24-hour esophageal pH-monitoring in children suspected of gastroesophageal reflux disease： Analysis of intraesophageal pH monitoring values recorded in distal and proximal channel at diagnosis

AIM To assess values of 24-h esophageal pH-monitoring parameters with dual-channel probe (distal and proximal channel) in children suspected of gastroesophageal reflux disease (GERD).METHODS 264 children suspected of gastroesophageal reflux (GER) were enrolled in a study (mean age χ = 20.78 ± 17.23 mo). The outcomes of this study,immunoallerrgological tests and positive result of oral food challenge test with a potentially noxious nutrient,enabled to qualify children into particular study groups.RESULTS 32 (12.1%) infants (group 1) had physiological GER diagnosed. Pathological acid GER was confirmed in 138 (52.3%) children. Primary GER was diagnosed in 76 (28.8%) children (group 2) and GER secondary to allergy to cow milk protein and/or other food (CMA/FA) in 62 (23.5%) children (group 3). 32(12.1%) of them had CMA/FA (group 4-reference group),and in remaining 62 (23.5%) children neither GER nor CMA/FA was confirmed (group 5). Mean values of pH monitoring parameters measured in distal and proximal channel were analyzed in individual groups. This analysis showed statistically significant differentiation of mean values in the case of number of episodes of acid GER,episodes of acid GER lasting ＞ 5 min, duration of the longest episode of acid GER in both channels, acid GER index total and supine in proximal channel. Statistically significant differences of mean values among examined groups, especially between group 2 and 3 in the case of total acid GER index (only distal channel) were confirmed.CONCLUSION 24-h esophageal pH monitoring confirmed pathological acid GER in 52.3% of children with typical and atypical symptoms of GERD. The similar pH-monitoring values obtained in group 2 and 3 confirm the necessity of implementation of differential diagnosis for primary vs secondary cause of GER.     

Role of gastroesophageal reflux symptoms in exacerbations of COPD

BACKGROUND AND AIMS: The impact of gastroesophageal reflux disease (GERD) on exacerbations of COPD has never been evaluated. The aims of this investigation were to determine the prevalence of gastroesophageal reflux (GER) symptoms in COPD patients and the effect of GER on the rate of exacerbations of COPD per year. METHODS: A questionnaire-based, cross sectional survey was performed. Subjects were recruited from the outpatient pulmonary clinics at the University of Florida Health Science Center/Jacksonville. Included patients had an established diagnosis of COPD. Exclusion criteria were respiratory disorders other than COPD, known esophageal disease, active peptic ulcer disease, Zollinger-Ellison syndrome, mastocytosis, scleroderma, and current alcohol abuse. Those meeting criteria and agreeing to participate were asked to complete the Mayo Clinic GERD questionnaire by either personal/telephone interview. Clinically significant reflux was defined as heartburn and/or acid regurgitation weekly. Other outcome measures noted were frequency and type of COPD exacerbations. Statistical analysis was performed using the Fisher exact test for categorical data and the independent t test for interval data. RESULTS: Eighty-six patients were enrolled and interviewed (mean age, 67.5 years). Male patients accounted for 55% of the study group. Overall, 37% of patients reported GER symptoms. The mean FEV(1) percentage of predicted was similar in those with or without GER. The rate of exacerbations of COPD was twice as high in patients with GER symptoms compared to those without GER symptoms (3.2/yr vs 1.6/yr, p = 0.02). CONCLUSIONS: The presence of GER symptoms appears to be associated with increased exacerbations of COPD.     

Prevalence of atypical symptoms and their association with typical symptoms of gastroesophageal reflux in Spain

BACKGROUND: The association between typical and atypical symptoms of gastroesophageal reflux (GER) has received little attention in population-based studies. This study therefore sought to examine the prevalence of atypical symptoms, and their association with typical GER symptoms in Spain. METHODS: A telephone survey using a validated questionnaire was conducted in 2002 on 2500 subjects aged 40-79 years, randomly selected from the general population of Spain. The questionnaire included items on typical GER symptoms (heartburn and acid regurgitation) and several atypical symptoms (chest pain, dysphagia, belching, dyspepsia, globus, hoarseness, hiccups, chronic cough and asthma). The association between typical GER symptoms and each atypical symptom was summarized using odds ratios obtained from logistic regression. RESULTS: The response rate was 71.2%. A total of 60.8% (95% confidence interval 59.0-62.8%) of subjects reported suffering from at least one atypical symptom during the year preceding the interview. The prevalence rates varied from 26.7% for hoarseness to 6.6% for asthma. The prevalence of atypical symptoms was higher among the 791 subjects with typical GER symptoms than among the 1709 subjects reporting no typical GER symptoms (79.6 versus 52.2%). It was also higher among those reporting frequent typical GER symptoms compared with those reporting occasional symptoms (87.8 versus 58%). After adjustment for age, sex, coffee, alcohol and tobacco consumption, and psychosomatic symptoms, an association (P<0.05) was observed between typical symptoms and the respective atypical symptoms, with odds ratios ranging from 1.4 for asthma to 4.6 for belching. After additional adjustment for the remaining atypical symptoms, chest pain, dysphagia, dyspepsia, belching and globus were each independently associated with typical reflux symptoms. CONCLUSION: The prevalence of atypical GER symptoms is extremely high. There is an association between typical and atypical GER symptoms, particularly chest pain, dysphagia, dyspepsia, belching and globus.     

24-h esophageal pH testing in asthmatics: respiratory symptom correlation with esophageal acid events

BACKGROUND: Gastroesophageal reflux (GER) may be a trigger for asthma and may be clinically silent. Twenty-four-hour esophageal pH testing accurately diagnoses GER in asthmatics. There are no reports correlating respiratory symptoms with esophageal acid events. This study examines the prevalence and severity of GER in asthmatics with and without reflux symptoms and examines respiratory symptom correlation with esophageal acid. METHODS: All esophageal manometry and 24-h esophageal pH tests performed were reviewed in asthmatics who met entrance criteria from July 1, 1989, through November 1, 1994. GER was present if esophageal pH tests were abnormal. Results of esophageal tests were compared for asthmatics with reflux symptoms and GER and asthmatics without reflux symptoms and GER. Respiratory symptoms correlated with esophageal acid events if the esophageal pH was < 4 simultaneously with the respiratory event or within 5 min before its onset. RESULTS: Of 199 asthmatics who qualified for analysis, 164 (82%) had reflux symptoms. The results of 24-h esophageal pH tests were abnormal in 118 of 164 asthmatics with reflux symptoms (72%), compared with 10 of 35 asthmatics without reflux symptoms (29%). Among asthmatics with GER, 119 of 151 respiratory symptoms (78.8%) were associated with esophageal acid. Seventy-six of 84 reported coughs (90.5%) were associated with esophageal acid. Theophylline did not alter esophageal parameters. CONCLUSIONS: There is a strong correlation between esophageal acid events and respiratory symptoms in asthmatics with GER. Respiratory symptom correlation with esophageal acid events further supports that GER may be a trigger for asthma.     

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.     

Gastroesophageal 99mTc scintigraphy in gastroesophageal reflux

The aim of this study was to compare gastroesophageal 99mTc scintiscanning (GES), the pH reflux test (TRA) and esophageal manometry in the assessment of gastroesophageal reflux (GER). GES was performed after oral intake of sulfur colloid labeled with 99m technetium and 300 ml of water. Calculation of an index of reflux gave a semi-quantitative assessment of the GER. Sixty patients with symptoms of GER (typical in 51 cases, atypical in 9 cases) had the three tests. A GES was also performed in 17 normal volunteers and in 12 patients of the series after fundoplication. The diagnostic specificity of GES was 1.0 in GER. GES was less frequently positive than the pH reflux test in GER (68.6 p. 100 versus 80.4 p. 100) but the difference was not significant. These two tests were more sensitive than manometry. The index of reflux was higher in patients than in control subjects (p less than 0.0005) and returned to normal values after fundoplication. A correlation between the index of reflux and the stage of pH-reflux test was observed. It is suggested that GES can be used in the initial assessment of GER as an alternative to TRA and performed repeatedly during the follow-up of patients treated surgically.     

Chronic hoarseness secondary to gastroesophageal reflux disease: documentation with 24-h ambulatory pH monitoring

Gastroesophageal reflux (GER) has been implicated in otolaryngologic problems, particularly chronic hoarseness that cannot be attributed to other causes. To study this relationship, we used 24-h ambulatory intraesophageal or dual pharyngoesophageal pH monitoring in 33 patients with chronic hoarseness and laryngeal lesions suggestive of acid irritation. Twenty-six of the patients (78.8%) had pH evidence of severe GER, being at least three times greater than the upper limit of normal. In contrast to 19 patients with proven esophagitis, this GER was worse in the upright position. Of 15 patients with both pharyngeal and esophageal probes, three had esophagopharyngeal reflux, and two had atypical unexplained pharyngeal decreases in pH to below 4.0. Less than half of the 33 patients had the typical symptoms of GER, and standard esophageal tests usually yielded normal findings. Occult GER, predominantly in the upright position, appears to be common and severe in patients with chronic hoarseness, who have laryngeal lesions suggestive of GER. The causative mechanisms are not clear. The 24-h esophageal pH monitor is useful in screening this potentially treatable problem.     

Severity of acid gastroesophageal reflux assessed by pH metry: Is it associated with respiratory disease?

About 50% of children with chronic respiratory diseases (RD) have "silent" gastroesophageal reflux (GER). Our purpose was to evaluate the possibility that RD in patients with GER reflects the presence of more severe acid reflux. We compared the severity of parameters from pH studies in children with chronic RD and "silent" GER, to children with signs of symptomatic gastrointestinal (GI) GER with and without RD. This study included 236 children (aged 1 month to 15 years) with abnormal 24-hr pH monitoring among 718 patients studied for suspected diagnosis of GER. Patients were divided into three groups. Group 1 consisted of children with chronic RD but without any GI symptoms of GER. Group 2 was comprised of children with symptomatic GI presentation of GER such as regurgitation, vomiting, heartburn, and failure to thrive, but without any signs or symptoms of RD. Group 3 included children with prevalent RD and concomitant signs of symptomatic GER. Patients with predominant GI manifestations (group 2) had a significantly higher fraction of time with pH <4 (P < 0.01), total time value of pH <4 (P < 0.05), and longest episode with pH <4 (P < 0.05). Esophageal clearance was significantly longer in group 1 patients than in the other two groups (P < 0.05). Patients with mixed disease (group 3) were similar to patients in group 2. Patients with GI symptoms had significantly worse scores for all parameters evaluated except esophageal clearance score, compared to patients without GI symptoms. Longer esophageal clearance was the only parameter associated with respiratory signs in patients with respiratory symptoms compared to those without. In conclusion, the presence of RD in pediatric patients with silent GER is related to longer esophageal clearance, but is not related to severity of reflux.     

十二指肠球部溃疡伴胃食管反流患者食管动力及胃内pH值监测

目的：探讨胃食管反流(GER)常见于十二指肠球部溃疡的原因。方法：选择近5年我院接受胃食管动力检查并行胃镜检查明确诊断为十二指肠球部溃疡的患者46例。食管pH监测胃食管酸反流阳性或胃镜检查存在反流性食管炎(RE)者为反流组，食管pH值监测胃食管酸反流阴性者为非反流组。比较两组食管下括约肌(IES)、食管体部及食管上括约肌(UES)等功能差别，同时对两组胃pH值监测进行比较。结果：十二指肠球部溃疡患者为GER／RE的高发人群，反流组与非反流组LES长度、功能压、食管体部清除功能、UES静息压比较差异无显著性。反流组每日不同时限胃酸分泌高于非反流组。结论：十二指肠球部溃疡易合并GER／RE与胃酸增高有关，与食管动力变化关系不大。     

Chronic cough caused by gastroesophageal reflux]

We reported a case of chronic cough due to gastroesophageal reflux (GER). The patient was a 29-year-old woman who had suffered from persistent chronic cough for more than 3 years. She had been treated with high doses of inhaled steroids, oral bronchodilators, and oral corticosteroids on a presumed diagnosis of asthma. However, her cough was not alleviated by these treatments, and the patient was referred to our hospital. She did not exhibit typical GER symptoms except for belch. Although esophagoscopy did not disclose reflux esophagitis, esophageal pH monitoring revealed acid reflux 7 to 8 times higher than the reference value. The patient was treated with a proton-pump inhibitor, which markedly alleviated her cough. Chronic cough due to GER was diagnosed. Although the incidence of chronic cough due to GER was thought to be rare in Japan, the findings in our case report underscored the importance of this association to the differential diagnosis of chronic cough.     

The acid perfusion test in gastroesophageal reflux disease

An acid perfusion test, isotope scanning, endoscopy, and esophageal biopsy were performed in 101 patients with symptoms strongly suggestive of gastroesophageal reflux (GER) disease. A positive acid perfusion test within 30 min (APT) and within 5 min (TAPT) was found in 70.2% and 37.6% of the patients, respectively. A positive APT was found significantly more often in patients with than without endoscopic esophagitis, whereas a positive TAPT was found significantly more often in patients with severe symptoms than in patients with moderate symptoms and in a significantly higher proportion of patients with than without GER by scintigraphy. Neither the APT nor the TAPT showed any dependency on the presence of histologic esophagitis. Most (97%) patients with a negative acid perfusion test, in addition to typical symptoms, also presented with scintigraphic, endoscopic, or histologic evidence of GER disease. Although it shows that the acid perfusion test, particularly when early positive, may serve as a weak predictor of the severity of GER disease, the present study gives little support to the test's clinical usefulness.     

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.     

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.     

Gastric Emptying in Patients with Severe Reflux Esophagitis

The pathogenesis of gastroesophageal reflux (GER) is not fully understood. There have been reports that delayed gastric emptying is a contributing factor in some patients. To determine whether delayed gastric emptying plays a role in the genesis of GER, we correlated gastric-emptying measures obtained by scintigraphic techniques with the degree of acid reflux assessed by esophageal pH monitoring. Ten patients, all of whom had evidence of esophageal mucosal disease and severe acid reflux, were studied. Four of the 10 patients with reflux had prolongation in the lag phase of gastric solid emptying, and one of the four showed prolonged gastric-emptying t1/2. There was no significant difference, however, in the mean gastric-emptying t1/2 between a control group and the patient group. Furthermore, there was no correlation between gastric-emptying measures and degree of acid reflux. We conclude that in this group of 10 patients with severe GER, delayed gastric emptying does not play an important role in the development of gastroesophageal reflux.     

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。     

Prolonged ambulatory esophageal pH monitoring in the evaluation of gastroesophageal reflux disease

Gastroesophageal reflux disease is a common problem that frequently presents with atypical complaints including nausea, hiccups, globus sensation, chest pain, hoarseness, coughing, or various pulmonary complaints. Diagnosis may be difficult, as these patients often do not have radiographic or endoscopic evidence of esophagitis. In these difficult cases, prolonged esophageal pH monitoring provides an accurate method of quantitating acid reflux parameters and correlating symptoms with reflux episodes in an outpatient setting. Current equipment is compact, durable, and not difficult to use or extremely expensive. Data analysis, with a particular emphasis on acid-exposure time (total, upright, supine), reliably discriminates between abnormal and normal subjects but it is not a perfect "gold standard" for gastroesophageal reflux disease. Indications for esophageal pH monitoring include: (1) atypical symptoms of acid reflux with normal endoscopy, (2) typical reflux symptoms unresponsive to medical therapy, and (3) the follow-up of reflux disease after either medical or surgical therapy. This test is currently performed primarily by gastroenterologists, but we believe many other groups may find this technology helpful. To meet these expanding applications, test refinements are necessary, particularly easier methods of placing the pH probe and better standards for defining abnormal pH parameters in older patients. The future for esophageal pH monitoring is bright. This technology has the potential to do for the diagnosis of gastroesophageal reflux disease what endoscopy has done for the diagnosis of peptic ulcer disease.     

支气管哮喘患者与胃食管返流的症状相关性

目的　探讨胃食管返流 (GER)与成人中、重度支气管哮喘的症状相关性 ,了解 2 4h食管pH监测对哮喘合并GER的诊断价值及抗返流治疗对合并GER的哮喘患者症状的影响。方法　对 2 6例常规治疗后仍有顽固性咳嗽等症状的成人哮喘患者进行 2 4h食管pH监测 ,严格记录监测期间患者出现的各种症状 ,每小时记录 1次呼气峰流速 (PEF)。筛选出适当病例分组抗返流治疗并观察疗效。结果　 2 6例中有 15例DeMeester总积分≥ 14 72 ,2例虽DeMeester总积分 <14 72 ,但咳嗽与返流的症状相关概率 (SAP)≥ 95 % ,共筛选出 17例。将 17例患者随机分为治疗组 (9例 )和对照组 (8例 )。经抗返流治疗后 ,治疗组咳嗽、胸闷和胸骨后烧灼感等症状均较对照组有明显改善 ,2 4hPEF波动率治疗前 [(3 8± 8) % ]、后 [(16± 3 ) % ]比较差异有显著性 (P <0 0 5 )。结论　 (1)中、重度支气管哮喘患者具有较高的GER发生率 (5 8% )。 (2 ) 2 4h食管pH监测有助于了解哮喘患者的症状与GER的相关性。 (3 )对于有GER并与哮喘症状密切相关的患者 ,抗返流治疗可显著地改善其症状及PEF波动率     

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.     

Characteristics and frequency of transient relaxations of the lower esophageal sphincter in patients with reflux esophagitis

Electromyogram of the submental muscles, esophageal manometry, and pH studies were simultaneously performed in an unselected group of 12 patients with subjective and objective evidence of gastroesophageal reflux (GER) disease to determine the frequency of transient relaxation of the lower esophageal sphincter (LES) and mechanisms of GER. Findings from these patients were compared with data from 10 asymptomatic healthy volunteers. Recordings were obtained for 1 h in the fasting state and 3 h after a standard 850-kcal meal. Transient relaxation of the LES was the only mechanism of acid reflux in normal subjects and accounted for 73.0% of the episodes of acid reflux in patients with GER disease. In both normal subjects and patients with GER, a large number of transient relaxations were associated at their onset with an attenuated submental EMG complex, a small pharyngeal contraction, and an esophageal contraction. The incidences of these associated events were similar in the two study populations. The frequency of transient relaxation of the LES in patients with GER was identical to that of controls. The frequency did not differ even in 9 patients with GER disease who had endoscopic esophagitis. Thirty-six percent of transient relaxations in the normal subjects were accompanied by pH evidence of reflux, but in the GER patients with endoscopic esophagitis 65% of the transient LES relaxations resulted in a reflux event. Acid reflux at the moment of deep inspiration was the second most common mechanism of GER in our patients. Four patients who demonstrated this mechanism had hiatal hernias and more severe esophagitis than the rest of the group. Our findings confirm that transient relaxation of the LES is the major mechanism of GER in patients with reflux esophagitis. However, the similar frequency of this relaxation in GER patients and in healthy asymptomatic subjects suggests that factors other than transient LES relaxation play an important role in the pathogenesis of GER disease.     

Gastroesophageal reflux symptoms not responding to proton pump inhibitor: GERD,NERD, NARD,esophageal hypersensitivity or dyspepsia?

Gastroesophageal reflux (GER) is a common gastrointestinal process that can generate symptoms of heartburn and chest pain. Proton pump inhibitors (PPIs) are the gold standard for the treatment of GER; however, a substantial group of GER patients fail to respond to PPIs. In the past, it was believed that acid reflux into the esophagus causes all, or at least the majority, of symptoms attributed to GER, with both erosive esophagitis and nonerosive outcomes. However, with modern testing techniques it has been shown that, in addition to acid reflux, the reflux of nonacid gastric and duodenal contents into the esophagus may also induce GER symptoms. It remains unknown how weakly acidic or alkaline refluxate with a pH similar to a normal diet induces GER symptoms. Esophageal hypersensitivity or functional dyspepsia with superimposed heartburn may be other mechanisms of symptom generation, often completely unrelated to GER. Detailed studies investigating the pathophysiology of esophageal hypersensitivity are not conclusive, and definitions of the various disease states may overlap and are often confusing. The authors aim to clarify the pathophysiology, definition, diagnostic techniques and medical treatment of patients with heartburn symptoms who fail PPI therapy.