Giorgia Mazzoleni

Oropharyngeal pH Monitoring for Laryngopharyngeal Reflux: Is It a Reliable Test Before Therapy?

OBJECTIVE Current methods of measuring pharyngeal pH are problematic. The aim of the study was to assess the ability of the oropharyngeal pH monitoring (Restech) in predicting the response to proton pump inhibitor (PPI) therapy in patients with gastroesophageal reflux disease-related laryngopharyngeal symptoms. STUDY DESIGN The study design is prospective and uncontrolled. METHODS Twenty-two consecutive naive patients with chronic laryngeal symptoms were enrolled. Reflux symptom index, fibrolaryngoscopy, and 24-hour oropharyngeal pH monitoring were performed. Both patients and laryngoscopist were blinded by the results of Restech. All the patients were given a 3-month therapy with pantoprazole of 40mg twice a day and then repeated both the reflux symptom index and fibrolaryngoscopic evaluation. Patients were considered as responders if a five-point decrease in symptom score was recorded. RESULTS Thirteen of the 22 patients (59.1%) responded to therapy. Laryngoscopic findings did not correlate with the clinical improvement after the 3 months of PPI. Nine patients (40.9%) had a pathologic Restech study, and all resulted responsive to PPI; nine patients (40.9%) with a negative Restech were nonresponsive to PPI, and four patients (18.2%) despite a negative Restech resulted responsive to therapy. Responsive patients showed both a higher oropharyngeal acid exposure in orthostatic position and a higher Ryan score, compared with nonresponders (49.74±58.11 vs 2.12±0.0, P=0.002). Considering responsiveness to medical therapy as the gold standard of laryngopharyngeal reflux (LPR) for the diagnosis of LPR, Restech showed a sensitivity of 69% and a specificity of 100%. CONCLUSIONS The high specificity and reasonable sensitivity of this technique make the Restech an interesting tool before therapy of patients with pharyngoesophageal reflux.

A single-centre prospective, cohort study of the natural history of acute pancreatitis

BACKGROUND The natural history of acute pancreatitis is based on clinical studies that aim to elucidate the course of disease on the basis of predicted risk factors. AIMS To evaluate the long-term occurrence of recurrent acute pancreatitis and chronic pancreatitis in a cohort of patients following an initial episode of acute pancreatitis. METHODS 196 patients were enrolled consecutively and studied prospectively. Clinical characteristics, exogenously/endogenously-associated factors, and evolution to recurrent acute pancreatitis and chronic pancreatitis were analyzed. RESULTS 40 patients developed recurrent acute pancreatitis 13 of whom developed chronic pancreatitis. In a univariate analysis, recurrent acute pancreatitis was associated with an idiopathic aetiology (p<0.001), pancreas divisum (p=0.001), and higher usage of cigarettes and alcohol (p<0.001; p=0.023). Chronic pancreatitis was associated with a severe first episode of acute pancreatitis (p=0.048), PD (p=0.03), and cigarette smoking (p=0.038). By multivariate analysis, pancreas divisum was an independent risk factor for recurrent acute pancreatitis (OR 11.5, 95% CI 1.6-83.3). A severe first-episode of acute pancreatitis increased the risk of progressing to chronic pancreatitis by nine-fold. CONCLUSIONS Special attention should be given to patients who experience a severe first attack of acute pancreatitis as there appears to be an increased risk of developing chronic pancreatitis over the long term.

Correlation between oropharyngeal pH‐monitoring and esophageal pH‐impedance monitoring in patients with suspected GERD‐related extra‐esophageal symptoms

24‐hour esophageal pH‐impedance (pH‐MII) is not totally reliable for laryngopharyngeal reflux (LPR). Oropharyngeal (OP) pH‐monitoring with the Dx‐pH probe may detect LPR better. The correlation between these two techniques is not thoroughly established. Aim of this study is to examine the correlation between OP pH‐metry and esophageal pH‐MII monitoring.

Transoral incisionless fundoplication for gastro-esophageal reflux disease: Techniques and outcomes

Gastro-esophageal reflux disease (GERD) is a very common disorder that results primarily from the loss of an effective antireflux barrier, which forms a mechanical obstacle to the retrograde movement of gastric content. GERD can be currently treated by medical therapy, surgical or endoscopic transoral intervention. Medical therapy is the most common approach, though concerns have been increasingly raised in recent years about the potential side effects of continuous long-term medication, drug intolerance or unresponsiveness, and the need for high dosages for long periods to treat symptoms or prevent recurrences. Surgery too may in some cases have consequences such as long-lasting dysphagia, flatulence, inability to belch or vomit, diarrhea, or functional dyspepsia related to delayed gastric emptying. In the last few years, transoral incisionless fundoplication (TIF) has proved an effective and promising therapeutic option as an alternative to medical and surgical therapy. This review describes the steps of the TIF technique, using the EsophyX(®) device and the MUSE(TM) system. Complications and their management are described in detail, and the recent literature regarding the outcomes is reviewed. TIF reconfigures the tissue to obtain a full-thickness gastro-esophageal valve from inside the stomach, by serosa-to-serosa plications which include the muscle layers. To date the procedure has achieved lasting improvement of GERD symptoms (up to six years), cessation or reduction of proton pump inhibitor medication in about 75% of patients, and improvement of functional findings, measured by either pH or impedance monitoring.

2-Litre polyethylene glycol-citrate-simethicone plus bisacodyl versus 4-litre polyethylene glycol as preparation for colonoscopy in chronic constipation.

BACKGROUND Chronic constipation is a risk factor of inadequate bowel preparation for colonoscopy; however, no large clinical trials have been performed in this subgroup of patients. AIMS To compare bowel cleansing efficacy, tolerability and acceptability of 2-L polyethylene-glycol-citrate-simethicone (PEG-CS) plus 2-day bisacodyl (reinforced regimen) vs. 4-L PEG in patients with chronic constipation undergoing colonoscopy. METHODS Randomized, observer-blind, parallel group study. Adult outpatients undergoing colonoscopy were randomly allocated to 2-L PEG-CS/bisacodyl or 4-L PEG, taken as split regimens before colonoscopy. Quality of bowel preparation was assessed by the Ottawa Bowel Cleansing Scale (OBCS). The amount of foam/bubble interfering with colonic visualization was also measured. RESULTS 400 patients were enrolled. There was no significant difference in successful cleansing (OBCS score ≤6): 80.2% in the 2-L PEG-CS/bisacodyl vs. 81.4% in the 4-L PEG group. Significantly more patients taking 2L PEG-CS/bisacodyl showed no or minimal foam/bubbles in all colonic segments (80% vs. 63%; p<0.001). 2-L PEG-CS/bisacodyl was significantly more acceptable for ease of administration (p<0.001), willingness to repeat (p<0.001) and showed better compliance (p=0.002). CONCLUSION Split 2-L PEG-CS plus bisacodyl was not superior to split 4-L PEG for colonoscopy bowel cleansing in patients with chronic constipation; however, it performed better than the standard regimen in terms of colonic mucosa visualization, patient acceptance and compliance.

Oropharyngeal acid reflux and motility abnormalities of the proximal esophagus

AIM To investigate the relationship between pathological oropharyngeal (OP) acid exposure and esophageal motility in patients with extra-esophageal syndromes. METHODS In this prospective study we enrolled consecutive outpatients with extra-esophageal symptoms suspected to be related to gastroesophageal reflux disease (GERD). We enrolled only patients with a reflux symptom index (RSI) score-higher than 13 and with previous lung, allergy and ear, nose and throat evaluations excluding other specific diagnoses. All patients underwent 24-h OP pH-metry with the Dx probe and esophageal high-resolution manometry (HRM). Patients were divided into two groups on the basis of a normal or pathological pH-metric finding (Ryan Score) and all manometric characteristics of the two groups were compared. RESULTS We examined 135 patients with chronic extra-esophageal syndromes. Fifty-one were considered eligible for the study. Of these, 42 decided to participate in the protocol. Patients were divided into two groups on the basis of normal or pathological OP acid exposure. All the HRM parameters were compared for the two groups. Significant differences were found in the median upper esophageal sphincter resting pressure (median 71 mmHg vs 126 mmHg, P = 0.004) and the median proximal contractile integral (median 215.5 cm•mmHg•s vs 313.5 cm•mmHg•s, P = 0.039), both being lower in the group with pathological OP acid exposure, and the number of contractions with small or large breaks, which were more frequent in the same group. This group also had a larger number of peristaltic contractions with breaks in the 20 mmHg isobaric contour (38.7% vs 15.38%, P < 0.0001). CONCLUSION In patients with suspected GERD-related extra-esophageal syndromes pathological OP acid exposure was associated with weaker proximal esophageal motility.

PH-impedance findings and proton pump inhibitors-responsiveness in patients with typical gastroesophageal reflux disease symptoms in a large single-center Italian Series

Introduction: A multicenter study with a limited sample size found that absence of esophagitis, presence of functional digestive disorders, and overweight were associated with proton pump inhibitors (PPI) failure. Aim: To assess clinical and reflux patterns associated with PPI-responsiveness. Materials and Methods: Patients with typical gastroesophageal reflux disease (GORD) symptoms had 24 hours pH-impedance monitoring off therapy. Responders had <2 days of symptoms per week while on standard-dose/double-dose PPI. Clinical and reflux parameters were considered for analysis. Results: A total of 514 patients were included (267 women), 185 patients were considered PPI responders, and 329 were considered nonresponders. In the whole population, the only significant factor in the prediction of responsiveness to PPI at the multivariate analysis was the presence of esophagitis (P=0.028). The factors identified as significant in patients with a pathologic acid exposure (142 patients) in the prediction of responsiveness to PPI were overweight (body mass index >25 kg/m2) and the presence of esophagitis (P=0.019 and 0.043, respectively). Conclusions: We confirm that no reflux pattern demonstrated by 24 hours pH-impedance monitoring is associated to PPI response in GORD patients. Presence of esophagitis in the whole population and overweight in patients with pathologic GORD, but not dyspepsia, are strongly associated with PPI-responsiveness.

An Italian family with inherited achalasia

We illustrate the case of a European family with an autosomal ominant pattern of achalasia. To date, very few reports of inherited esophageal achalasia have been published [1], most of them with n autosomal recessive pattern. A 55-year female patient was referred to our motility lab with omplaints of chronic recurrent episodes of cough, pneumonia and ronchitis. These symptoms had occurred for the first time 5 years arlier, and recently had became more frequent. Intermittent mild ysphagia had appeared 20 years earlier, but she developed avoidnce behaviours to overcome this problem and had never reported his symptom to her primary care physician. A previous total-body ontrast-enhanced compute tomography scan showed pneumoia and ingested foods within the oesophagus in the absence f neoplastic changes of the oesophago-gastric junction. Upper astro-intestinal endoscopy was then performed, which showed narrowed cardia. High-resolution manometry was performed with a probe ith 36 solid-state transducers (Medical Measurement System, MS, Netherlands). The manometric tracing was diagnostic for esophageal achalasia (type II according the Chicago Classification) ith a hypertensive lower oesophageal sphincter (LES, Fig. 1a). The roposed treatment was pneumatic dilation. Five members of the patient’s family belonging to 3 consecutive enerations were found to have achalasia (Fig. 1b). The family orignated from Southern Italy, but was currently settled in the north f Italy. The patient’s father had been diagnosed with achalasia at he age of 85; he also suffered from G6PD deficiency. Three daughers also had a diagnosis of achalasia; two of them were treated

Endoluminal Therapy for Treatment of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common disorder that is currently treated by medical therapy and surgical or endoscopic transoral interventions. Medical therapy is the most common approach, though concerns have been raised in recent years about the potential side effects of continuous long-term medication, drug intolerance, or unresponsiveness and the need for high dosages for long periods to treat symptoms or prevent recurrences. Surgery too may have consequences such as long-lasting dysphagia, flatulence, inability to belch or vomit, diarrhea, or functional dyspepsia related to delayed gastric emptying. For these reasons in the last 15 years, a variety of transoral endoscopic techniques have been developed as alternatives to antisecretory therapy or antireflux surgery. Endoluminal techniques included three categories (implantation or injection of foreign materials, application of radiofrequency ablation, and endoscopic tissue apposition techniques) and showed significant symptom control in the short-term period in the majority of published studies. However, most of them had disappointing long-term results or did not demonstrate long-lasting benefits and have been abandoned. In the last years, transoral incisionless fundoplication has been shown to be an effective and promising therapeutic option, allowing endoscopists to bring the surgical principles of an anterior partial fundoplication to patients with fewer post-fundoplication complications than surgery. Two FDA-approved endoluminal platforms are currently available, namely, the EsophyX® device and the MUSE™ system: improvement of GERD symptoms up to 6 years, cessation or reduction of proton pump inhibitor medication in about 75 % of patients, and improvement of functional findings, measured by either pH or impedance monitoring, have been shown with these techniques.