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.
Similar content being viewed by others
References
Moore JM, Vaezi MF (2010) Extraesophageal manifestations of gastroesophageal reflux disease: real or imagined? Curr Opin Gastroenterol 26:389–394
Heidelbaugh JJ, Gill AS, Van Harrison R et al (2008) Atypical presentations of gastroesophageal reflux disease. Am Fam Physician 78:483–488
Stefanidis D, Hope WW, Kohn GP et al (2010) Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 24:2647–2669
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 87:1102–1111
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 114:177–182
Wo JM, Jabbar A, Winstead W et al (2002) Hypopharyngeal pH monitoring artifact in detection of laryngopharyngeal reflux. Dig Dis Sci 47:2579–2585
Johnson LF, Demeester TR (1974) Twenty-four-hour pH monitoring of the distal esophagus: a quantitative measure of gastroesophageal reflux. Am J Gastroenterol 62:325–332
Sweet MP, Herbella FA, Leard L et al (2006) The prevalence of distal and proximal gastroesophageal reflux in patients awaiting lung transplantation. Ann Surg 244:491–497
Bove M, Ruth M, Cange L et al (2000) 24-h Pharyngeal pH monitoring in healthy volunteers: a normative study. Scand J Gastroenterol 35:234–241
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 101:1–78
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 24–25
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 210:345–350
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 44:23–31
Ulualp SO, Toohill RJ, Shaker R (1999) Pharyngeal acid reflux in patients with single and multiple otolaryngologic disorders. Otolaryngol Head Neck Surg 121:725–730
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 25:678–681
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 52:451–456
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 6:189–194
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 163:401–406
Patti MG, Arcerito M, Tamburini A et al (2000) Effect of laparoscopic fundoplication on gastroesophageal reflux disease-induced respiratory symptoms. J Gastrointest Surg 4:143–149
Wright RA, Miller SA, Corsello BF (1990) Acid-induced esophagobronchial-cardiac reflexes in humans. Gastroenterology 99:71–73
Agrawal A, Roberts J, Sharma N et al (2009) Symptoms with acid and nonacid reflux may be produced by different mechanisms. Dis Esophagus 22:467–470
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 99:981–988
Herbella FA (2012) Critical analysis of esophageal multichannel intraluminal impedance monitoring 20 years later. ISRN Gastroenterol 2012:903240. doi:10.5402/2012/903240
Misra S (2010) Can acid (pH) refluxes predict multichannel intraluminal impedance refluxes? A correlation study. J Gastroenterol Hepatol 25:817–822
Dobhan R, Castell DO (1993) Normal and abnormal proximal esophageal acid exposure: results of ambulatory dual-probe pH monitoring. Am J Gastroenterol 88:25–29
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 49:1607–1611
Ceccatelli P, Mariottini M, Agnolucci A et al (1998) Acid exposure of proximal esophagus in healthy subjects. Minerva Gastroenterol Dietol 44:129–134
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.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Neto, S.C.P., Herbella, F.A.M., Silva, L.C. et al. Ratio Between Proximal/Distal Gastroesophageal Reflux Does Not Discriminate Abnormal Proximal Reflux. World J Surg 38, 890–896 (2014). https://doi.org/10.1007/s00268-013-2341-x
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00268-013-2341-x