (32 men, 44 ± 2 yr) without Barrett's esophagus and with persistent heartburn or regurgitation during standard PPI doses were studied. They underwent upper gastrointestinal endoscopy and simultaneous 24-h ambulatory pH and Bilitec^® monitoring while PPIs were continued.
RESULTS:   Thirty-three patients (51%) had persistent esophagitis. Seven patients (11%) had only pathological acid exposure, 25 (38%) had only pathological DGER exposure, and 17 (26%) had pathological exposure to both acid and DGER. Acid exposure under PPI was positive in only 37%, but adding Bilitec^® increased the diagnoses of persistent reflux to 75%. Patients with persistent esophagitis had similar acid exposure, but significantly higher DGER exposure than those without esophagitis. The highest prevalence of esophagitis was found in patients with pathological exposure to both acid and DGER; symptoms did not differ according to the type of reflux.
CONCLUSIONS:   Combined pH and Bilitec^® monitoring is superior to pH monitoring alone in demonstrating ongoing pathological reflux in patients with medically poorly responsive reflux disease.     

Is impedance pH monitoring superior to the conventional 24‐h pH meter in the evaluation of patients with laryngorespiratory symptoms suspected to be due to gastroesophageal reflux disease?

OBJECTIVE: Cough and laryngo‐pharyngeal symptoms (LPS) are associated with gastroesophageal reflux disease (GERD). The role of acid reflux (AR) and non‐acid reflux (NAR) in atypical GERD pathogenesis is controversial. The aims of the study were to determine the prevalence of high esophageal acid exposure time (AET) in patients presenting with cough or LPS and determine the incremental yield of multichannel intraluminal impedance–pH (MII‐pH) monitoring. METHODS: We undertook a prospective study of patients with cough or LPS referred for GERD evaluation between January 2009 and May 2011. All patients underwent esophageal manometry, gastroscopy and MII‐pH. Patients' characteristics, gastroscopy findings, distal esophageal AET, bolus exposure (BE) time and numbers of AR and NAR episodes in the proximal and distal esophagus were studied. RESULTS: Overall 50 patients (22 male, mean age 47.5 ± 14.2 years) were evaluated for unexplained chronic cough (n = 23, 46.0%), and LPS symptoms including globus (n = 10, 20.0%), sore throat (n = 12, 24.0%) and hoarse voice (n = 5, 10.0%). A normal gastroscopy, Los Angeles grade A and B esophagitis occurred in 44 (88.0%), 5 (10.0%) and 1 (2.0%) patient, respectively. Seven (14.0%) recorded elevated AET (chronic cough, 4; sore throat, 2; and hoarse voice, 1). Nine patients recorded abnormal impedance characteristics (raised BE time and/or increased reflux numbers) despite a normal AET leading to an incremental diagnostic yield of 18%. CONCLUSION: An isolated high AET is uncommon in patients with cough or LPS. Combined MII‐pH improves the diagnostic yield in patients with atypical GERD manifestations.     

正常人和胃食管反流病人的昼夜食管pH和动力变化

目的:为探讨正常人和胃食管反流病(gastroesophageal reflux disease,GERD)病人昼夜食管运动规律以及食管运动与酸反流的关系。方法:45例GERD病人和10名正常人均接受食管测压和动态食管pH及压力同步监测。结果:(1)下食管括约肌压、远端食管蠕动压及有效食管蠕动百分比在酸反流DeMeester高计分组明显低于低计分组(P<0.05),在反流性食管炎组也明显低于非反流性食管炎组(P<0.05)。(2)有GERD症状或食管炎的卧位有效蠕动百分比明显低于立位(P<0.05)。反流性食管炎组80％有夜间或伴有夜间反流,而不伴反流性食管炎的GERD无1例出现夜间反流。结论:昼夜食管pH和压力动态监测有利于进一步探讨GERD的运动病理,除LES功能外,食管清除功能在GERD发病中起重要作用。     

胆汁在胃食管反流病中的作用

随着24 h食管pH监测和胆汁监测技术的开展,胃、十二指肠液混合反流在胃食管反流病(GERD)的发生、发展中的作用已被逐步认识.胆汁反流在GERD发病过程中所扮演的角色,成为近年来人们研究的焦点之一.基础研究证明胆汁在不同酸碱环境、不同浓度对食管黏膜的损伤作用是不同的.不少临床试验对GERD进行研究发现,胆汁反流与症状和食管损伤严重度存在一定关系,但研究结果不尽一致,胆汁在GERD中的作用仍有争议.明确胆汁在GERD中的作用,有助于为预防此类疾病开辟新的道路.本文就有关胆汁反流在胃食管反流病中的作用的研究进展作一综述.