Gastro-oesophageal reflux demonstrated by radiography. A supplement to 24-h pH monitoring

Purpose: Gastro-oesophageal reflux (GOR) is demonstrated by radiography as a supplement to 24-h pH monitoring.Material and Methods: Forty-two patients (mean age 44 years) with suspicion of GOR disease were assessed according to a standard questionnaire. GOR was investigated by 24-h pH-monitoring and by radiography. Oesophageal emptying and the presence of rings or strictures were registered as well. Mucosal biopsies, classified as normal, light oesophagitis, severe oesophagitis, or Barrett's oesophagus, were correlated to age, gender, symptomatology, pH monitoring, and oesophageal emptying. GOR and morphological changes demonstrated by radiography were correlated to pH monitoring and mucosa biopsies.Results: Based on pH monitoring, patients with severe oesophagitis and Barrett's oesophagus had a significantly higher acid exposure compared to patients with normal mucosa and light oesophagitis, with no difference concerning age, gender, and symptoms. Severe oesophagitis, including Barrett's oesophagus, was found only in patients with a positive test for radiologic GOR. Eleven patients had rings or strictures independent of oesophageal mucosal changes.Conclusion: GOR demonstrated by radiography identified patients where complications could be expected, which was not possible by pH monitoring alone.     

Radiological demonstration of gastroesophageal reflux. Diagnostic value of barium and bread studies compared with 24-hour pH monitoring

PURPOSE: To correlate gastroesophageal reflux (GER), demonstrated by a radiological method using food, with the reflux events, as determined by 24-h pH monitoring. MATERIAL AND METHODS: One hundred and seventeen patients with a median age of 47 years (86 male and 31 female) were examined. In the supine left position, the patient consumed 360 ml of barium contrast. Fluoroscopy was performed with the patient in the supine right oblique position during mastication and swallowing a piece of rye bread with liver pate and barium. The test was positive if barium was observed > or =5 cm proximal to the gastroesophageal junction. An antimony pH-probe was placed 5 cm above the lower esophageal sphincter, previously determined by manometry. The position was controlled by radiography after positioning and before removal. The total time of esophageal pH<4 exceeding 5.0% was considered pathological. RESULTS: The radiological method had a specificity of 100% and a sensitivity of 52% compared to 24-h pH monitoring. CONCLUSION: The high specificity of this radiological method justify direct therapeutic consequence of a positive test. However, a negative test still renders the problem unsolved.     

Gastroesophageal reflux disease: integrating the barium esophagram before and after antireflux surgery

Gastroesophageal reflux disease (GERD) is a common medical problem in the United States. As a result, laparoscopic antireflux surgery is a common surgical procedure. At the authors' institution, the barium esophagram before and after antireflux surgery is a critical examination in patients with GERD. This article summarizes the authors' examination protocol and describes how the findings are integrated in the care of these patients.     

Gastroesophageal reflux disease: correlation of esophageal pH testing and radiographic findings.

In an attempt to ascertain radiologic efficacy in patients with evidence of gastroesophageal reflux disease (GERD) at pH testing, radiographic findings were correlated with pH values obtained with an esophageal monitor worn for a 24-hour period in 112 patients. Fifteen (30%) of 50 patients with abnormal pH test results had esophagitis diagnosed radiographically, compared with six (10%) of 62 with normal pH test results (P < .05). The severity of abnormal pH monitoring results was classified but did not correlate significantly with the prevalence of esophagitis diagnosed radiographically. Hiatal hernia was also more common (80% vs 60%) in patients with abnormal pH test results (40 of 50 patients) than in those with normal results (37 of 62 patients) (P < .05). Pharyngeal, laryngeal, and pulmonary symptoms were common indications for evaluation, and 14 of 27 (52%) patients with hoarseness had an abnormal pH tracing. Only a minority of patients with evidence of GERD as defined by abnormal pH test results had reflux esophagitis diagnosed radiographically.     

Gastroesophageal reflux in children: radionuclide gastroesophagography

Sixty-five symptomatic infants and children underwent radionuclide gastroesophagography, acid reflux testing, and barium esophagography with water-siphon testing to evaluate the clinical efficacy of the scintigraphic technique in detecting gastroesophageal reflux. After ingesting 99mTc sulfur colloid in fruit juice, patients rested beneath the gamma camera for 30-60 min while esophageal activity was monitored continuously. By using the acid reflux test as a standard of comparison, the sensitivity of radionuclide gastroesophagography was 75%. Because of its physiologic nature, low radiation exposure, and convenience, radionuclide gastroesophagography warrants further evaluation as a screening test for gastroesophageal reflux.     

Association between esophageal dysmotility and gastroesophaeal reflux on barium studies

OBJECTIVE: To determine whether there is an association between abnormal primary peristalsis in the esophagus and gastroesophageal reflux (GER) on barium studies. METHODS: A computerized search of radiologic reports revealed 151 patients with esophageal dysmotility (characterized by intermittently decreased or absent peristalsis in the esophagus on upper gastrointestinal tract examinations) who fulfilled our study's entry criteria. These 151 patients were stratified into two groups depending on whether this dysmotility was associated with nonperistaltic contractions (NPCs): 92 patients had no NPCs (Dysmotility and No NPCs Group) and 59 had NPCs (Dysmotility and NPCs Group). An age-matched control group of 92 patients with normal motility was also generated from the radiologic reports. The reports were also reviewed for the presence and degree of GER and other complications of GER. The frequency and degree of GER were tabulated for each group, and the data were analyzed using a Pearson chi square test to determine if significant differences were present in the frequency and degree of GER or other findings among the groups. RESULTS: The frequency of GER was significantly higher in patients with abnormal peristalsis and no NPCs than in controls (p = 0.02). When GER was stratified based on the degree of reflux, the frequency of moderate-to-marked GER was significantly higher in patients with abnormal peristalsis and no NPCs than in patients with abnormal peristalsis and NPCs (p = 0.01) or in controls (p = 0.0031). The frequency of reflux esophagitis also was significantly higher in patients with abnormal peristalsis and no NPCs than in controls (p = 0.04). CONCLUSION: Our findings suggest that patients with esophageal dysmotility characterized by intermittently decreased or absent peristalsis without NPCs have a significantly higher frequency and degree of GER than patients with normal motility. The presence of this specific form of esophageal dysmotility on barium studies therefore should suggest underlying reflux disease.     

胃食管反流病pH联合阻抗监测与单纯pH监测效果的对比研究

 目的 探讨pH联合阻抗监测(multiple channel intraluminal pH-impedance reflux monitoring,MII-pH)相对于单纯pH监测在胃食管反流病(gastroesophageal reflux disease,GERD)评估中的优点,及胃食管反流病患者反流事件的特征。方法 纳入2015-06至2017-06火箭军特色医学中心胃食管反流病中心首次行MII-pH监测的成年GERD患者,分析MII-pH监测的pH通道和阻抗通道的各主要反流指标的阳性率,以及各反流指标之间的统计学关系。结果 共纳入GERD患者1780例,男889例,女891例,年龄(51.6±12.9)岁,有反酸、烧心、嗳气、胸痛、咳嗽、哮喘和咽部异物感等症状的患者分别为1026、1045、462、258、448、370、540例。pH通道的阳性率为26.3%,其中DeMeester积分的阳性率为25.4%,酸反流时间百分比的阳性率为25.4%。阻抗通道监测的阳性率为69.0%,其中反流总次数的阳性率为21.5%,液体酸反流和非酸反流次数相比有统计学差异(P＜0.001),液体酸反流和气体反流次数相比有统计学差异(P＜0.001);食团暴露时间百分比的阳性率为40.3%;症状相关性的阳性率为53.0%。MII-pH监测的总阳性率为71.3%。阻抗通道和pH通道的酸反流次数相比有统计学差异(P＜0.001)和相关性(r=0.904＞0.9,P＜0.001)。反流总量阳性率和症状相关性阳性率的McNemar卡方检验P＜0.001,Kappa=0.15;pH通道阳性率和症状相关性阳性率的McNemar卡方检验P＜0.001,Kappa=0.120。结论 MII-pH监测与单纯pH监测相比对酸反流事件的检出一致性非常高,并且更为敏感。MII-pH监测通过阻抗通道对非酸反流和气体反流的检测可显著提高GERD的检出率,并通过症状相关性分析可进一步提高GERD乃至反流高敏感(食管和气道)的检出率。     

Gastroesophageal reflux studies using milk in infants and children--the need for multiple views

The aim of this study was to assess the value of multiple acquisitions in detecting position-related gastroesophageal reflux (GER). We retrospectively reviewed milk scans of 105 patients with suspected GER and possible lung complications. After 2 h of fasting, 11.4 MBq Tc-99m-sulfur colloid was given to the patient orally along with formula or milk (infants). Without sedation in most patients, serial images (30 s each for 15 frames=8 min) were acquired in the supine, prone, right-side down, and left-side down positions. If reflux was detected in one position, before proceeding to the next position the patient was given water or milk to clear the esophagus.The study was considered positive if the activity reappeared in the esophagus. Anterior and posterior chest images were obtained after a delay of 2-4 h to detect any pulmonary aspiration. A total of 59 patients (56.2%) tested negatively for GER in all four positions and also showed a negative delayed scan for pulmonary aspiration. In contrast, 46 patients tested positively for GER in variable positions (prone=4, supine=6, left-side down=3, right-side down=12, and in more than one position=21, of which six included the supine position). The percentage yield of a positive GER position-related technique was three-fold that of conventional single supine position. These results may aid a better understanding of the pathophysiology of the disease and the design of preventive and therapeutic measures.     

Gastroesophageal reflux scintigraphy with radioactive capsules--a new technique for detection and quantitation of reflux

A new technique for performing quantitative gastroesophageal scintigraphy has been described. The method involves administration of radioactivity in capsule form into the stomach; the isotope is released after dissolution of the capsule. The mean time of onset of capsule breakage was 3.3 min (range 2-5 min) and complete dissolution occurred by 6.0 min (range 5-8 min). The appearance of isotope activity in the oesophagus by means of cine scintigraphy was quantified by PDP 11/34 computer (Gamma-11) in terms of percentage of gastroesophageal reflux (GER). In 15 healthy subjects, the percentage of reflux (mean +/- S.D.) in the lower, middle and upper oesophagus was found to be 1.25 +/- 0.67, 0.26 +/- 0.23 and 0.02 +/- 0.04 respectively. We have studied 52 patients using this technique, and results are encouraging.     

Gastroesophageal reflux: how much imaging is required?

The authors present a protocol for the selection of imaging studies for infants suspected of gastroesophageal reflux. In most cases, only a single imaging procedure is required. Three groups of patients are considered: those suspected of an esophageal or postgastric obstruction who require a barium GI series; those who appear to have reflux and a possible gastric obstruction in whom sonographic study of the gastric outlet is advised; and those suspected of aspirating in whom the possibility of reflux is studied by scintigraphy. Esophagoscopy and other studies are reserved for those refractory to therapy.     

The 24-h urinary cortisol/cortisone ratio for monitoring training in elite swimmers

PURPOSE: The effect of training variations on 24-h urinary cortisol/cortisone (C/Cn) ratio was investigated in highly trained swimmers to determine whether it could be a good marker of training stress and performance. METHODS: Fourteen swimmers (five female and nine male) were tested after 4 wk of intense training (IT), 3 wk of reduced training (RT), and 5 wk of moderate training (MT). At the end of each period, the swimmers performed in their best event at an official competition. Individual performances were expressed as a percentage of the previous season's best performance. The fatigue state was evaluated with a questionnaire. RESULTS: The C/Cn ratio was statistically different for the three periods (IT: 1.10 +/- 0.7, RT: 0.64 +/- 0.3, and MT: 0.57 +/- 0.2). The differences in the C/Cn ratio between two consecutive performances were related to the differences in performance (r = -0.52, P < 0.01), and the C/Cn ratio was significantly related to the total training (r = 0.32, P < 0.05) and total score of fatigue (TSF) (r = 0.35, P < 0.03) over the follow-up period. Cn levels were related to the dryland training (r = -0.46; P < 0.01) and TSF (r = -0.40; P < 0.02). During IT, variations in the C/Cn ratio were related to the changes in the mean intensity (r = -0.67; P < 0.02) and to TSF (r = 0.69; P < 0.01). CONCLUSION: The 24-h C/Cn ratio was moderately related to both training and performance whereas Cn levels were only related to training. The C/Cn ratio could be a useful indicator for monitoring the overreaching state in elite swimmers.     

Gastroesophageal reflux scintigraphy with radioactive capsules — a new technique for detection and quantitation of reflux

A new technique for performing quantitative gastroesophageal scintigraphy has been described. The method involves administration of radioactivity in capsule form into the stomach; the isotope is released after dissolution of the capsule. The mean time of onset of capsule breakage was 3.3 min (range 2–5 min) and complete dissolution occurred by 6.0 min (range 5–8 min). The appearance of isotope activity in the oesophagus by means of cine scintigraphy was quantified by PDP 11/34 computer (Gamma-11) in terms of percentage of gastroesophageal reflux (GER). In 15 healthy subjects, the percentage of reflux (mean ±S.D.) in the lower, middle and upper oesophagus was found to be 1.25±0.67, 0.26±0.23 and 0.02±0.04 respectively. We have studied 52 patients using this technique, and results are encouraging.     

Double contrast barium enema sensitivity: a comparison of studies by radiographers and radiologists

PURPOSE: A retrospective study of histologically proven cases of colorectal cancer (CRC) was performed to assess whether the sensitivity of the radiographer-performed double contrast barium enema (DCBE) differed from that of the radiologist-performed study. MATERIALS AND METHODS: Histologically proven cases of CRC were reviewed over a 3-year period to ascertain whether: the diagnosis had been made by DCBE in the 3 years before histological diagnosis; the lesion had been correctly diagnosed; the examination had been performed by a radiologist or radiographer. RESULTS: In the 3-year period there were 478 cases with histologically proven CRC. Of these, 239 (50%) had undergone DCBE as the initial radiological investigation of the colon. Sixty-four examinations had been performed by radiographers. A correct diagnosis was made in 58 cases (90.6%), the report was equivocal in one case (1.6%), there were four false-negatives (6.25%), and one case was abandoned (1.6%). One hundred and seventy-five examinations were performed by radiologists. A correct diagnosis was made in 157 cases (89.7%), the report was equivocal in one case (0.6%), there were 16 false-negatives (9.1%), and one case was abandoned (0.6%). CONCLUSION: A sensitivity of 90.6% for radiographer-performed studies compared favourably with 89.7% for radiologist-performed studies and supports the practice of radiographers undertaking barium enemas.     

Gastroesophageal reflux in children: evaluation of the water siphon test.

Fifty-nine symptomatic children were radiologically evaluated for gastroesophageal reflux with the water siphon test and also with the acid reflux test and esophageal manometry. Of those with reflux on pH testing, 95% had positive water siphon tests, and 38% also had spontaneous barium reflux. Of those with negative acid reflux tests, 29% had positive water siphon tests. Lower esophageal sphincter pressure did not correlate with either test unless the pressure was less than 10 mm Hg. Barium esophagography with the water siphon test is the appropriate initial examination in symptomatic patients, but the false-positive rate is high.     

Gastro-esophageal reflux demonstrated by radiography in infants less than 1 year of age. Comparison with pH monitoring

PURPOSE: To correlate gastro-esophageal reflux (GER) demonstrated on radiography, with reflux determined on 24-h pH monitoring among infants of less than 1 year of age. MATERIAL AND METHODS: Twenty-one infants with suspected GER were examined. In the supine position the infants drank 20-60 ml of barium contrast, and the presence or absence of hiatal hernia, gastric outlet obstruction, or intestinal malrotation was evaluated. The infant was placed in the 25 degrees right oblique supine position and fed 2-3 swallows of milk by a feeding bottle. GER was scored as positive on radiography when the contrast column reached a level of at least 3 vertebral segments above the gastro-esophageal junction (GEJ). An antimony intraluminal esophageal pH probe was positioned 2 vertebral segments above the GEJ as identified by the barium swallow, confirmed on radiography after positioning and prior to probe removal. A total time of esophageal pH <4 exceeding 5% was assigned as pathological. RESULTS: The radiological method of GER evaluation showed a specificity of 50% and a sensitivity of 29%, as compared to 24-h pH monitoring. CONCLUSION: The radiological method was of no value among infants of less than 1 year when demonstrating GER.     

Sigmoid diverticulitis: diagnostic role of CT--comparison with barium enema studies

The diagnostic value of computed tomography (CT) and barium enema (BE) studies was evaluated prospectively in hospitalized patients with the presumptive diagnosis of acute sigmoid diverticulitis based on the presence of left-lower-quadrant pain and tenderness, fever, and leukocytosis. Of 56 patients, 11 had sigmoid diverticulitis confirmed at surgery and 16 by clinical response to medical therapy. CT, performed in all diverticulitis patients, had positive results in 93% (25 of 27). These compared favorably with BE study results, of which 80% (20 of 25) were positive. Neither examination had false-positive results. In the 29 patients who did not have diverticulitis, an alternative diagnosis was made by means of CT in 20, but in only three by means of BE studies. Many of the extracolonic abnormalities recognized at CT were clinically unexpected and necessitated emergency surgery. The excellent sensitivity and specificity of CT coupled with its versatility in the detection of extracolonic disease give it an advantage over contrast enema studies for diagnosis of sigmoid diverticulitis. CT should be the initial study in acutely ill patients, especially when the clinical features are atypical for sigmoid diverticulitis.     

Gastroesophageal reflux--the acid test: scintigraphy or the pH probe?

The best established technique for diagnosing gastroesophageal reflux in children is the 24 hr esophageal pH probe test. No simultaneous comparison of this technique with radionuclide scans has been reported. Therefore, simultaneous 1 hr pH monitoring and gastroesophageal scintigraphy were performed in 49 infants and children with suspected gastroesophageal reflux. Forty-seven of these patients also were later monitored by the 24 hr pH probe test. Upper gastrointestinal series were performed on all patients. All patients with a positive 1 hr pH monitoring also had positive simultaneous scintigraphy. All patients with positive scintigraphy and pH probe monitoring also had a positive upper gastrointestinal series for reflux. The sensitivity of gastroesophageal scintigraphy, when compared to the 24 hr probe as a standard, was 79%; its specificity was 93%. The sensitivity of the upper gastrointestinal series was 86%, when compared to the 24 hr pH probe test. However, it specificity was only 21%.     

A comparison of three methods for performing barium follow-through studies of the small intestine

Domperidone 8 mg intravenously and metoclopramide 10 mg intravenously, in patients given a standard barium sulphate preparation, were compared with a rapid-transit barium (E-Z-Paque, E-Z-Em) in a double-blind random controlled manner. E-Z-Paque and metoclopramide given with a standard barium preparation decreased small-bowel transit time and resulted in fewer radiographs being taken. Gastric emptying occurred most rapidly with metoclopramide and a standard barium sulphate preparation. There was no significant difference in the quality or diagnostic accuracy of the examinations with any of the three techniques, and no difference in the incidence of side-effects with the two drugs.