Advertisement

World Journal of Surgery

, Volume 38, Issue 4, pp 890–896 | Cite as

Ratio Between Proximal/Distal Gastroesophageal Reflux Does Not Discriminate Abnormal Proximal Reflux

  • Sebastião Carlos Pannocchia Neto
  • Fernando A. M. Herbella
  • Luciana C. Silva
  • Marco G. Patti
Article

Abstract

Introduction

The threshold for pathologic proximal acid reflux is a controversial topic. Most values previously published are based on absolute numbers. We hypothesized that a relative value representing the quantitative relation between the amount of acid reflux that reaches proximal levels and the amount of distal reflux would be a more adequate parameter for defining pathologic proximal reflux.

Methods

We studied 20 healthy volunteers (median age 30 years, 70 % women) without gastroesophageal reflux disease (GERD); 50 patients (median age 51 years, 60 % women) with esophageal symptoms of GERD (heartburn, regurgitation); and 50 patients (median age 49 years, 60 % women) with extra-esophageal symptoms of GERD. All individuals underwent manometry and dual-probe pH monitoring. GERD was defined as a DeMeester score >14.7. The proximal/distal reflux ratio was calculated for all six parameters that constitute the DeMeester score.

Results

Absolute numbers for proximal reflux were not different for the three groups except for the number of episodes of reflux, which was higher for patients with GERD and esophageal symptoms than for patients with GERD and extra-esophageal symptoms (p = 0.007). The number of episodes of distal reflux reaching proximal levels was significantly higher in volunteers than in all patients with GERD and significantly higher in patients with GERD and esophageal symptoms than in those with extra-esophageal symptoms.

Conclusions

Our results suggest that the proximal/distal reflux ratio is not a good normative value for defining proximal reflux.

Keywords

Lower Esophageal Sphincter Acid Exposure GERD Patient DeMeester Score Proximal Sensor 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

We are indebted to Ms. Mirian Wolfarth and Ms. Priscila M.A. Capuzzo for their invaluable assistance with the tests. Dr. Sebastião C.P. Neto was funded by a governmental funding agency, the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior.

References

  1. 1.
    Moore JM, Vaezi MF (2010) Extraesophageal manifestations of gastroesophageal reflux disease: real or imagined? Curr Opin Gastroenterol 26:389–394PubMedCrossRefGoogle Scholar
  2. 2.
    Heidelbaugh JJ, Gill AS, Van Harrison R et al (2008) Atypical presentations of gastroesophageal reflux disease. Am Fam Physician 78:483–488PubMedGoogle Scholar
  3. 3.
    Stefanidis D, Hope WW, Kohn GP et al (2010) Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 24:2647–2669PubMedCrossRefGoogle Scholar
  4. 4.
    Jamieson JR, Stein HJ, DeMeester TR et al (1992) Ambulatory 24-h esophageal pH monitoring: normal values, optimal thresholds, specificity, sensitivity, and reproducibility. Am J Gastroenterol 87:1102–1111PubMedGoogle Scholar
  5. 5.
    Merati AL, Lim HJ, Ulualp SO et al (2005) Meta-analysis of upper probe measurements in normal subjects and patients with laryngopharyngeal reflux. Ann Otol Rhinol Laryngol 114:177–182PubMedGoogle Scholar
  6. 6.
    Wo JM, Jabbar A, Winstead W et al (2002) Hypopharyngeal pH monitoring artifact in detection of laryngopharyngeal reflux. Dig Dis Sci 47:2579–2585PubMedCrossRefGoogle Scholar
  7. 7.
    Johnson LF, Demeester TR (1974) Twenty-four-hour pH monitoring of the distal esophagus: a quantitative measure of gastroesophageal reflux. Am J Gastroenterol 62:325–332PubMedGoogle Scholar
  8. 8.
    Sweet MP, Herbella FA, Leard L et al (2006) The prevalence of distal and proximal gastroesophageal reflux in patients awaiting lung transplantation. Ann Surg 244:491–497PubMedCentralPubMedGoogle Scholar
  9. 9.
    Bove M, Ruth M, Cange L et al (2000) 24-h Pharyngeal pH monitoring in healthy volunteers: a normative study. Scand J Gastroenterol 35:234–241PubMedCrossRefGoogle Scholar
  10. 10.
    Koufman JA (1991) The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 101:1–78PubMedCrossRefGoogle Scholar
  11. 11.
    Hoppo T, Sanz AF, Nason KS et al (2012) How much pharyngeal exposure is “normal”? Normative data for laryngopharyngeal reflux events using hypopharyngeal multichannel intraluminal impedance (HMII). J Gastrointest Surg 16:16–24 discussion 24–25PubMedCrossRefGoogle Scholar
  12. 12.
    Ayazi S, Hagen JA, Zehetner J et al (2010) Proximal esophageal pH monitoring: improved definition of normal values and determination of a composite pH score. J Am Coll Surg 210:345–350PubMedCrossRefGoogle Scholar
  13. 13.
    Andersson O, Möller RY, Finizia C et al (2009) A more than 10-year prospective, follow-up study of esophageal and pharyngeal acid exposure, symptoms and laryngeal findings in healthy, asymptomatic volunteers. Scand J Gastroenterol 44:23–31PubMedCrossRefGoogle Scholar
  14. 14.
    Ulualp SO, Toohill RJ, Shaker R (1999) Pharyngeal acid reflux in patients with single and multiple otolaryngologic disorders. Otolaryngol Head Neck Surg 121:725–730PubMedCrossRefGoogle Scholar
  15. 15.
    Roberts JR, Aravapalli A, Pohl D et al (2012) Extraesophageal gastroesophageal reflux disease (GERD) symptoms are not more frequently associated with proximal esophageal reflux than typical GERD symptoms. Dis Esophagus 25:678–681PubMedCrossRefGoogle Scholar
  16. 16.
    Korkmaz M, Tarhan E, Unal H et al (2007) Esophageal mucosal sensitivity: possible links with clinical presentations in patients with erosive esophagitis and laryngopharyngeal reflux. Dig Dis Sci 52:451–456PubMedCrossRefGoogle Scholar
  17. 17.
    Oelschlager BK, Eubanks TR, Maronian N et al (2002) Laryngoscopy and pharyngeal pH are complementary in the diagnosis of gastroesophageal-laryngeal reflux. J Gastrointest Surg 6:189–194PubMedCrossRefGoogle Scholar
  18. 18.
    Patti MG, Debas HT, Pellegrini CA (1992) Esophageal manometry and 24-hour pH monitoring in the diagnosis of pulmonary aspiration secondary to gastroesophageal reflux. Am J Surg 163:401–406PubMedCrossRefGoogle Scholar
  19. 19.
    Patti MG, Arcerito M, Tamburini A et al (2000) Effect of laparoscopic fundoplication on gastroesophageal reflux disease-induced respiratory symptoms. J Gastrointest Surg 4:143–149PubMedCrossRefGoogle Scholar
  20. 20.
    Wright RA, Miller SA, Corsello BF (1990) Acid-induced esophagobronchial-cardiac reflexes in humans. Gastroenterology 99:71–73PubMedGoogle Scholar
  21. 21.
    Agrawal A, Roberts J, Sharma N et al (2009) Symptoms with acid and nonacid reflux may be produced by different mechanisms. Dis Esophagus 22:467–470PubMedCrossRefGoogle Scholar
  22. 22.
    Tack J, Koek G, Demedts I et al (2004) Gastroesophageal reflux disease poorly responsive to single-dose proton pump inhibitors in patients without Barrett’s esophagus: acid reflux, bile reflux, or both? Am J Gastroenterol 99:981–988PubMedCrossRefGoogle Scholar
  23. 23.
    Herbella FA (2012) Critical analysis of esophageal multichannel intraluminal impedance monitoring 20 years later. ISRN Gastroenterol 2012:903240. doi: 10.5402/2012/903240 PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Misra S (2010) Can acid (pH) refluxes predict multichannel intraluminal impedance refluxes? A correlation study. J Gastroenterol Hepatol 25:817–822PubMedCrossRefGoogle Scholar
  25. 25.
    Dobhan R, Castell DO (1993) Normal and abnormal proximal esophageal acid exposure: results of ambulatory dual-probe pH monitoring. Am J Gastroenterol 88:25–29PubMedGoogle Scholar
  26. 26.
    McCollough M, Jabbar A, Cacchione R et al (2004) Proximal sensor data from routine dual-sensor esophageal pH monitoring is often inaccurate. Dig Dis Sci 49:1607–1611PubMedCrossRefGoogle Scholar
  27. 27.
    Ceccatelli P, Mariottini M, Agnolucci A et al (1998) Acid exposure of proximal esophagus in healthy subjects. Minerva Gastroenterol Dietol 44:129–134PubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2013

Authors and Affiliations

  • Sebastião Carlos Pannocchia Neto
    • 1
  • Fernando A. M. Herbella
    • 1
  • Luciana C. Silva
    • 1
  • Marco G. Patti
    • 2
  1. 1.Department of Surgery, Escola Paulista de MedicinaFederal University of Sao PauloSão PauloBrazil
  2. 2.Department of Surgery, Pritzker School of MedicineUniversity of ChicagoChicagoUSA

Personalised recommendations