Can multichannel intraluminal pH-impedance monitoring be limited to 3 hours? Comparison between ambulatory 24-hour and post-prandial 3-hour recording

Digestive Biomarkers of Laryngopharyngeal Reflux: A Preliminary Prospective Controlled Study

OBJECTIVE

To investigate the digestive enzymes and biomarkers in the saliva of patients with laryngopharyngeal reflux (LPR) and asymptomatic individuals.

STUDY DESIGN

Prospective controlled study.

SETTING

Multicenter study.

METHODS

Patients with LPR at the hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH) and asymptomatic individuals were consecutively recruited from January 2020 to April 2023 from 2 University Hospitals. The saliva of patients (off PPIs) and asymptomatic individuals was collected to measure pH, elastase, bile salts, cholesterol, gastric, and pancreatic lipases. Anxiety, symptoms, and findings were studied through perceived stress scale (PSS), reflux symptom score (RSS), and reflux sign assessment (RSA).

RESULTS

Sixty-seven LPR patients and 57 asymptomatic individuals completed the evaluations. LPR patients reported higher PSS, RSS, and RSA than asymptomatic individuals. The mean saliva pH was more alkaline in LPR patients (7.23: 95% confidence interval [CI]: 7.08, 7.38) compared to controls (6.13; 95% CI: 5.95, 6.31; P = .001). The mean concentration of elastase was higher in patients (51.65 µg/mL; 95% CI: 44.47, 58.83 µg/mL) versus asymptomatic individuals (25.18 µg/mL; 95% CI: 21.64, 28.72 µg/mL; P = .001). The saliva cholesterol reported higher concentration in healthy individuals (3.43 mg/dL; 95% CI: 3.21, 3.65 mg/dL) compared to patients (1.16 mg/dL; 95% CI: 1.05, 1.27 mg/dL; P = .001). The saliva pH, and elastase concentration were significantly associated with the baseline RSS, while saliva cholesterol was negatively associated with the severity of RSS and RSA.

CONCLUSION

Cholesterol, bile salts, and elastase are biomarkers of LPR and should be considered to develop future non-invasive saliva device for the detection of LPR.

Difference in meal-related esophageal intraluminal impedance change between gastroesophageal reflux disease and functional disorders

OBJECTIVES

Gastroesophageal reflux disease (GERD) has overlapping symptoms with functional disorders such as functional heart burn. Twenty-four-hour pH with impedance monitoring is useful for differentiation. The intraluminal impedance change with meal in distal esophagus is not investigated.

METHODS

We performed a retrospective investigation of clinical files, 24-hour pH with intraluminal impedance monitoring in patients with GERD and functional disorders. The post-reflux swallow induced peristaltic wave (PSPW) index as well as the impedance in distal esophagus before the first meal and 30 min and 60 min after the meal were measured and analyzed.

RESULTS

A significant decrease of intraluminal impedance in distal esophagus was noted at 30 min (ΔI_30min -301.5 [747.5] Ω, p = 0.018) and recovered at 60 min (ΔI_60min -194.6 [766.0] Ω, p = 0.126) after meals in GERD patients. On the other hand, there was no significant change of impedance in patients with functional disorders. There were positive correlations between ΔI_30min and PSPW index (correlation = 0.232, p = 0.038). Comparing GERD to functional disorders, the best cut-off value for ΔI_30min was -212Ω with 74.4% sensitivity and 60.5% specificity.

CONCLUSIONS

The intraluminal impedance in distal esophagus was lowered after meals in GERD patients other than functional disorders. This impedance change was correlated with PSPW index and could help differentiate GERD from functional disorders.

Hypopharyngeal-Esophageal Impedance-pH Monitoring Profiles of Laryngopharyngeal Reflux Patients

OBJECTIVES/HYPOTHESIS

To investigate the profile of patients with laryngopharyngeal reflux (LPR) at hypopharyngeal-esophageal multichannel intraluminal impedance-pH (HEMII-pH) monitoring and the relationship between hypopharyngeal-proximal reflux episodes (HREs) and saliva pepsin concentration.

STUDY DESIGN

Prospective non-controlled.

METHODS

Patients were recruited from three European hospitals from January 2018 to October 2019. Patients benefited from HEMII-pH monitoring and saliva collections to measure saliva pepsin concentration in the same time. Saliva pepsin concentration was measured in the morning (fasting), after lunch, and after dinner. The LPR profile of patients was studied through a breakdown of the HEMII-pH findings over the 24 hours of testing. The relationship between the concentrations of saliva pepsin and 24-hour HREs was studied through linear multiple regression.

RESULTS

One hundred twenty-six patients completed the study. The HEMII-pH analyses revealed that 73.99% of HREs occurred outside 1-hour postmeal times, whereas 20.49% and 5.52% of HREs occurred during the 1-hour postmeal and nighttime, respectively. Seventy-four patients (58.73%) did not have nighttime HREs. Patients with both daytime and nighttime HREs had more severe HEMII-pH parameters and reflux symptom score compared with patients with only daytime HREs. There were no significant associations between HREs and saliva pepsin concentration.

CONCLUSIONS

Unlike gastroesophageal reflux disease, HREs occur less frequently after meals and nighttime. The analysis of the HEMII-pH profile of the LPR patients has to be considered to develop future personalized therapeutic strategies.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:268-276, 2021.

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.

Esophageal Impedance Monitoring: Clinical Pearls and Pitfalls

The development of intraluminal esophageal impedance monitoring has improved our ability to detect and measure gastroesophageal reflux without dependence on acid content. This ability to detect previously unrecognized weak or nonacid reflux episodes has had important clinical implications in the diagnosis and management of gastroesophageal reflux disease (GERD). In addition, with the ability to assess bolus transit within the esophageal lumen, impedance monitoring has enhanced the recognition and characterization of esophageal motility disorders in patients with nonobstructive dysphagia. The assessment of the intraluminal movement of gas and liquid has also been proven to be of diagnostic value in conditions such as rumination syndrome and excessive belching. Further, alternative applications of impedance monitoring, such as the measurement of mucosal impedance, have provided novel insights into assessing esophageal mucosal integrity changes as a consequence of inflammatory change. Future applications for esophageal impedance monitoring also hold promise in esophageal conditions other than GERD. However, despite all of the clinical benefits afforded by esophageal impedance monitoring, important clinical and technical shortcomings limit its diagnostic value and must be considered when interpreting study results. Overinterpretation of studies or application of impedance monitoring in patients can have deleterious clinical implications. This review will highlight the clinical benefits and limitations of esophageal impedance monitoring and provide clinical pearls and pitfalls associated with this technology.