Long-term ambulatory enterogastric reflux monitoring. Validation of a new fiberoptic technique

Development of a new endoscopy system to visualize bilirubin for the diagnosis of duodenogastroesophageal reflux

OBJECTIVES

Reflux hypersensitivity (RH) is a form of refractory gastroesophageal reflux disease in which duodenogastroesophageal reflux (DGER) plays a role. This study aimed to determine the usefulness of an endoscopy system equipped with image-enhanced technology for evaluating DGER and RH.

METHODS

The image enhancement mode for detecting bilirubin and calculated values were defined as the Bil mode and Bil value, respectively. First, the visibility of the Bil mode was validated for a bilirubin solution and bile concentrations ranging from 0.01% to 100% (0.002-20 mg/dL). Second, visibility scores of the Bil mode, when applied to the porcine esophagus sprayed with a bilirubin solution, were compared to those of the blue laser imaging (BLI) and white light imaging (WLI) modes. Third, a clinical study was conducted to determine the correlations between esophageal Bil values and the number of nonacid reflux events (NNRE) during multichannel intraluminal impedance-pH monitoring as well as the utility of esophageal Bil values for the differential diagnosis of RH.

RESULTS

Bilirubin solution and bile concentrations higher than 1% were visualized in red using the Bil mode. The visibility score was significantly higher with the Bil mode than with the BLI and WLI modes for 1% to 6% bilirubin solutions (P < 0.05). The esophageal Bil value and NNRE were significantly positively correlated (P = 0.031). The area under the receiver operating characteristic curve for the differential diagnosis of RH was 0.817.

CONCLUSION

The Bil mode can detect bilirubin with high accuracy and could be used to evaluate DGER in clinical practice.

Long-term (18 Years) Results of Patients With Long-segment Barrett Esophagus Submitted to Acid Suppression-duodenal Diversion Operation: Better Than Nissen Fundoplication?

OBJECTIVE

To determine late results of AS-DD procedure in long-segment (LSBE) and extralong-segment BE (ELSBE) using subjective and objective measurements to ascertain the histological impact over intestinal metaplasia (IM) and progression to EAC.

SUMMARY OF BACKGROUND DATA

Barrett esophagus (BE) is a known precursor of esophageal adenocarcinoma (EAC), and Nissen fundoplication has proven to be unable to stop mixed reflux among them. Our group proposed a surgical procedure that handles pathophysiological changes responsible for BE.

METHODS

This prospective study included 127 LSBE and ELSBE subjects submitted to clinical and functional analyses. They were presented to selective vagotomy, fundoplication, partial gastrectomy with Roux-en-Y reconstruction. The changes in IM were determined in both groups.

RESULTS

Follow-up was completed at a mean of 18 years in 81% of the cases. Visick I-II scores were seen in 88% of LSBE and 65% in ELSBE ( P < 0.01). There was significant healing of erosive esophagitis and esophageal peptic ulcers, and strictures were resolved in 71%. There was 38% of IM regression in LSBE. Two cases in each group progressed to EAC at a mean of 15 years. Pathologic acid reflux was abolished in 91% and duodenal in 100%. There was a regression of low-grade dysplasia to IM in 80%.

CONCLUSIONS

AS-DD permanently eliminates pathologic refluxate to the esophagus. The progression to HGD/EAC is lower compared to medical treatment, with an 8-fold reduction in LSBE and 2.2-fold in ELSBE. AS-DD seems to influence IM behaviors, and it is a tool that could reduce and delay progression to EAC.

Clinical practice guidelines for esophageal ambulatory reflux monitoring in Chinese adults

Esophageal ambulatory reflux monitoring is the current gold standard for the diagnosis of gastroesophageal reflux disease (GERD). In order to facilitate standardized procedure and improve diagnostic accuracy, clinical guidelines for ambulatory esophageal reflux monitoring were developed based on thorough literature search and working group conference by experts in gastrointestinal motility. Indications, contraindications, methodology, and reporting of ambulatory esophageal reflux monitoring were discussed in these clinical guidelines.

Bile reflux in patients with nerd is associated with more severe heartburn and lower values of mean nocturnal baseline impedance and chemical clearance

BACKGROUND

Mean nocturnal baseline impedance (MNBI) and postreflux swallow-induced peristaltic wave (PSPW) index are novel impedance-based markers of reflux, but the effect of bile reflux on these metrics is unknown. The aim of this study was to evaluate bile reflux, MNBI, and PSPW index in patients with endoscopy-negative GERD partially responsive to PPI therapy.

METHODS

All patients underwent off-PPI endoscopy, esophageal manometry, multichannel intraluminal impedance pH (MII-pH), and bile reflux monitoring. Abnormal esophageal acid exposure time (AET) was required for inclusion. Symptom intensity (using 10-cm visual analog scales), and conventional and novel MII-pH metrics were compared between patients with and without abnormal bile reflux.

KEY RESULTS

We evaluated 42 NERD patients (29 males, mean age: 53.4 ± 13. years), mean AET 6.1 ± 2%, of which 21 had abnormal bile reflux (Group A, 10.2 ± 4.9%), and 21 had normal bile reflux (Group B, 0.4 ± 0.1%, P < .05 compared with Group A). Heartburn reporting on PPI was higher in Group A (7.2 ± 2.1 vs 5.8 ± 0.9; P = .002), but AET, number of reflux events (acidic and weakly acidic), did not differ between the two groups. However, both PSPW index and MNBI were lower in Group A (P < .001). A strong inverse linear correlation was found between bile reflux and both MNBI (Pearson's test; R = -0.714; P < .001) and PSPW index (R = -0.722; P < .001).

CONCLUSIONS AND INFERENCES

Compared to acid reflux alone, the presence of bile in an acidic esophageal environment is associated with more severe heartburn, lesser relief from PPI therapy, higher impairment of esophageal mucosal integrity and less effective chemical clearance.

Improving the width of lossy mode resonances in a reflection configuration D-shaped fiber by nanocoating laser ablation

The full width at half maximum (FWHM) of lossy mode resonances (LMRs) in the optical spectrum depends on the homogeneity of the thin film deposited. In this Letter, a method for improving the FWHM is applied for an LMR generated by a D-shaped optical fiber in reflection configuration. For this purpose, three samples with different attenuation were deposited with DC sputtering thin films of SnO_2-x, and a further controlled immersion of the samples in water was performed. A laser-cleaner method was used to improve the FWHM characteristics of one of the samples from 106 to 53 nm. This improvement can be applied to thin-film-based sensors where there is a problem with the inhomogeneity of the coating thickness. Moreover, with this technique, it was proved that a coated length of just 3-4 mm permits the generation of an LMR, with implications for the miniaturization of the final device.

Analysis of major bile acids in saliva samples of patients with Barrett's esophagus using high-performance liquid chromatography-electrospray ionization-mass spectrometry

A fast, non-invasive, high-performance liquid chromatographic screening method with electrospray ionization mass spectrometric detection was developed for the analysis of three major glycine-conjugated bile acids in human saliva. Using a mobile phase composed of 80% methanol and 0.1% formic acid, glycocholic, glycodeoxycholic, and glycochenodeoxycholic acids were separated in less than 4 minutes with sensitivity in the low nM range. Bile acids are thought to contribute to the pathology of various complications in gastroesophageal reflux disease, for instance, Barrett's esophagus, which may eventually lead to esophageal carcinoma. In this pilot study, samples of saliva obtained from 15 patients with Barrett's esophagus of various severities were compared to saliva samples from 10 healthy volunteers. Glycochenodeoxycholic acid was significantly elevated in the patients and principal component analysis of all bile acids could distinguish the most severe Barrett's esophagus patients. We also reported on the detection of glycochenodeoxycholic acid in exhaled breath condensate for the first time. The promising results of this pilot study warrant future investigation, aiming at non-invasive diagnostics of Barrett's esophagus susceptibility in patients with gastroesophageal reflux disease.

Barrett's esophagus: "All diseases are divine and all are human"

Barrett's esophagus (BE) is a controversial condition. The significance of this condition lies in its premalignant potential, so it is important that clinically applicable biomarkers be identified for early detection and targeted prevention. Dysplasia is currently used as main biomarker, but others most recently surveyed in cancer also include microRNAs. Classically, BE was considered to be an acquired disease related to pathological gastroesophageal acid and bile reflux. However, some cases are associated with genetic predisposition, representing an inherited, familial form of BE. The actual gene, or genes, involved in this condition have not yet been identified. Main therapeutic options include medical treatment and antireflux surgery. Both types of treatment are equally efficient in controlling symptoms and neither is able to cause the metaplastic segment to disappear, which is why the risk of malignancy remains. However, we may use endoscopic radiofrequency to eradicate BE and replace it by the typical squamous epithelium of the esophagus. The currently accepted indications of radiofrequency in BE include low- and high-grade dysplasia, but not Barrett's esophagus without dysplasia. In conclusion, BE may have two different presentations: environmental ("human", reflux) or sporadic BE, which is the most common form, and genetic ("divine", inherited) or familiar BE, less common but with a greater risk for malignancy. As they might be two different diseases, surveillance programs and treatments should also be different.

The impact of cervical lymph node dissection on acid and duodenogastroesophageal reflux after intrathoracic esophagogastrostomy following transthoracic esophagectomy

PURPOSE

The aim of this study was to evaluate the impact of cervical lymph node dissection on acid reflux and duodenogastroesophageal reflux (DGER) in patients undergoing transthoracic esophagectomy with gastric tube reconstruction and intrathoracic esophagogastrostomy.

METHODS

Thirty-one patients receiving transthoracic esophagectomy with gastric tube reconstruction by intrathoracic esophagogastrostomy were divided into the following two groups: a two-field lymph node dissection group (2F group) and a three-field lymph node dissection group (3F group). All patients underwent 24-h pH and bilirubin monitoring and gastrointestinal endoscopy at 1 year after surgery. The 24-h pH and bilirubin monitoring results, endoscopic findings, and reflux symptoms were compared between the 2 groups.

RESULTS

No acid reflux was observed in the 2F group, whereas it was observed in 6 (40%) patients in the 3F group (p = 0.007). DGER was found in 2 patients (13%) in the 2F group and in 8 (53%) in the 3F group (p = 0.023). Four patients (25%) in the 2F group and 9 (60%) in the 3F group (p = 0.048) had reflux esophagitis.

CONCLUSION

Cervical lymph node dissection increases acid reflux and DGER and can lead to an increase in the incidence of reflux esophagitis in patients undergoing intrathoracic esophagogastrostomy.

Detecting Bile Reflux-the Enigma of Bariatric Surgery

Duodeno-gastro-esophageal reflux, or bile reflux, is a condition for which there is no diagnostic gold standard, and it remains controversial in terms of carcinoma risk. This is pertinent in the context of an increasingly overweight population who are undergoing weight-loss operations that theoretically further increase the risk of bile reflux. This article reviews investigations for bile reflux based on efficacy, patient tolerability, cost, and infrastructure requirements. At this time, whilst no gold standard exists, hepatobiliary scintigraphy is the least invasive investigation with good-patient tolerability, sensitivity, and reproducibility to be considered first-line for diagnosis of bile reflux. This review will guide clinicians investigating bile reflux.

Diagnostic yield of ambulatory oesophageal studies on versus off proton pump inhibitors: a systematic review and meta-analysis

BACKGROUND

Patients with persistent gastroesophageal reflux disease symptoms despite proton pump inhibitors are increasingly encountered. It remains controversial if proton pump inhibitors should be stopped before functional oesophageal tests.

AIM

This meta-analysis compares the positive yield of oesophageal studies performed off versus on proton pump inhibitors.

METHODS

Pubmed, Embase and the Cochrane Library were searched for eligible studies. Outcomes assessed were the number of subjects with: elevated oesophageal acid exposure time when studied off versus on proton pump inhibitors; positive symptom index (≥50%) and/or positive symptom association probability (≥95%) for acid reflux; and/or non-acid reflux events off versus on proton pump inhibitors. The random effects model was applied.

RESULTS

Fifteen studies (n = 5033 individuals; 33% on proton pump inhibitors; 32% men; mean age 52.1 years) were analysed. Pooled risk ratio for the comparison of high oesophageal acid exposure time off versus on proton pump inhibitors was 2.16 (95% confidence interval (CI) 1.42-3.28). The risk ratio of a positive symptom index (acid reflux) was 2.64 (95% CI 1.52-4.57) and the risk ratio of a positive symptom association probability (acid reflux) was 2.94 (95% CI 2.31-3.74). Conversely, the risk ratio of a positive symptom index (non-acid reflux) was 0.96 (95% CI 0.49-1.88) and risk ratio of a positive symptom association probability (non-acid reflux) was 0.54 (95% CI 0.30-0.99).

CONCLUSIONS

Oesophageal studies after proton pump inhibitor cessation improve the positive yield for acid reflux-related events but reduce the detection of symptomatic non-acid reflux events.

The Impact of the Location of Esophagogastrostomy on Acid and Duodenogastroesophageal Reflux After Transthoracic Esophagectomy with Gastric Tube Reconstruction and Intrathoracic Esophagogastrostomy

BACKGROUND

The aim of this study was to evaluate the impact of the location of esophagogastrostomy on acid and duodenogastroesophageal reflux (DGER) in patients undergoing gastric tube reconstruction and intrathoracic esophagogastrostomy.

METHODS

Thirty patients receiving transthoracic esophagectomy without cervical lymph node dissection and gastric tube reconstruction by intrathoracic anastomosis were enrolled. All patients underwent 24-h pH and bilirubin monitoring and gastrointestinal endoscopy one year after surgery. Patients were divided into three groups according to esophagogastrostomy location: group A (n = 9), above the top of the aortic arch; group B (n = 15), between the top and bottom of the aortic arch; and group C (n = 6), below the bottom of the aortic arch. The relations among the esophagogastrostomy location, 24-h pH and bilirubin monitoring results, endoscopic findings, and reflux symptoms were investigated.

RESULTS

No acid reflux into the remnant esophagus was observed in group A, whereas it was observed in three of 15 patients (20%) in group B and in two of six patients (33%) in group C (P = 0.139). No DGER was found in group A, whereas DGER was observed in eight (53%) patients in group B and all patients in group C (P < 0.001). Reflux esophagitis was observed in one patient (11%) in group A, five patients (33%) in group B, and all patients in group C (P = 0.002).

CONCLUSION

In gastric tube reconstruction via intrathoracic anastomosis, esophagogastrostomy should be performed above the top of the aortic arch to prevent postoperative DGER and reduce the incidence of reflux esophagitis.

Optical sensing in POCT: the contribution of the Institute of Applied Physics of the Italian CNR

The activity developed at the Institute of Applied Physics “Nello Carrara” in strict collaboration with physicians is described with particular attention to the measurement of bile-containing refluxes in the gastroesophageal apparatus, to the detection of gastric carbon dioxide in intensive care patients, to the measurement of sepsis biomarkers in serum samples and to the measurements of immunosuppressants in transplanted patients.

The laparoscopic hiatoplasty with antireflux surgery is a safe and effective procedure to repair giant hiatal hernia

Background

Although minimally invasive repair of giant hiatal hernias is a very surgical challenge which requires advanced laparoscopic learning curve, several reports showed that is a safe and effective procedure, with lower morbidity than open approach. In the present study we show the outcomes of 13 patients who underwent a laparoscopic repair of giant hiatal hernia.

Methods

A total of 13 patients underwent laparoscopic posterior hiatoplasty and Nissen fundoplication. Follow-up evaluation was done clinically at intervals of 3, 6 and 12 months after surgery using the Gastro-oesophageal Reflux Health-Related Quality of Life scale, a barium swallow study, an upper gastrointestinal endoscopy, an oesophageal manometry, a combined ambulatory 24-h multichannel impedance pH and bilirubin monitoring. Anatomic recurrence was defined as any evidence of gastric herniation above the diaphragmatic edge.

Results

There were no intraoperative complications and no conversions to open technique. Symptomatic GORD-HQL outcomes demonstrated a statistical significant decrease of mean value equal to 3.2 compare to 37.4 of preoperative assessment (p < 0.0001). Combined 24-h multichannel impedance pH and bilirubin monitoring after 12 months did not show any evidence of pathological acid or non acid reflux.

Conclusion

All patients were satisfied of procedure and no hernia recurrence was recorded in the study group, treated respecting several crucial surgical principles, e.g., complete sac excision, appropriate crural closure, also with direct hiatal defect where possible, and routine use of antireflux procedure.

Histological features of the gastric mucosa in children with primary bile reflux gastritis

BACKGROUND

Bile reflux is one of the primary factors involved in the pathogenesis of gastric mucosal lesions in patients with chronic gastritis; however, little is known about the exact histological features of bile reflux and its contributions to gastric mucosal lesions in this disease, especially in children with primary bile reflux gastritis (BRG). The aim of this study was to investigate the classic histological changes of the gastric mucosa in children with primary BRG.

METHODS

The Bilitec 2000 was used for 24 h monitoring of gastric bile in 59 children with upper gastrointestinal symptoms. The histological characteristics of the gastric mucosa were examined and scored.

RESULTS

Thirteen of the 59 patients had a helicobacter pylori infection and were excluded; therefore, 46 cases were included in this study. The positive rate of pathological duodenogastric reflux was significantly higher in patients with foveolar hyperplasia than those without foveolar hyperplasia; however, the rate was significantly lower in patients with vascular congestion than those without vascular congestion. The longest reflux time and the total percentage time of bile reflux were significantly lower in patients with vascular congestion than those without vascular congestion. A total of 9 types of histological changes were analyzed using a binary logistic regression. Foveolar hyperplasia and vascular congestion in the superficial layer became significant variables in the last step of the stepwise regression.

CONCLUSIONS

Foveolar hyperplasia was associated with the severity of bile reflux, suggesting that it is a histological feature of primary BRG in children, while vascular congestion may be a protective factor.

What influences the acidity in the gastric conduit in patients who underwent cervical esophagogastrostomy for cancer?

The aim of this study was to determine the factors influencing acidity in the gastric conduit after esophagectomy for cancer. Acidity and bile reflux in the stomach and in the gastric conduit were examined by 24-h pH monitoring and bilimetry in 40 patients who underwent transthoracic subtotal esophagectomy followed by esophageal reconstruction using a gastric conduit, which was pulled up to the neck through a posterior mediastinal route in 17 patients, through a retrosternal route in 10 patients, and through a subcutaneous route in 13 patients. They were examined at 1 week before surgery, at 1 month after surgery, and at 1 year after surgery. Helicobacter pylori infection was examined pathologically and using the (13) C-urea breath test. The factors influencing acidity of the gastric conduit were analyzed using the stepwise regression model. Gastric acidity assessed by percentage (%) time of pH < 4 was reduced after surgery and was significantly less in patients with H. pylori infection compared with those without H. pylori infection throughout the period from 1 week before surgery to 1 year after surgery. Duodenogastric reflux (DGR) assessed by % time absorbance > 0.14 into the lower portion of the gastric conduit was significantly increased after surgery throughout the period from 1 month after surgery to 1 year after surgery. Multivariate analysis showed that the acidity in the gastric conduit was influenced by H. pylori infection and DGR at 1 month after surgery, and by H. pylori infection and the route for esophageal reconstruction at 1 year after surgery. Acidity in the gastric conduit was significantly decreased after surgery. Acidity in the gastric conduit for esophageal substitutes is influenced by H. pylori infection and surgery. DGR influences the gastric acidity in the short-term after surgery, but not in the long-term after surgery.

Modulation of the postprandial acid and bile pockets at the gastro-oesophageal junction by drugs that affect gastric motility

BACKGROUND

Previous studies have established the presence of a postprandial acid pocket at the gastro-oesophageal junction.

AIMS

To investigate whether altering gastric motility would affect the location and the extent of postprandial acid pockets in healthy volunteers and also to study the presence of bile in this pocket.

METHODS

A total of 16 healthy volunteers underwent pH and Bilitec probe stepwise pull-through to measure regional differences in pH and bile absorbance before and 10, 30 and 50 min after a liquid meal. At the start of the meal, saline, erythromycin or sumatriptan was administered.

RESULTS

After saline, ingestion of a meal induced an acid pocket, with a mean pH drop of 2.26 (compared to 0.25 before the meal, P < 0.05) and a nadir pH of 2.71. The acid pocket persisted 30 and 50 min postprandially (pH drops 1.59 and 1.68 and nadir pH 3.17 and 2.52 respectively). Compared with saline, erythromycin significantly suppressed the pH drop and nadir pH (on average 0.66 and 3.4 at 10 min; comparable patterns at 30 and 50 min). After sumatriptan a significantly lower nadir pH was observed at 30 and 50 min (respectively 2.02 and 1.74, P < 0.05 compared with saline). A postprandial bile pocket was noted in 50% of pull-throughs after saline, compared to 78% after erythromycin and 31% after sumatriptan.

CONCLUSIONS

The presence of a bile pocket in a subset of the subjects confirms the heterogeneity of postprandial intragastric contents. Erythromycin disrupts the acid pocket but increases the presence of bile, while sumatriptan has opposite effects.

Combined lung-sound and reflux-monitoring: a pilot study of a novel approach to detect nocturnal respiratory symptoms in gastro-oesophageal reflux disease

BACKGROUND

Increased prevalence of respiratory symptoms has been commonly reported in patients with gastro-oesophageal reflux disease (GERD).

AIM

To introduce a novel Lung-Sound-Monitoring device that allows simultaneous measurement of both nocturnal respiratory symptoms and episodes of acidic and biliary refluxes.

METHODS

Nocturnal respiratory symptoms (coughing and wheezing) were continuously recorded in 20 healthy subjects and 30 reflux patients with respiratory symptoms in parallel to combined pH-monitoring and Bilitec measurement.

RESULTS

Analysis could be completed in 20 healthy subjects and in 25 patients with reflux. A clear temporal correlation to reflux phases was detected in 49% of coughing and 41% of wheezing events, respectively. Moreover, 89% of the coughing and 100% of the wheezing events succeeded reflux episodes. Finally, the technique was capable of assessing a statistically significant difference between patients and controls regarding the occurrence of these symptoms.

CONCLUSIONS

Our pilot study establishes the Lung-Sound-Monitoring system as a unique tool to measure objectively the temporal correlation between gastroesophageal reflux and the appearance of respiratory symptoms. It represents a useful technique to identify patients with respiratory symptoms due to reflux, and therefore allows one to determine and quantify the impact of therapeutic interventions such as antireflux therapy on respiratory symptoms.

The refluxate: The impact of its magnitude, composition and distribution

The pathogenesis of gastrointestinal reflux disease is multifactoral. Integral to the disease process is the refluxate itself. The characteristics and composition of the refluxate are dependent on several physiological variables. The refluxate may contain varying concentrations of acid, pepsin, gas, or contents of duodenal reflux (such as bile acid and pancreatic enzymes). Characteristics such as volume and proximal extent of the refluxate, and the chemical content of this refluxate can strongly influence the risk of symptom perception. Strong acid (pH<4) and duodeno-gastro-oesophageal reflux are also implicated in the development of mucosal damage in the form of oesophagitis, Barrett's metaplasia and oesophageal adenocarcinoma. The manifestation of disease, however, is not entirely reliant on the refluxate, which must be considered in the context of the genetic, environmental and psychological susceptibility of the individual.

Emerging concepts of bile reflux in the constellation of gastroesophageal reflux disease

RATIONALE

Reflux of gastric and duodenal contents in patients with gastroesophageal reflux disease (GERD) has been postulated as a major cause of complications, such as Barrett's esophagus or malignant degeneration.

FINDINGS

We present a summary of experimental, clinical, and immunohistochemical studies that show that acid and bile reflux are increased in patients who suffer from GERD, are the key factor in the pathogenesis of Barrett's esophagus, and are possibly related to the development of esophageal adenocarcinoma.

Gastroesophageal reflux disease: medical or surgical treatment?

Background. Gastroesophageal reflux disease is a common condition with increasing prevalence worldwide. The disease encompasses a broad spectrum of clinical symptoms and disorders from simple heartburn without esophagitis to erosive esophagitis with severe complications, such as esophageal strictures and intestinal metaplasia. Diagnosis is based mainly on ambulatory esophageal pH testing and endoscopy. There has been a long-standing debate about the best treatment approach for this troublesome disease. Methods and Results. Medical treatment with PPIs has an excellent efficacy in reversing the symptoms of GERD, but they should be taken for life, and long-term side effects do exist. However, patients who desire a permanent cure and have severe complications or cannot tolerate long-term treatment with PPIs are candidates for surgical treatment. Laparoscopic antireflux surgery achieves a significant symptom control, increased patient satisfaction, and complete withdrawal of antireflux medications, in the majority of patients. Conclusion. Surgical treatment should be reserved mainly for young patients seeking permanent results. However, the choice of the treatment schedule should be individualized for every patient. It is up to the patient, the physician and the surgeon to decide the best treatment option for individual cases.

Esophageal motility in nonacid reflux compared with acid reflux

Esophageal motility has been well studied in gastroesophageal reflux disease (GERD) and acid reflux, but not in nonacid reflux. Consecutive patients who had both 24-h multichannel intraluminal impedance-pH (MII-pH) and esophageal motility tests for suspected GERD were studied. Patients were grouped into nonacid refluxers, acid refluxers, and nonrefluxers based on positive symptom correlation and objective findings of acid reflux. Of 96 patients enrolled, 21 patients (22%) were nonacid refluxers, 44 patients (46%) were acid refluxers, and 31 patients (32%) had no objective evidence of reflux. Normal motility was recorded in 86% of nonacid refluxers, 71% of acid refluxers, and 60% of nonrefluxers. Ineffective esophageal motility was seen in 24% of acid refluxers, and 5% of nonacid refluxers (P = 0.11). Symptomatic nonacid reflux events comprised 22% of patients studied for GERD symptoms by MII-pH. Esophageal motility in nonacid reflux is normal 86% of the time.

Comparison of gastroesophageal reflux in 100 patients with or without prior gastroesophageal surgery

BACKGROUND AND PURPOSE

The role of duodenogastroesophageal reflux (DGER) in gastroesophageal reflux disease (GERD) remains controversial. Few studies of reflux have compared patients with an intact stomach to those without intact stomach after gastroesophageal surgery. This study aimed to investigate differences of the refluxate between patients with and without prior gastroesophageal surgery and to assess the role of DGER in GERD.

METHODS

One hundred patients (34% with reflux symptoms) were divided into four groups: 23 with an intact stomach, and 27, 42, and 8 with esophagectomy followed by gastric tube reconstruction, distal gastrectomy, and total gastrectomy, respectively. Reflux symptoms were evaluated, and endoscopy and simultaneous 24-h monitoring of esophageal pH and bilirubin were performed.

RESULTS

Of 44 patients with increased DGER but without increased acid reflux, three had severe reflux esophagitis and seven had Barrett's esophagus. DGER was most frequent under weakly acidic conditions in the intact stomach, esophagectomy, and distal gastrectomy groups. Pure acid reflux and DGER at any pH were elevated in GERD patients with an intact stomach, while weakly acidic and alkaline DGER were elevated in GERD patients after gastrectomy. Esophagectomy patients had reflux with the combined characteristics of those in the intact stomach and gastrectomy groups. Weakly acidic or alkaline DGER was correlated with symptoms and esophageal mucosal changes in gastrectomy patients.

CONCLUSION

The refluxate causing GERD differed between patients with and without prior gastroesophageal surgery. Weakly acidic or alkaline DGER may cause both symptoms and esophageal mucosal damage.

Comparison of the degree of duodenogastroesophageal reflux and acid reflux between patients who failed to respond and those who were successfully treated with a proton pump inhibitor once daily

OBJECTIVES

The objective of this study was to compare the degree of esophageal acid exposure and duodenogastroesophageal reflux (DGER) during treatment between gastroesophageal reflux disease (GERD) patients who responded fully to proton pump inhibitor (PPI) once a day and those who failed to respond.

METHODS

Gastroesophageal reflux disease patients who continued to report symptoms 3 times a week for 3 months while on PPI once a day were assigned to the PPI failure group. GERD patients who were asymptomatic on PPI once a day for 3 months were assigned to the PPI success group. All patients underwent upper endoscopy to assess esophageal mucosal injury. Subsequently, all patients underwent simultaneous 24-h esophageal Bilitec 2000 and pH testing while on treatment. Patients recorded GERD-related symptoms during the test.

RESULTS

Twenty-four patients were enrolled in the PPI failure group and 23 patients were enrolled in the PPI success group. Endoscopy was normal in 63% of PPI failure patients and 76% of PPI success patients. Abnormal DGER was documented in 82% of PPI success patients vs. 67% of PPI failure patients (P=NS). All pH testing and Bilitec parameters in the PPI failure group were similar to those in the PPI success group (P=NS). Of the 34 GERD symptoms recorded by the PPI failure group, 64% were associated with acid reflux and 41% were associated with DGER (P<0.05).

CONCLUSIONS

There is no difference in the degree of DGER and acid exposure during treatment between patients who failed to respond and those who achieved complete symptom resolution on PPI once daily. GERD symptoms in the PPI failure group are more commonly associated with acid reflux than with DGER.

Effects of half-solid nutrients on gastroesophageal reflux in beagle dogs with or without cardioplasty and intrathoracic cardiopexy

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has become an important modality to provide enteral access for long-term nutritional support. Nevertheless, aspiration of liquid nutrients due to vomiting and reflux esophagitis caused by gastroesophageal reflux (GER) is a significant problem associated with tube feeding by PEG.

MATERIALS AND METHODS

First, gastrostomy as an access for enteral nutrition and esophagostomy for gastroesophageal pH and Bilitec monitoring were performed in eight beagle dogs, in which the influence of viscosity of an enteral formula on the degree of GER was investigated using a commercially available liquid meal and a nearly isocaloric half-solid diet that was prepared by adding a solution mixed with dextrin, pectin, and calcium lactate. Second, similar studies were accomplished in seven beagle dogs that underwent cardioplasty and intrathoracic cardiopexy (a model of GER disease [GERD]).

RESULTS

There was no difference in the degree of GER evaluated by Bilitec monitoring between liquid and half-solid nutrients in eight normal dogs, whereas solidifying nutrients significantly reduced the frequency of reflux during the feeding periods (P=0.0180) and post-feeding periods (P=0.0277) in a model of GERD.

CONCLUSION

The use of half-solid nutrients for enteral feeding reduced the frequency of reflux in a dog model of GERD.

Prevalence of bile reflux in gastroesophageal reflux disease patients not responsive to proton pump inhibitors

AIM: To determine the prevalence and characteristics of bile reflux in gastroesophageal reflux disease (GERD) patients with persistent symptoms who are non-responsive to medical therapy.

METHODS: Sixty-five patients (40 male, 25 female; mean age, 50 ± 7.8 years) who continued to report symptoms after 8 wk of high-dose proton pump inhibitor (PPI) therapy, as well as 18 patients with Barrett’s esophagus, were studied. All patients filled out symptom questionnaires and underwent endoscopy, manometry and combined pH-metry and bilimetry.

RESULTS: There were 4 groups of patients: 22 (26.5%) without esophagitis, 24 (28.9%) grade A-B esophagitis, 19 (22.8%) grade C-D and 18 (21.6%) Barrett’s esophagus. Heartburn was present in 71 patients (85.5%) and regurgitation in 55 (66.2%), with 44 (53%) reporting simultaneous heartburn and regurgitation. The prevalence of pathologic acid reflux in the groups without esophagitis and with grades A-B and C-D esophagitis was 45.4%, 66.6% and 73.6%, respectively. The prevalence of pathologic bilirubin exposure in these 3 groups was 53.3%, 75% and 78.9%, respectively. The overall prevalence of bile reflux in non-responsive patients was 68.7%. Pathologic acid and bile reflux was observed in 22.7% and 58.1% of non-esophagitic patients and esophagitic patients, respectively.

CONCLUSION: The high percentage of patients poorly responsive to PPI therapy may result from poor control of duodenogastroesophageal reflux. Many patients without esophagitis have simultaneous acid and bile reflux, which increases with increasing esophagitis grade.

Bile and acid reflux in the pathogenesis of reflux oesophagitis in children

AIM

The aim of this study was to investigate the role of bile and acid reflux in the pathogenesis of reflux oesophagitis (RE) in children.

METHODS

A total of 44 patients aged 5-17 years with gastro-oesophageal reflux symptoms were enrolled. Simultaneous 24-h oesophageal Bilitec 2000 (Medtronic Instruments, Minneapolis, MN, USA) bilirubin monitoring and pH monitoring, in biopsy of oesophageal mucosa by gastro-endoscopy, were performed in all patients.

RESULTS

According to the diagnostic criteria of pathological acid reflux and pathological bile reflux, 10 of 44 cases (22.7%) had acid reflux, 10 (22.7%) had isolated bile reflux, 16 (36.4%) had mixed acid and bile reflux, and the other eight (18.2%) had no reflux. Significant difference was observed in the ratio of different patterns of reflux between the RE group (26 cases) and the non-erosive reflux disease (NERD) group (18 cases) (chi(2) = 9.096, P < 0.01). All the parameters of acid reflux in the RE group were higher significantly than that in the NERD group (P < 0.05 or P < 0.01). A total of 20 out of 26 cases (76.9%) with RE had oesophageal acid reflux as against six out of 18 cases (33.3%) in patients with NERD (P < 0.01). The difference of each parameter of bile reflux had not reached significance between the two groups.

CONCLUSIONS

Mixed reflux is the predominant form of reflux in the causation of oesophageal mucosal injury in children. Isolated bile reflux also plays a role in the development of RE, although only in patients without acid reflux.

Ambulatory monitoring of GERD: current technology

Various techniques have been devised to diagnose, characterize, and classify gastroesophageal reflux (GER). Stationary techniques, such as fluoroscopy and scintigraphy, provide interesting anatomic and functional information related to GER but are not sensitive enough and are usually performed in nonphysiologic conditions. Ambulatory techniques for GER monitoring have been developed and used since 1974. The current available techniques include catheter and wireless pH-metry, Bilitec, and impedance-pH monitoring. Prolonged wireless pH monitoring can be useful to evaluate patients off and on proton pump inhibitor (PPI) treatment. Impedance-pH monitoring is being used increasingly in patients who have persistent symptoms on PPI therapy because it can establish an association between symptoms and weakly acidic or nonacid reflux. Bilitec is performed in patients suspected to have increased duodenogastroesophageal reflux (DGER). This article discusses the technical details, clinical indications, and applications of these diagnostic techniques.

NERD, GERD, and Barrett's esophagus: role of acid and non-acid reflux revisited with combined pH-impedance monitoring

INTRODUCTION

Gastroesophageal reflux is the most important factor in the development of Barrett's metaplasia. The effect of acid reflux is commonly accepted today, but there is controversy about the role of non-acid reflux. With introduction of combined esophageal pH-impedance monitoring, a precise diagnostic test for acid and non-acid reflux is now available.

METHODS

Ninety two consecutive patients (33 women) off acid-suppressive therapy underwent diagnostic work-up for suspected gastroesophageal reflux disease including upper-GI endoscopy, esophageal manometry, barium swallow, and combined esophageal pH-impedance monitoring. Patients were subdivided into three groups according to symptoms and endoscopic appearance: typical symptoms without esophagitis (n = 28; NERD); erosive esophagitis (n = 52, ERD), and patients with intestinal metaplasia (n = 12, BE).

RESULTS

Pathologic acid reflux during pH-metry was found in 35.7%, 63.5%, and 75.0% for NERD, ERD, and BE patients, respectively (P = 0.022). Likewise, the percentage of time pH < 4 rose significantly during upright, supine, and total phases. In contrast, combined pH-impedance monitoring showed no significant difference between groups for the number of acid reflux events and for percentage of acid bolus reflux time. However, BE patients had significantly more non-acid reflux events and a higher percentage of non-acid bolus reflux time during the supine (P = 0.043, P = 0.020, respectively), but not during the upright phase (P = 0.740, P = 0.730, respectively).

CONCLUSION

Patients with BE are exposed to increased supine non-acid reflux and to increased acid reflux during upright and supine phases. This observation supports the concept that nocturnal non-acid reflux may play a role in the pathogenesis of BE.

Prevalence of pathological duodenogastric reflux and the relationship between duodenogastric and duodenogastrooesophageal reflux in chronic gastrooesophageal reflux disease

The role of duodenogastric reflux in gastrooesophageal reflux disease is still controversial.

AIMS

(i) To determine the prevalence of pathological duodenogastric reflux (DGR) in gastrooesophageal reflux disease patients and (ii) to define the relationship between DGR and duodenogastrooesophageal reflux.

METHODS

We evaluated 92 patients referred for investigation of recurrent reflux symptoms after proton pump inhibitors (PPI) therapy. All the patients filled out symptom questionnaires and underwent endoscopy, oesophageal manometry and combined oesophagogastric pH and bilirubin monitoring.

RESULTS

Endoscopy divided the 92 patients into four groups (group I: 25 nonoesophagitis patients, group II: 26 patients with grade A-B oesophagitis, group III: 21 patients with grade C-D oesophagitis and group IV: 20 patients with Barrett's oesophagus. Twenty-four of the 92 patients (26%) showed pathological DGR. Abnormal oesophageal bilirubin exposure was observed in 62 of the 92 patients (67.4%). Of the 62 patients with abnormal oesophageal bilimetry, 15 (24.2%) patients simultaneously showed pathological DGR. The gastric bilirubin exposure in patients with abnormal oesophageal, Bilitec tests did not differ from that in patients with normal oesophageal bilimetry (P>0.05). A weak correlation between oesophageal and gastric bilirubin exposure, both expressed as a percentage of time, was found (r=0.28; P<0.01).

CONCLUSION

Pathological DGR is present in a little more than a quarter of patients with recurrent reflux and dyspeptic symptoms after PPI therapy. Excessive DGR is not a prerequisite for pathological oesophageal exposure to duodenal contents. Gastric bilirubin monitoring may be useful to choose the best surgical treatment for patients with reflux and dyspeptic symptoms refractory to PPI.

Yield of 24-hour esophageal pH and bilitec monitoring in patients with persisting symptoms on PPI therapy

Current management algorithms propose pH monitoring under proton pump inhibitors (PPIs) in suspected gastroesophageal reflux disease (GERD) with insufficient treatment response, but recent observations challenge this approach because of its low yield.

AIM

To perform an audit of the outcomes of pH monitoring under PPI therapy in our unit, and to study the yield of additional nonacid reflux monitoring.

METHODS

All pH monitoring studies under antireflux therapy since 1997, with or without simultaneous Bilitec monitoring, were analyzed.

RESULTS

From 1997 to 2003, 347 patients (157 men, mean age 49.4 +/- 0.8 years) underwent pH studies on PPI therapy (28% half-, 67% full-, and 5% double-dose PPI) for persisting typical (53%) or atypical (75%) symptoms. In 184 patients, simultaneous Bilitec monitoring was performed. Esophageal pH monitoring on PPI was pathological in 105 (30%) patients. Pathological pH monitoring on PPI was associated with typical reflux symptoms (64 versus 52%, P = 0.03), and a higher prevalence of persisting esophagitis (54 versus 36%, P < 0.005) and of hiatal hernia (58 versus 27%, P < 0.005). Bilitec monitoring on PPI therapy was pathological in 114 (62%) patients, of which 74 (40%) had normal pH monitoring. Adding Bilitec increased the rate of abnormal results over pH monitoring alone, from 38% to 69% on half-dose, from 27% to 69% on full-dose, and from 0% to 38% on double-dose PPI.

CONCLUSIONS

The rate of abnormal pH monitoring in symptomatic GERD patients while on PPI therapy is relatively low, especially in those on double-dose PPI. Combined pH and Bilitec monitoring significantly increased the rate of ongoing pathological reflux compared to pH alone in refractory to PPI therapy GERD patients.

New developments in gastroesophageal reflux disease diagnosis and therapy

PURPOSE OF REVIEW

Gastroesophageal reflux disease is a highly prevalent chronic condition in Western populations. It has a profound effect on our society in terms of economic cost and quality of life. There have been major advances in understanding of disease pathogenesis over the last few years which are summarized in this article.

RECENT FINDINGS

With improved understanding of gastroesophageal reflux disease, newer developments in diagnostic techniques have evolved. The proton pump inhibitor test has been formally described as one of the initial diagnostic tests. Other new tests include multiple channel impedance monitoring, bilirubin reflux monitoring, Barostat measurements and intraluminal ultrasounds which, along with other newer technologies, are described in this review.

SUMMARY

The mechanisms involved in the pathogenesis of gastroesophageal reflux disease are complex and multifactorial. The lower esophageal sphincter pressure, the motility of the esophageal body and the stomach, the composition of the reflux material and the sensitivity or resistance of the esophageal mucosa to the reflux material are important factors involved in the pathogenesis of disease-related symptoms and lesions. Based on our improving understanding, novel diagnostic tools are available to improve investigation of the disease.

Mechanisms of heartburn

Heartburn is a typical symptom of GERD. The spectrum of diseases associated with GERD includes reflux esophagitis, Barrett's esophagus and nonerosive reflux disease (NERD). Although acid reflux is the classic cause of heartburn in patients with erosive esophagitis, the relationship between acid and heartburn is far from clear, especially in patients with NERD. Strong evidence exists that weakly acidic reflux and/or non-acid-related events have a significant role in the generation of heartburn. In addition to the role of nonacidic refluxate components, activation of mechanoreceptors and chemoreceptors, and a possible role for central and peripheral sensitization, has been described. Although patients with erosive esophagitis respond well to acid-suppressive therapy, the same does not hold true for those with NERD. NERD represents a major clinical problem, and its management remains a challenge. Discussion of NERD focuses on the mechanisms that cause chest pain in this subgroup of patients. Improved understanding of the pathogenesis underlying heartburn in patients with GERD, in particular those with NERD, will shape our understanding of this condition. Such understanding will serve as a platform for further research and allow additional therapies to be developed for this increasingly encountered clinical condition.

Stratification and symptom characteristics of non-erosive reflux disease based on acid and duodenogastroesophageal reflux

BACKGROUND AND AIM

The subgroups and symptom characteristics of non-erosive reflux disease (NERD) based on acid and duodenogastroesophageal reflux may be different in Chinese patients to Western patients. This study aimed to explore the stratification and symptom characteristics of patients with NERD.

METHODS

Patients with typical heartburn and/or acid regurgitation symptoms were enrolled. Each patient filled out a questionnaire. An upper gastrointestinal endoscopy was performed for each patient followed by simultaneous ambulatory 24-h esophageal pH and Bilitec (bilirubin) monitoring. A symptom index (SI) of > or =50% was considered to be positive.

RESULTS

Eighty-two consecutive NERD patients were evaluated. Abnormal (NERD pH+) and normal (NERD pH-) 24-h pH tests were found in 24 (29.3%) and 58 (70.7%) patients, respectively. Among 42 NERD pH- patients who reported heartburn symptoms during monitoring, SI was positive in 19 (45.2%) patients (NE-SI+) and negative in 23 (54.8%) patients (NE-SI-). Pathological duodenogastroesophageal reflux (DGER) was found in 43 (52.4%) patients. No significant differences were noted regarding the prevalence of other upper gastrointestinal symptoms, except for acid regurgitation in NERD pH+ and NERD pH- groups. Additionally, no significant differences were seen in the prevalence of other symptoms, except for chest pain, in groups with pathological and normal DGER.

CONCLUSION

The proportion of NERD patients with pathological acid reflux was somewhat lower than that reported in Western countries. The role of DGER in NERD may be important. It is difficult to differentiate whether NERD patients have pathological acid or bile reflux according to symptoms.

New technologies to evaluate esophageal function

This review provides an overview of the recent advances made in diagnostic technologies of esophageal functional disorders. There is discussion of technologies that evaluate esophageal motor function with special attention to high-resolution manometry and esophageal manometry combined with intraluminal impedance testing. Technologies to evaluate gastroesophageal reflux disease are presented with focus on 24-h ambulatory pH monitoring with intraluminal impedance testing and 48-h ambulatory catheter-free pH monitoring. These new technologies have advanced the study and treatment of esophageal disorders in that they allow for more accurate diagnosis of known esophageal disorders and have introduced previously unexplored disorders, such as achalasia with shortening of the esophagus and nonacid reflux.

Biliary reflux and non-acid reflux are two distinct phenomena: a comparison between 24-hour multichannel intraesophageal impedance and bilirubin monitoring

OBJECTIVE

Duodenogastroesophageal reflux (DGER) can greatly increase microscopic and macroscopic esophageal mucosal damage caused by acid. The aim of this study was simultaneously to assess the chemical composition of DGER by detecting bilirubin in the refluxate by means of Bilitec and describe its pH and physical properties by impedance monitoring, in order to prove that non-acid reflux and biliary reflux are two distinct phenomena.

MATERIAL AND METHODS

Twenty patients with gastroesophageal reflux disease (GERD) with symptoms refractory to conventional proton-pump inhibitor (PPI) therapy or with atypical GERD symptoms were included in the study. All patients underwent upper gastrointestinal endoscopy and simultaneous Bilitec and intraeosophageal impedance (IIM) and pH monitoring. In the majority of patients (16/20), the tests were performed while assuming a standard PPI dose.

RESULTS

Pathological bilirubin exposure, as defined by intraesophageal bilirubin absorbance above 0.14 for more than 3.9% of the time, was present in 9 cases, 6 of them with normal values of non-acid reflux, as detected by IIM. A pathological non-acid reflux, as defined by an IIM showing a percentage time with non-acid reflux greater than 1.4%, was observed in 5 patients, 2 of whom had no pathological biliary reflux, as detected by Bilitec. No correlation was found between the two indices, as expressed by an r-value of -0.12 (p>0.05).

CONCLUSIONS

Our study confirms that biliary reflux and non-acid reflux as detected by Bilitec and by IIM, respectively, are two distinct phenomena that require different techniques in order to be assessed in humans.

ACG practice guidelines: esophageal reflux testing

Investigations and technical advances have enhanced our understanding and management of gastroesophageal reflux disease. The recognition of the prevalence and importance of patients with endoscopy-negative reflux disease as well as those refractory to proton pump inhibitor therapy have led to an increasing need for objective tests of esophageal reflux. Guidelines for esophageal reflux testing are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. Issues regarding the utilization of conventional, catheter-based pH monitoring are discussed. Improvements in the interpretation of esophageal pH recordings through the use of symptom-reflux association analyses as well as limitations gleaned from recent studies are reviewed. The clinical utility of pH recordings in the proximal esophagus and stomach is examined. Newly introduced techniques of duodenogastroesophageal reflux, wireless pH capsule monitoring and esophageal impedance testing are assessed and put into the context of traditional methodology. Finally, recommendations on the clinical applications of esophageal reflux testing are presented.

Duodenal switch operation for pathologic transpyloric duodenogastric reflux

OBJECTIVE

To assess the long-term results of the duodenal switch operation made for pathologic transpyloric duodenogastric reflux (DGR).

SUMMARY BACKGROUND DATA

DGR symptoms and lesions are poorly responsive to medical treatment.

METHODS

A duodenal switch operation was made on 48 patients suffering from pathologic transpyloric DGR either unrelated (n = 28) or secondary (n = 20) to previous upper gastrointestinal (GI) surgery, including cholecystectomy or vagotomy. The diagnosis was based on the combination of several objective arguments: a long history of gastric symptoms (ie, nausea, epigastric pain, and/or bilious vomiting) poorly responsive to medical treatment (48 of 48), gastroesophageal reflux symptoms unresponsive to proton-pump inhibitors (PPI) (23 of 29), gastritis on upper GI endoscopy (37 of 48) and/or at histology (28 of 41), presence of a bilious gastric lake at >1 upper GI endoscopy (30 of 48), DGR at diisopropyl iminodiacetic acid (DISIDA) scintigraphy scanning (7 of 13), pathologic 24-hour intragastric bile monitoring with the Bilitec device (40 of 41), and absence of Helicobacter pylori antral infection (39 of 41).

RESULTS

At follow-up (median, 81 months), gastric symptoms were nil, had improved, and remained unchanged in 29 (60.4%), 16 (33.3%), and 2(4.2%) patients, respectively, and 1 patient experienced symptomatic recurrence after a 92-month symptom-free period (2.1%). Among the 44 patients who had postoperative upper GI endoscopy, 42 (95.5%) had no gastritis whereas 5 (11.3%) had an ulcer at the duodenojejunostomy. Gastric exposure to bile at postoperative 24-hour intragastric Bilitec test in 36 patients was nil, within the normal range, and still slightly pathologic in 15 (41.7%), 19 (52.8%), and 2 (5.5%), respectively.

CONCLUSIONS

The duodenal switch operation made on patients in whom diagnosis of pathologic transpyloric DGR is supported by several objective arguments provides most of them with symptomatic and endoscopic improvement parallel to abolishment or normalization of gastric exposure to bile. Postoperative PPI therapy during a 2-month period is to be recommended to prevent the development of an anastomotic ulcer.

Importance of duodenogastric reflux in gastro-oesophageal reflux disease

BACKGROUND

Bile in the oesophagus occurs frequently in patients with gastro-oesophageal reflux disease (GORD) and has been linked to Barrett's metaplasia and cancer. Although duodenogastric reflux is a prerequisite for bile in the oesophagus, little is known about its importance in GORD.

METHODS

Some 341 patients with GORD were assessed by simultaneous 24-h gastric and oesophageal bilirubin monitoring. Definitions of increased bilirubin exposure were based on the 95th percentiles in healthy volunteers. The relationship between gastric and oesophageal bilirubin exposure and the correlation with disease severity were analysed.

RESULTS

Of the 341 patients with GORD, 130 (38.1 per cent) had increased gastric and 173 (50.7 per cent) had increased oesophageal bilirubin exposure. Of the 173 patients with bile in the oesophagus, 89 (51.4 per cent) had normal and 84 (48.6 per cent) had increased gastric bilirubin exposure. Of these 84 patients, 75 (89 per cent) had oesophagitis or Barrett's oesophagus (P = 0.003). These effects were mainly related to differences in supine reflux.

CONCLUSION

Bile in the oesophagus originates from either normal or increased gastric bilirubin exposure. Patients with increased duodenogastric reflux are more likely to have oesophagitis or Barrett's oesophagus. These findings highlight the role of duodenogastric reflux as an additional factor in the pathogenesis of GORD.

Le reflux biliaire duodéno-gastrique et gastro-œsophagien

This study reviews current data regarding duodenogastric and gastroesophageal bile reflux-pathophysiology, clinical presentation, methods of diagnosis (namely, 24-hour intraluminal bile monitoring) and therapeutic management. Duodenogastric reflux (DGR) consists of retrograde passage of alkaline duodenal contents into the stomach; it may occur due to antroduodenal motility disorder (primary DGR) or may arise following surgical alteration of gastoduodenal anatomy or because of biliary pathology (secondary DGR). Pathologic DGR may generate symptoms of epigastric pain, nausea, and bilious vomiting. In patients with concomitant gastroesophageal reflux, the backwash of duodenal content into the lower esophagus can cause mixed (alkaline and acid) reflux esophagitis, and lead, in turn, to esophageal mucosal damage such as Barrett's metaplasia and adenocarcinoma. The treatment of DGR is difficult, non-specific, and relatively ineffective in controlling symptoms. Proton pump inhibitors decrease the upstream effects of DGR on the esophagus by decreasing the volume of secretions; promotility agents diminish gastric exposure to duodenal secretions by improving gastric emptying. In patients with severe reflux resistant to medical therapy, a duodenal diversion operation such as the duodenal switch procedure may be indicated.

Familial adenomatous polyposis predisposes to pathologic exposure of the stomach to bilirubin

BACKGROUND

The role of duodenogastric reflux in the genesis of gastric polyps in familial adenomatous polyposis (FAP), although suggested by scintigraphy scanning studies, remains unclear.

METHODS

Twenty-four hour intragastric bilirubin monitoring with the Bilitec optoelectronic device was carried out in 25 FAP patients, of whom 19 had gastric polyps (fundic gland in 13, adenomatous in 2, and both histologic types in 4) on endoscopic examination. Gastric exposure to bilirubin was expressed as the percentage of total recording time that absorbance exceeded the threshold of 0.25 and was calculated in reference to values obtained from 25 healthy volunteers. Helicobacter pylori status of the stomach was checked as well.

RESULTS

Gastric exposure to bilirubin was pathologic in 14 (56%) patients. Gastric exposure to bilirubin was of longer duration in FAP patients than in healthy volunteers (mean+/-SEM: 19%+/-4% vs 6%+/-2%) (P<.005). It increased from healthy volunteers (6%+/-2%) to FAP patients without gastric polyps (10%+/-3%), and to FAP patients with gastric polyps (22%+/-5%) (P<.004). Bilirubin exposure times were similar in FAP patients with fundic gland polyps only and in those having either adenomatous polyps only or both types of polyps (24%+/-7% vs 17%+/-4%). No patient with pathologic gastric exposure to bilirubin as well as none having gastric polyps, had H. pylori in the antrum.

CONCLUSIONS

This study shows that gastric exposure to bilirubin is of longer duration in FAP patients than in healthy volunteers, and in FAP patients with gastric polyps than in those without polyps. This study supports the existence of a direct correlation between pathologic duodenogastric reflux (DGR), the absence of H. pylori in the antrum, and the presence of gastric polyps in FAP patients.

The impact of reflux composition on mucosal injury and esophageal function

The components of refluxed gastric juice are known to cause mucosal injury, but their effect on esophageal function is less appreciated. Our aim was to determine the effect of acid and/or bile on mucosal injury and esophageal function. From 1993-2004, 402 patients with reflux symptoms had 24-hour pH and Bilitec monitoring, manometry, and endoscopy with biopsies. Mucosal injury (esophagitis or Barrett's esophagus) and esophageal function (lower esophageal sphincter [LES] characteristics and body contractility) in patients with acid reflux, bile reflux, or both were compared with patients without reflux. Reflux was present in 273/402 patients; of these, 37 (13.5%) had increased exposure to bile, 82 (30.0%) had increased exposure to acid, and 154 (56.4%) had increased exposure to both. Mucosal injury was most common with increased mixed acid and bile exposure, followed by acid alone, and was uncommon with bile alone (P < 0.0001). Functional deterioration paralleled mucosal injury (P < 0.0001). Mixed acid and bile exposure was present in more than half of patients with reflux and was associated with the most severe mucosal injury and the greatest deterioration of esophageal function. This suggests that composition of gastric juice is the primary determinant of inflammatory mucosal injury and subsequent loss of esophageal function.

Treatment of oesophageal bile reflux in children: the results of a prospective study with omeprazole

OBJECTIVES

Reflux of duodenal juice into the oesophagus has a role in the pathogenesis of both oesophageal and laryngopharyngeal inflammatory and neoplastic lesions. As little is known about effective therapy, we studied the effect of proton pump inhibitor therapy on oesophageal bile reflux in children.

METHODS

Twenty-nine children with moderate to severe erosive oesophagitis and abnormal oesophageal bile reflux were studied before and after treatment with omeprazole 1 mg/kg per day. Outcomes included a clinical symptom score, oesophageal acid and bile reflux (simultaneous 24-hour pH and Bilitec 2000 monitoring), and mucosal healing.

RESULTS

After 8 weeks of therapy, 17 (59%) of the patients were symptom-free, and 5 (17%) had minimal symptoms. Mucosal healing or reduction to low-grade oesophagitis was achieved in 25 children (86%; P < 0.0005). Mean percentages of total, upright, and supine time with oesophageal pH less than 4 were reduced from 17.0%, 16.8%, and 19.2% before treatment, to 2.83%, 3.17%, and 2.07%, respectively, after treatment (all P < 0.00001). Similarly, mean percentages of total, upright, and supine time with bile reflux were reduced from 16.96%, 12.67%, and 22.0%, to 2.27%, 1.91%, and 2.23%, respectively (P < 0.000001, P < 0.0001, and P < 0.000001, respectively).

CONCLUSIONS

Omeprazole 1 mg/kg per day is an effective therapy for the majority of children with severe erosive oesophagitis due to abnormal isolated bile reflux or combined acid and bile reflux. It remains unclear how patients with treatment-resistant bile reflux should be managed.

New techniques to evaluate esophageal function

Classical techniques like videofluoroscopy, stationary manometry and ambulatory 24-hour pH-metry are routinely used in the clinic to study patients with dysphagia, chest pain and reflux-related symptoms. Although many patients can be accurately diagnosed and their therapy successfully guided with these techniques, in many other patients, non-obstructive dysphagia or chest pain cannot be attributed to clear fluoroscopic or manometric abnormalities. Furthermore, ambulatory 24-hour pH-metry often shows a poor association between spontaneous acid reflux events and esophageal or extraesophageal symptoms, particularly in patients 'on' treatment. Non-obstructive dysphagia can be assessed with high-resolution manometry to detect segmental disturbances of peristalsis, increase in pressure gradient across the lower esophageal sphincter (LES) or abnormal axial movement of the LES during esophageal spasm. Impedance evaluation of bolus transit is a non-radiological method that can evaluate the functional relevance of manometric abnormalities. Patients with non-cardiac chest pain that do not respond to proton pump inhibitor therapy can be further assessed with intraluminal high-frequency ultrasound to detect sustained esophageal contractions of the longitudinal muscle layer. Impedance planimetry, with multimodal esophageal stimulation, may contribute to evaluate the sensitivity to mechanical, thermal and chemical stimuli. Finally, patients with persistent symptoms of gastroesophageal reflux in spite of adequate treatment with proton pump inhibitors may still have weakly acidic reflux and/or bile reflux associated with their symptoms. These types of refluxates can now be detected with combinations of pH-impedance or pH-Bilitec monitoring. This review will describe the available new techniques to evaluate patients with non-obstructive dysphagia, non-cardiac chest pain and persistent gastroesophageal reflux symptoms.

Jejunal pouch interposition with fundic-like plication after total gastrectomy

PURPOSE

We developed a technique of jejunal pouch interposition with a fundic-like jejunal plication (JPI-FP) for reconstruction after total gastrectomy (TG) for gastric cancer. The aim of this study was to investigate the advantages of JPI-FP over Roux-en-Y reconstruction (R-Y).

METHODS

Twenty-two patients who had undergone TG more than 1 year earlier were classified into two groups according to the method of reconstruction used: Group A (n = 7) underwent R-Y, and group B (n = 15) underwent JPI-FP. Group B was subdivided into two groups to examine the usefulness of additional pylorus preservation: group B1 (n = 8), pylorus (-) and group B2 (n = 7), pylorus (+).

RESULTS

Food intake and body weight were significantly higher in group B than in group A (P < 0.05). Reflux esophagitis was diagnosed in two of the group A patients, but in none of the group B patients. Excessive esophageal bile exposure, determined as the fraction time of esophageal bilirubin absorbance over 0.14 > 50%, was significantly higher in group A than in group B (P < 0.05). There was no significant difference in bile exposure in the jejunal pouch between groups B1 and B2.

CONCLUSIONS

JPI-FP is a superior method of reconstruction after TG to prevent excessive esophageal bile reflux and from a nutritional aspect. The advantage of pylorus preservation remains unconfirmed.

[Correct diagnosis for indication in gastroesophageal reflux disease]

For diagnosis and quantitation of gastroesophageal reflux disease, a number of different examinations are available. The simplest are the patient's history and complaints as well as the proton pump inhibitor test; both methods have a positive predictive value of 65% to 70%. Esophagogastroduodenoscopy is the gold standard for differentiation between erosive and nonerosive reflux disease. Biopsy does not enhance the significance of endoscopy except for proof of Barrett's epithelium or malignant degeneration. Twenty-four-hour pH monitoring has the highest sensitivity and specificity for the diagnosis of gastroesophageal reflux disease. Barium swallow provides only additional information concerning hiatal hernia or stenosis. Manometry can clarify lower esophageal sphincter insufficiency or motility disorders of the tubular esophagus. However, the available studies show that manometry has no influence on postoperative outcome after fundoplication. The indication for medical therapy can primarily be based only on the history and complaints of the patient. As surgical therapy affords a high degree of diagnostic accuracy, at least endoscopy and 24-h pH monitoring are necessary for indication.

Bile reflux in the constellation of gastroesophageal reflux disease

Gastric acid and bile acids are a particularly noxious combination when they interact with the mucosa of the upper intestinal tract. There is a critical pH range, between 3 and 6, in which bile acids exist in their soluble, un-ionized form, can penetrate cell membranes, and accumulate within mucosal cells. At a lower pH, bile acids are precipitated, and at a higher pH, bile acids exist in their noninjurious ionized form. Experimental, clinical, and immunohistochemical studies show that acid and bile reflux are increased in patients who suffer from GERD, are the key factor in the pathogenesis of Barrett's esophagus, and possibly are related to the development of esophageal adenocarcinoma.

Gastroesophageal reflux and cancer

The causal relationship between GERD and esophageal adenocarcinoma, although unclear just a few decades ago, now is established fairly well. The physiologic changes and the biocellular alterations of the damaged esophageal mucosa are documented better. Despite this knowledge, the dramatic increase in the incidence of esophageal cancer cannot be explained. The absolute risk of esophageal adenocarcinoma arising from GERD is low, and, at present, does not justify population-screening programs. Still, with the notion that adenocarcinoma of the esophagus is an aggressive cancer once documented, important questions still are in need of answers for patients suffering from reflux symptoms. Patients who have reflux disease are not necessarily symptomatic. It remains unclear if patients experiencing reflux symptoms should undergo mandatory endoscopy with biopsies at the esophagogastric junction. Furthermore, metaplasia of the lower esophagus often is not readily recognizable at endoscopy, and only biopsies can document abnormal histology. A severe and prolonged history of reflux always should orient to the possibility of a reflux-related columnar-lined esophagus. Once documented, Barrett's esophagus needs to be seen as a premalignant condition not necessarily leading to adenocarcinoma formation; despite their increased risk of tumor formation, most patients who have Barrett's esophagus die of other causes. During regular endoscopic follow-up, multilevel circumferential biopsies should document the evolution of the histologic changes in the lower esophagus and at the gastroesophageal junction of these patients. It is the only method available to document the appearance of dysplasia. It still is unclear if medicine or surgery provides the best quality of life and the best protection against the development of dysplasia and the possible progression toward adenocarcinoma formation when intestinal metaplasia is present in the esophagus.