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Lu MM, Kahrilas PJ, Teitelbaum EN, Pandolfino JE, Carlson DA. Secondary peristalsis and esophagogastric junction distensibility in symptomatic post-fundoplication patients. Neurogastroenterol Motil 2024; 36:e14746. [PMID: 38263867 DOI: 10.1111/nmo.14746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/12/2024] [Accepted: 01/14/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND The impact of esophageal dysmotility among patients with post-fundoplication esophageal symptoms is not fully understood. This study aimed to investigate secondary peristalsis and esophagogastric junction (EGJ) opening biomechanics using functional lumen imaging probe (FLIP) panometry in symptomatic post-fundoplication patients. METHODS Eighty-seven adult patients post-fundoplication who completed FLIP for symptomatic esophageal evaluation were included. Secondary peristaltic contractile response (CR) patterns and EGJ opening metrics (EGJ distensibility index (EGJ-DI) and maximum EGJ diameter) were evaluated on FLIP panometry and analyzed against high-resolution manometry (HRM), patient-reported outcomes, and fundoplication condition seen on esophagram and/or endoscopy. KEY RESULTS FLIP CR patterns included 14 (16%) normal CR, 30 (34%) borderline CR, 28 (32%) impaired/disordered CR, 13 (15%) absent CR, and 2 (2%) spastic reactive CR. Compared with normal and borderline CRs (i.e., CR patterns with distinct, antegrade peristalsis), patients with impaired/disordered and absent CRs demonstrated significantly greater time since fundoplication (2.4 (0.6-6.8) vs. 8.9 (2.6-14.5) years; p = 0.002), greater esophageal body width on esophagram (n = 50; 2.3 (2.0-2.8) vs. 2.9 (2.4-3.6) cm; p = 0.013), and lower EGJ-DI (4.3 (2.7-5.4) vs. 2.6 (1.7-3.7) mm2/mmHg; p = 0.001). Intact fundoplications had significantly higher rates of normal CRs compared to anatomically abnormal (i.e., tight, disrupted, slipped, herniated) fundoplications (9 (28%) vs. 5 (9%); p = 0.032), but there were no differences in EGJ-DI or EGJ maximum diameter. CONCLUSIONS & INFERENCES Symptomatic post-fundoplication patients were characterized by frequent abnormal secondary peristalsis after fundoplication, potentially worsening with time after fundoplication or related to EGJ outflow resistance.
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Affiliation(s)
- Michelle M Lu
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ezra N Teitelbaum
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Smith MR, Ayazi S, Grubic AD, Shen X, Jobe BA. Swallow-induced syncope after magnetic sphincter augmentation: a case report and physiologic explanation. Clin J Gastroenterol 2021; 14:1318-1323. [PMID: 34053004 DOI: 10.1007/s12328-021-01448-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/21/2021] [Indexed: 11/25/2022]
Abstract
Swallow-induced syncope is a rare cause of syncope that occurs during or immediately after swallowing. This phenomenon has been reported in association with few esophageal pathologies and the likely explanation is a vagal reflex during deglutition that results in inhibition of the cardiac conduction system. This report describes a case of swallow-induced syncope related to the implantation of a magnetic sphincter augmenting (MSA) device. Two episodes of syncope after food bolus occurred with the device in place and upon removal of the device, the patient had no further episodes of syncope. Vagal stimulation from distention of the esophagus or vagus nerve contact irritation by the implant are the potential explanation for syncope in this patient. Although this is an extremely rare complication of magnetic sphincter device augmentation, it is one that physicians should be cognizant of given the dangers of syncope events.
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Affiliation(s)
- Mathew R Smith
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Shahin Ayazi
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA.
| | - Andrew D Grubic
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Xinxin Shen
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Blair A Jobe
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
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Renzi A, Minieri G, Coretti G, Di Marzo M, Di Sarno A, Odierna G, Barbato D, Barone G. Severe dysphagia after antireflux surgery: a rare case of esophageal hiatal stenosis. Clin J Gastroenterol 2021; 14:39-43. [PMID: 33449311 DOI: 10.1007/s12328-020-01318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
Severe and persistent dysphagia (PD) due to a stenosis of the esophageal hiatus is a serious and rare complication after antireflux procedures. In the case report presented here, the treatment of dysphagia, which arose eight weeks after surgery and progressively worsened, required a new laparoscopic approach. The re-intervention undertaken allowed us to identify the cause of the dysphagia, a tight hiatal stenosis, and to treat it successfully.
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Affiliation(s)
- Adolfo Renzi
- Esophageal Diseases Center and GERD Unit, Buon Consiglio Hospital-Fatebenefratelli, Naples, Italy.
| | - Gianluca Minieri
- Esophageal Diseases Center and GERD Unit, Buon Consiglio Hospital-Fatebenefratelli, Naples, Italy
| | - Guido Coretti
- Esophageal Diseases Center and GERD Unit, Buon Consiglio Hospital-Fatebenefratelli, Naples, Italy
| | - Michele Di Marzo
- Esophageal Diseases Center and GERD Unit, Buon Consiglio Hospital-Fatebenefratelli, Naples, Italy
| | - Antonia Di Sarno
- Esophageal Diseases Center and GERD Unit, Buon Consiglio Hospital-Fatebenefratelli, Naples, Italy
| | - Giovanni Odierna
- Esophageal Diseases Center and GERD Unit, Buon Consiglio Hospital-Fatebenefratelli, Naples, Italy
| | - Domenico Barbato
- Esophageal Diseases Center and GERD Unit, Buon Consiglio Hospital-Fatebenefratelli, Naples, Italy
| | - Gianni Barone
- Esophageal Diseases Center and GERD Unit, Buon Consiglio Hospital-Fatebenefratelli, Naples, Italy
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Caruso AM, Milazzo M, Tulone V, Acierno C, Girgenti V, Amoroso S, Bommarito D, Calcaterra V, Pelizzo G. High Resolution Manometry Guidance During Laparoscopic Fundoplication in Pediatric Surgically "Fragile" Patients: Preliminary Report. CHILDREN-BASEL 2020; 7:children7110215. [PMID: 33171722 PMCID: PMC7695016 DOI: 10.3390/children7110215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
Background: High resolution manometry (HRM), has been recently introduced in clinical practice to detect esophageal intraluminal pressure and esophageal motor function. We evaluated the feasibility and usefulness of intraoperative esophageal HRM during antireflux laparoscopic procedures in pediatric cases with neurological impairment (NI) or esophageal atresia (EA). Methods: From January to November 2019, seven children (5 NI, 2 EA) with gastroesophageal reflux (GER) were enrolled. Data on intraoperative pressure changes of the esophagogastric junction (EGJ) and postoperative follow-up data were collected. Results: Average preoperative LES pressures were not significantly different from postoperative pressures. A sliding hernia was detected in all patients as evidenced by EGJ double peak pressures. Hernia correction after esophageal traction was complete in 71.4% of the patients, and residual hernia (<2 cm) was detected in 28.6%. Postoperative EGJ pressures were higher compared to preoperative sphincteric pressures (p < 0.001); in NI patients, higher postoperative values were noted compared to EA (p = 0.05). No sliding hernia and/or GER relapses were recorded. Two patients reported dysphagia postoperatively. Conclusions: Intraoperative HRM may optimize esophageal pressure changes during laparoscopic fundoplication. Further studies are needed to confirm the usefulness of a tailored surgical approach to reduce postoperative complications.
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Affiliation(s)
- Anna Maria Caruso
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Mario Milazzo
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Vincenzo Tulone
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Carlo Acierno
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Vincenza Girgenti
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Salvatore Amoroso
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Denisia Bommarito
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Valeria Calcaterra
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy;
- Pediatric Unit, “V. Buzzi” Children’s Hospital, University of Milano, 20154 Milano, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Unit, “V. Buzzi” Children’s Hospital, University of Milano, 20154 Milano, Italy
- Department of Biomedical and Clinical Science, “L. Sacco”, University of Milano, 20154 Milano, Italy
- Correspondence:
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Samo S, Mulki R, Godiers ML, Obineme CG, Calderon LF, Bloch JM, Kim JJ, Shahnavaz N, Raja SM, Patnana SV, Willingham FF, Keilin SA, Cai Q, Christie JA, Srinivasan S, Lin E, Davis SS, Jain AS. Utilizing functional lumen imaging probe in directing treatment for post-fundoplication dysphagia. Surg Endosc 2020; 35:4418-4426. [PMID: 32880014 DOI: 10.1007/s00464-020-07941-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 08/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Esophagogastric junction obstruction (EGJO) post-fundoplication (PF) is difficult to identify with currently available tests. We aimed to assess the diagnostic accuracy of EGJ opening on functional lumen imaging probe (FLIP) and dilation outcome in FLIP-detected EGJO in PF dysphagia. METHODS We prospectively collected data on PF patients referred to Esophageal Clinic over 18 months. EGJO diagnosis was made by (a) endoscopist's description of a narrow EGJ/wrap area, (b) appearance of wrap obstruction or contrast/tablet retention on esophagram, or (c) EGJ-distensibility index (DI) < 2.8 mm2/mmHg on real-time FLIP. In patients with EGJO and dysphagia, EGJ dilation was performed to 20 mm, 30 mm, or 35 mm in a stepwise fashion. Outcome was assessed as % dysphagia improvement during phone call or on brief esophageal dysphagia questionnaire (BEDQ) score. RESULTS Twenty-six patients were included, of whom 17 (65%) had a low EGJ-DI. No patients had a hiatal hernia greater than 3 cm. Dysphagia was the primary symptom in 17/26 (65%). In 85% (κ = 0.677) of cases, EGJ assessment (tight vs. open) was congruent between the combination of endoscopy (n = 26) and esophagram (n = 21) vs. EGJ-DI (n = 26) on FLIP. Follow-up data were available in 11 patients who had dilation based on a low EGJ-DI (4 with 20 mm balloon and 7 with ≥ 30 mm balloon). Overall, the mean % improvement in dysphagia was 60% (95% CI 37.7-82.3%, p = 0.0001). Nine out of 11 patients, including 6 out of 7 undergoing pneumatic dilation, had improvement ≥ 50% in dysphagia (mean % improvement 72.2%; 95% CI 56.1-88.4%, p = 0.0001). CONCLUSIONS AND INFERENCES Functional lumen imaging probe is an accurate modality for evaluating for EGJ obstruction PF. FLIP may be used to select patients who may benefit from larger diameter dilation.
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Affiliation(s)
- Salih Samo
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Ramzi Mulki
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Marie L Godiers
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Chuma G Obineme
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Lucie F Calderon
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - John M Bloch
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Joyce J Kim
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Nikrad Shahnavaz
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Shreya M Raja
- Atlanta VA Medical Center and Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, USA
| | - Srikrishna V Patnana
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Steven A Keilin
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Qiang Cai
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Jennifer A Christie
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Shanthi Srinivasan
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Edward Lin
- Division of Foregut Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, USA
| | - S Scott Davis
- Division of Foregut Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, USA
| | - Anand S Jain
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA, 30322, USA.
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Surgical Therapy of Esophagus Reflux Disease. ACTA MEDICA MARTINIANA 2020. [DOI: 10.2478/acm-2020-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: Fundoplication is the most frequently used action in the surgical treatment of gastroesophageal reflux disease (GERD). There are several types of fundoplication. The objective of our study was to identify complications after surgical treatment of GERD.
Material and Methods: We determined several parameters of the monitored and we recorded complications related to surgery: occurrence of surgical, early and late post-surgical complications.
Results: 52 patients (24 men and 28 women) with an average age of 53.3 years were included. The most frequently chosen type of fundoplication was Nissen-Rossetti. The most frequently occurring subjective post-surgery difficulties were temporal dysphagia (11.5%), sensation of nausea and vomiting after eating (3.8 %), pain in the surgical wound, and dyspnoea occurring in all patients after thoracotomy. Early post-surgery complication developed in 6 patients (11.5 %)
Conclusion: Occurrence of complications in the group monitored by us was up to 11.5 % and perioperative mortality was 0 %. Hiatal hernia is frequently found in patients with GERD and it is considered to be one of the major causes for the development of this disease.
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Vogt CD, Panoskaltsis-Mortari A. Tissue engineering of the gastroesophageal junction. J Tissue Eng Regen Med 2020; 14:855-868. [PMID: 32304170 DOI: 10.1002/term.3045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 04/03/2020] [Indexed: 12/12/2022]
Abstract
The gastroesophageal junction has been of clinical interest for some time due to its important role in preventing reflux of caustic stomach contents upward into the esophagus. Failure of this role has been identified as a key driver in gastroesophageal reflux disease, cancer of the lower esophagus, and aspiration-induced lung complications. Due to the large population burden and significant morbidity and mortality related to reflux barrier dysfunction, there is a pressing need to develop tissue engineering solutions which can replace diseased junctions. While good progress has been made in engineering the bodies of the esophagus and stomach, little has been done for the junction between the two. In this review, we discuss pertinent topics which should be considered as tissue engineers begin to address this anatomical region. The embryological development and adult anatomy and histology are discussed to provide context about the native structures which must be replicated. The roles of smooth muscle structures in the esophagus and stomach, as well as the contribution of the diaphragm to normal anti-reflux function are then examined. Finally, engineering considerations including mechanics and current progress in the field of tissue engineering are presented.
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Affiliation(s)
- Caleb D Vogt
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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Tariq H, Makker J, Ahmed R, Vakde T, Patel H. Frequent Sips of the Water for the Management of Gastroesophageal Reflux Induced Refractory Cough: A Case Report and Review of the Literature. Case Rep Gastrointest Med 2019; 2019:9205259. [PMID: 31275669 PMCID: PMC6582892 DOI: 10.1155/2019/9205259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 05/09/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Chronic cough is often associated with gastroesophageal reflux disease (GERD). The role of gastroenterologist in the management of the chronic cough is to identify and manage GERD. Ineffective esophageal motility is often associated with GERD induced cough. Chronic cough is often refractory to medical and surgical management despite adequate acid control. Unresponsiveness warrants a thorough pulmonary evaluation. The pathophysiology of refractory cough in these patients is poorly understood, and hence management is often challenging. CASE PRESENTATION A 75-year-old woman from Ghana was evaluated for GERD associated chronic cough. A 48-hour ambulatory pH study revealed acid exposure of 4.9% and high-resolution manometry showed decreased lower esophageal sphincter pressure, an inadequate response to medical and surgical management of GERD. Postfundoplication ambulatory pH testing demonstrated well-controlled acid reflux but her cough still persisted. Repeat manometry showed an ineffective motility disorder (IEM). Taking frequent sips of water eventually resolved her chronic cough. CONCLUSION Frequent sips of water can be used in the management of the gastroesophageal reflux and ineffective motility induced cough. It results in increased esophageal clearance of acid, nonacid reflux, and ingested pharyngeal secretions, thus breaking the cycle of cough generated increased intra-abdominal pressure with reflux and more cough.
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Affiliation(s)
- Hassan Tariq
- Department of Medicine, BronxCare Hospital System, Bronx, New York 10457, USA
- Division of Gastroenteorlogy, BronxCare Hospital System, Bronx, New York 10457, USA
| | - Jasbir Makker
- Department of Medicine, BronxCare Hospital System, Bronx, New York 10457, USA
- Division of Gastroenteorlogy, BronxCare Hospital System, Bronx, New York 10457, USA
| | - Rafeeq Ahmed
- Department of Medicine, BronxCare Hospital System, Bronx, New York 10457, USA
- Division of Gastroenteorlogy, BronxCare Hospital System, Bronx, New York 10457, USA
| | - Trupti Vakde
- Department of Medicine, BronxCare Hospital System, Bronx, New York 10457, USA
- Division of Pulmonary and Critical Care Medicine, BronxCare Hospital System, Bronx, New York 10457, USA
| | - Harish Patel
- Department of Medicine, BronxCare Hospital System, Bronx, New York 10457, USA
- Division of Gastroenteorlogy, BronxCare Hospital System, Bronx, New York 10457, USA
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