Tolerance and reliability of wireless pH monitoring in children

Evaluation of Gastroesophageal Reflux Disease in Children on the Autism Spectrum: A Study Evaluating the Tolerance and Utility of the BRAVO Wireless pH Monitoring

OBJECTIVES

Children on the autism spectrum disorder (ASD) may express pain or discomfort through stereotypic or self-injurious behaviors. Gastroesophageal reflux disease (GERD) may be challenging to diagnose in a child who is non-verbal or has impaired communication skills, diagnostic testing for GERD may be the only way to establish the diagnosis. We report our experience using the BRAVO wireless pH monitoring device for the evaluation of GERD in this patient population.

METHODS

Tolerance and feasibility as well as pH parameters and symptom correlation of the BRAVO pH were evaluated retrospectively in ASD children and compared it to a large cohort of non-ASD children. Only patients with studies lasting >24 hours were included.

RESULTS

A total of 172 patients were included, 27 of those were diagnosed with autism (median age 11 years, 17 male). We found no difference in age and weight between both groups but there was a male predominance in the autism group ( P = 0.007). We found no difference in the ability to complete at least 24 hours of study duration between both groups (24/27 or 89% in ASD vs 133/145 or 92% non-ASD patients, P = 0.632). We also found no difference in the median reflux index on the worst day ( P = 0.27) or the average of both days ( P = 0.75), BRAVO pH parameters and the proportion of abnormal studies between ASD and non-ASD children. When evaluating the overall symptom correlation with GER episodes, we did not find a difference between both groups, but we did find a higher symptom correlation for GER symptom during supine position in ASD children. Study was performed for behavioral indication in 11 ASD children, all had normal esophageal mucosa but 4 of those had an abnormal BRAVO pH study. No significant side effects were reported during the study, only 2 patients (1 non-ASD and 1 ASD) complained of self-limited chest pain.

CONCLUSIONS

BRAVO wireless pH is well tolerated and feasible in evaluating GER and behavioral symptoms in ASD children and provides a reasonable alternative to standard trans-nasal pH monitoring.

Capsule Endoscopy: Pitfalls and Approaches to Overcome

Capsule endoscopy of the gastrointestinal tract is an innovative technology that serves to replace conventional endoscopy. Wireless capsule endoscopy, which is mainly used for small bowel examination, has recently been used to examine the entire gastrointestinal tract. This method is promising for its usefulness and development potential and enhances convenience by reducing the side effects and discomfort that may occur during conventional endoscopy. However, capsule endoscopy has fundamental limitations, including passive movement via bowel peristalsis and space restriction. This article reviews the current scientific aspects of capsule endoscopy and discusses the pitfalls and approaches to overcome its limitations. This review includes the latest research results on the role and potential of capsule endoscopy as a non-invasive diagnostic and therapeutic device.

Gastrointestinal diagnosis using non-white light imaging capsule endoscopy

Capsule endoscopy (CE) has proved to be a powerful tool in the diagnosis and management of small bowel disorders since its introduction in 2001. However, white light imaging (WLI) is the principal technology used in clinical CE at present, and therefore, CE is limited to mucosal inspection, with diagnosis remaining reliant on visible manifestations of disease. The introduction of WLI CE has motivated a wide range of research to improve its diagnostic capabilities through integration with other sensing modalities. These developments have the potential to overcome the limitations of WLI through enhanced detection of subtle mucosal microlesions and submucosal and/or transmural pathology, providing novel diagnostic avenues. Other research aims to utilize a range of sensors to measure physiological parameters or to discover new biomarkers to improve the sensitivity, specificity and thus the clinical utility of CE. This multidisciplinary Review summarizes research into non-WLI CE devices by organizing them into a taxonomic structure on the basis of their sensing modality. The potential of these capsules to realize clinically useful virtual biopsy and computer-aided diagnosis (CADx) is also reported.

Continuous 48-Hour Wireless Esophageal pH Monitoring in Children: Comparison Between Days 1 and 2

AIM

Comparison of days 1 and 2 to each other and to the total recording of 48 hours in continuous 48-hour wireless esophageal pH monitoring in children.

METHODS

A retrospective study of 105 patients who underwent 48-hour pH monitoring (Bravo) studies between January 1992 and June 2010 was performed. Reflux variables were compared between days 1 and 2.

RESULTS

A total of 58 (55.2%) patients were men. The number of reflux episodes, number of long reflux >5 minutes, duration of the longest reflux (minutes), time pH <4 (minutes), fraction time pH <4 supine (%), fraction time pH <4 upright (%), reflux index, and DeMeester score did not differ between days 1 and 2.

CONCLUSIONS

No effect of anesthesia was observed on the gastroesophageal reflux parameters on children.

Effect of anesthesia on gastroesophageal reflux in children: a study using BRAVO wireless pH study measurements

BACKGROUND

Adult studies suggest conscious sedation increases gastroesophageal reflux (GER), but the role of anesthesia on GER in children is unclear. Our aim was to study the anesthesia effects on GER and pH study interpretation in children.

METHODS

Children undergoing BRAVO wireless pH capsule placement under anesthesia and study duration >36 h were included. We evaluated the pH parameters (number of reflux episodes >5 min, duration of longest reflux episode, time pH <4 and fraction time pH <4) at 1, 2, 6-h and total study duration blocks using 2 cutoff values (5.3% and 6%) for the worst day, average of both days, and 1st day alone. We compared time blocks to evaluate the effect of anesthesia on GER and the proportions of studies changing interpretation after excluding the 1st hour and 1st 2-h blocks to evaluate anesthesia effect on study interpretation.

KEY RESULTS

A total of 150 children were included. We found a significant increase on the pH parameters in the 1st hour compared to subsequent block times suggesting an effect of anesthesia on GER. We found no significant change in the proportion of studies interpreted as normal vs abnormal, however, excluding the initial 2 h of the study would change the study interpretation from abnormal to normal in up to 5% of patients.

CONCLUSIONS & INFERENCES

We found an effect of anesthesia increasing the GER parameters mainly in the 1st hour and up to the first 6 h of the study that may result in a change in the study interpretation.

Pediatric gastroesophageal reflux disease

This article reviews the mechanisms responsible for gastroesophageal reflux disease (GERD), available techniques for diagnosis, and current medical management. In addition, it extensively discusses the surgical treatment of GERD, emphasizing the use of minimally invasive techniques.

Esophageal pH monitoring with the BRAVO capsule: experience in a single tertiary medical center

AIM

The aim of the present study was to report the global experience with placement, complication rate, and recording of esophageal pH using the BRAVO capsule at our institution.

PATIENTS AND METHODS

We recorded the rate of any technical problems and complications during placement in all of the patients (ages 4-22 years) who received this device during a 2-year period. All of the patients undergoing esophagogastroduodenoscopy with the placement of BRAVO pH capsule were included in this analysis. We also examined the pH data recorded on days 1 and 2 for significant day-to-day variability during 2 days of pH monitoring.

RESULTS

Two hundred eighty-nine BRAVO pH probes were placed from January 1, 2006 to December 31, 2008. At least 1 day of data was obtained in 278 patients (96.2%). Two days of data were obtained in 274 patients (94.8%). Of all of the reported complications, 1% occurred before deployment of the capsule, 4% occurred during deployment of the capsule, and 9% occurred after successful deployment of the capsule. One patient experienced a superficial esophageal tear that was associated with failure of the capsule to release from the delivery system. No patient requested removal of the capsule and all of the capsules detached within 14 days. In 9.12% of our patients, reflux index was normal on day 1 and abnormal on day 2. There was no statistically significant difference between reflux index recorded on day 1 versus day 2 (P = 0.686).

CONCLUSIONS

The BRAVO pH capsule is easy to place, safe, and well tolerated by children. Performing a 48-hour study detected abnormal reflux in an additional 9% of our patients.

Can acid (pH) refluxes predict multichannel intraluminal impedance refluxes? A correlation study

BACKGROUND AND AIM

The present study aims to explore if and when acid (pH) refluxes can predict refluxes detected by multichannel intraluminal impedance (MII) studies. This correlation may indicate whether pH probe-only and MII-pH studies are interchangeable.

METHODS

Prospective observational cross sectional study of symptomatic children (below 18 years) who had MII-pH studies done for gastroesophageal reflux. Clinical data were extracted from patient records. Non-parametric tests, Pearson's rho and receiver operating characteristic (ROC) curves were used for data analysis.

RESULTS

A total of 153 children were included in the study and 62% were on acid suppression. Indices for acid and MII refluxes correlated with each other only in those without acid suppression. This correlation was lost in children on acid suppression. There was no statistically significant difference in acid or MII reflux indices in children with or without acid suppression. Like acid reflux, indices for MII refluxes had good correlation with each other irrespective of acid suppression. Liquid and mixed MII refluxes showed excellent correlation with respective types of proximally migrating refluxes. The values for MII reflux indices derived from our patient population were in broad agreement with available pediatric and adult data.

CONCLUSIONS

A pH probe-only study in patients without acid suppression may reflect both acid and volume (MII) reflux activities adequately and can substitute for MII-pH study. The observed excellent correlation between acid and MII refluxes with proximal migration may justify using pH probe-only studies for extra esophageal symptoms in patients without acid suppression.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

Tolerability and clinical utility of the Bravo pH capsule in children

GOALS

To prospectively evaluate the tolerability and clinical utility of the Bravo pH capsule in children.

BACKGROUND

Acid reflux is common in children, and pH testing can be used to correlate acid exposure with symptom expression. The tolerability and clinical utility of the Bravo capsule in children has not been prospectively evaluated.

METHODS

This was a prospective, open-label trial conducted at an academic medical center. Patient demographics, symptoms, and medication use were recorded in an outpatient setting. After Bravo capsule placement, patients were followed to determine whether the results of the Bravo capsule study changed clinical management.

RESULTS

Fifty children (mean+/-SD=13+/-3 y; 52% female) were studied; no complications occurred. Reflux symptoms (40%), abdominal pain (18%), and nausea/vomiting (14%) were the 3 most common symptoms leading to Bravo capsule placement. Nearly all studies (96%) were performed off acid-suppressing medications. Results of the Bravo pH study changed clinical care in 88% of children; management changed more frequently in children with an abnormal study (94%) versus those with a normal study (78%; P<0.0001).

CONCLUSIONS

The Bravo pH capsule is a safe, well-tolerated test to evaluate acid reflux symptoms in children, and the data obtained frequently changes patient management.

Reproducibility of 24-hour combined multiple intraluminal impedance (MII) and pH measurements in infants and children. Evaluation of a diagnostic procedure for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common disease in infants and children. Prolonged (24-hr) pH monitoring in the esophagus for determination of increased acid exposure has, together with endoscopy, been the only routinely implemented method for GERD diagnosis. The recently introduced multiple intraluminal impedance (MII) provides additional information about the number of both acid and nonacid episodes of retrograde bolus movement in the esophagus. The aim of this study was to investigate the day-to-day reproducibility and the interobserver variability of 24-hr combined MII (number of nonacid and acidic reflux episodes) and pH in the esophagus in infants and children. Upper endoscopy followed by 2 x 24-hr consecutive combined MII and pH monitoring was performed in 33 infants and children referred to a tertiary center for evaluation of GERD. The study was performed in a hospital setting without dietary restrictions. Bland-Altman difference versus mean plots and calculation of the limits of agreement (LOA) were used for assessment of the reproducibility of the total number of acidic and nonacidic reflux episodes. LOA for the number of acidic reflux episodes on day 2 were 0.2-5.3 times the value obtained on day 1. For the total number of nonacidic reflux episodes, LOA were 0.04-8.6; for the total number of reflux episodes, 0.3-3.3. An abnormal reflux index on one or both recording days was found in 7 of 30 patients. In conclusion, considerable day-to-day variability was found for nonacidic reflux episodes. Less variability was found for acidic reflux episodes. This variability must be taken into consideration for the use of MII in the clinical evaluation of infants and children with GERD.

Wireless pH monitoring: better tolerability and lower impact on daily habits

BACKGROUND

Twenty-four hours oesophageal pH monitoring is considered the reference-standard for the diagnosis of gastro-oesophageal reflux disease, but it is limited by catheter discomfort and limitations of daily habits.

AIM

We evaluated tolerability and impact on food intake and daily activities of catheter-based compared to wireless pH monitoring.

PATIENTS

One-hundred and thirty-three consecutive patients with suspected gastro-oesophageal reflux disease were enrolled.

METHODS

Seventy-eight patients (36 M, 53+/-2 years) underwent the 24 h catheter-based and 55 patients (25 M, 44+/-3 years) the 48 h wireless pH monitoring. Discomfort at placement and during the test was evaluated by 100 mm visual analogue scales. Limitations of food intake and of daily activities were evaluated by standardized questionnaires (score 0 to 3).

RESULTS

Discomfort (mean+/-standard error of the mean) at placement and during the test was 32+/-3 versus 29+/-4 (p=ns) and 37+/-3 versus 22+/-3 (p<0.001) for the catheter-based versus wireless techniques. Limitation of food intake and of daily activities (mean+/-standard error of the mean) were 0.9+/-0.1 versus 0.4+/-0.1 (p<0.05) and 1.2+/-0.1 versus 0.2+/-0.1 (p<0.0001), respectively.

CONCLUSIONS

The wireless pH monitoring is better tolerated and has minor impact on daily habits compared to the traditional technique. Whether this translates into better diagnostic accuracy remains to be evaluated.

Extraesophageal reflux in children

PURPOSE OF REVIEW

To summarize and contextualize current concepts in the incidence, diagnosis, management and long-term sequelae of extraesophageal reflux disease in children.

RECENT FINDINGS

Extraesophageal reflux disease is a different disease entity from gastroesophageal reflux disease. The two diseases have a common etiology, refluxate causing mucosal damage, but the extent and location of the damage varies considerably depending on the underlying mucosal characteristics. Extraesophageal reflux disease in children is characterized by a broad set of symptoms and signs that vary according to age at presentation and severity of disease. Serious long-term effects begin in childhood. The role of pepsin, bile acids, pancreatic enzymes, motility disorders, and food allergies have only recently been recognized. Newer diagnostic modalities include multichannel intraluminal pH/impedance, the 48 h Bravo implantable probe, and hypopharyngeal pH monitoring. While proton pump inhibitors provide superior acid suppression compared with histamine-2 blockers, variability in response and lack of efficacy for alkaline refluxate often require other therapeutic interventions.

SUMMARY

Pediatric extraesophageal reflux disease has variable presentation and a gold standard test is still lacking. Primary treatment includes lifestyle and feeding changes and medical therapy. Ongoing monitoring for recurrence and agreement as to duration of therapy present significant challenges not yet standardized amongst practitioners.

Gastroesophageal reflux disease in 2006. The imperfect diagnosis

There continues to be significant controversy related to diagnostic testing for gastroesophageal reflux disease (GERD). Clearly, barium contrast fluoroscopy is superior to any other test in defining the anatomy of the upper gastrointestinal (UGI) tract. Although fluoroscopy can demonstrate gastroesophageal reflux (GER), this observation does not equate to GERD. Fluoroscopy time should not be prolonged to attempt to demonstrate GER during barium contrast radiography. There are no data to justify prolonging fluoroscopy time to perform provocative maneuvers to demonstrate reflux during barium contrast UGI series. Symptoms of GERD may be associated with physiologic esophageal acid exposure measured by intraesophageal pH monitoring, and a significant percentage of patients with abnormal esophageal acid exposure have no or minimal clinical symptoms of reflux. Abnormal acid exposure defined by pH monitoring over a 24-h period does not equate to GERD. In clinical practice presumptive diagnosis of GERD is reasonably assumed by substantial reduction or elimination of suspected reflux symptoms during therapeutic trial of acid reduction therapy.