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T1677 Inspiratory Diaphragm Workout Improves GERD Symptoms and LES Function
respiratory symptoms were evaluated using standardized questionnaire. A 24-hour intraluminal impedance-pH (IIP) monitoring was performed in all 11 patients : 5 patients had normal IIP (group 2) and 6 patient had increased esophageal acid exposure time defining them as GERD associated with respiratory symptoms (group 3). The exhaled air was collected by condensation using a condenser (Ecoscreen) and the 8-IP levels were measured by immuno-enzymology (Cayman, Ann Arbor, MI) according to an automated method on EtiMax3000 (DiaSorin, Antony, France). RESULTS The exhaled 8-IP levels were not different between Groups 1 and 2 (respectively 17 ± 3 vs 34 ± 8 ng / L; p > 0.05), but were increased in the group 3 (63 ± 11 ng / L; p < 0.05 vs group 1 and 2). The pH of the exhaled air was not different among the 3 groups (respectively 7.16 ± 0,33; 7.12 ± 0.04; 7.04 ± 0.08; p> 0.05). In patients, the exhaled 8-IP levels were correlated with the acid exposure time (R = 0.62; p = 0.05), and with the number of liquid and/or mixed reflux with proximal extent (17 cm above the lower sphincter of the esophagus) during 24h (R = 0.75; p = 0.02). Conclusion GERD with respiratory symptoms is associated with an increased exhaled 8-IP levels, which is correlated with the acid exposure time and the proximal extent of reflux. This pilot study warrants further work to appreciate the usefulness of this marker to assess the involvement of the respiratory tract during GERD associated with respiratory symptoms.
Inspiratory Diaphragm Workout Improves GERD Symptoms and LES Function Miguel Souza, Tárcia N. Gomes, Ricardo B. Oliveira, Armênio A. Santos Crural diaphragm is an important component of LES. However, it is not know if improving diaphragmatic mechanics ameliorates LES function and GERD symptoms. We claim that the diaphragmatic component of LES is weakened in GERD, and that a diaphragmatic workout (DW) may enhance LES function and symptoms. METHODS. After local ethical committee approval, we studied 6 healthy (C) volunteers (age range: 20-41y, average age: 25.2y, 2 males), and 9 GERD volunteers (age range: 22-43y, average age: 36.3y, 6 males; 4 with grade LA A esophagitis, 1 with grade B, and 3 with NERD). Eight GERD volunteers enrolled in an inspiratory 5-days-a-week DW under progressive airway resistance (starting at 30% of maximal inspiratory pressure - maxIP - and increasing 5% every five days for 2 months). Each DW session consisted of 10 series of 15 inspirations. maxIP was measured with an analog vacuumeter, and inspiratory resistance was accomplished with an inspiratory resistive device (Threshold® IMT, Philips Respironics). Symptoms and functional studies (manometry and double-probe - 15 cm apart - ambulatory esophageal pH study) were done before and after the DW. A sleeve catheter was used to measure basal LES pressure (Pbasal), LES pressure increase after respiratory sinus arrhythmia maneuver (5-second inspiration and 5-second expiration, Prsa), and transient spontaneous relaxation (tLESR) after the first hour of a 200-mL chocolate-soya liquid meal (ADES, Unilever, Brazil). A frequency-based symptom score was attributed for heartburn and regurgitation (1-less than once a week, 2once a week, 3-two to 4 times a week, 4- more than 5 times a week). Healthy volunteers were submitted only to the manometric study. Data were presented in median and range, or mean and SEM, and analyzed as appropriate. RESULTS. GERD patients had a significantly (p=0.04) lower Pasr than controls (GERD: 151.7 ± 14.7 mmHg; C: 223.1 ± 30.9 mmHg). Pbasal were similar between GERD and controls (GERD: 32.6 ± 4.7 mmHg; C: 35.5 ± 2.3 mmHg). The number of tLESR decreased after DW [13.5/h (8-31) vs 25/h (16-38), p=0.04]. The sum of tLESR durations was shorter after DW (421.5 ± 61.9 minutes vs 814.9 ± 150.2 minutes, p=0.02). The score of heartburn and regurgitation decreased significantly after the DW [0 (0-10) vs 3 (1-4), p=0.001, and 0 (0-3) vs 1.5 (0-4), p=0.047, respectively]. Time pH < 4 (proximal esophagus, supine period) was shorter after DW but non-significantly (0.84 ± 0.81 minutes vs 1.79 ± 1.36 minutes, p=0.08). CONCLUSION. Voluntary diaphragmatic contraction seems important in the pathogenesis of GERD, and diaphragmatic workout improves both GERD symptoms and LES function.
T1680 Functional Heartburn Patients are Characterized by Increased Frequency and Perception of Liquid-Gas and Proximal Reflux Mentore Ribolsi, Sara Emerenziani, Paola Balestrieri, Maria Chiara Addarii, Michele Cicala Introduction: In functional heartburn (FH) patients, defined as poor or not responder to proton pump inhibitor (PPI) therapy, with normal pH-metric profile and negative symptomreflux association, the mechanisms of symptom production remain unclear. pH-impedance studies have identified the reflux pattern in non-erosive reflux disease (NERD) patients sensitive and non responder to PPIs, but no data are available in FH patients. Aim: To define the reflux pattern in FH patients. Methods: Of consecutive patients with recurrent typical GERD symptoms and no evidence of erosive esophagitis, those non responder (<50% improvement) to full or double dose PPI therapy (≥ 4 weeks), underwent, following a 3week washout of PPI or H2 antagonists, stationary manometry and ambulatory pH-impedance monitoring. Data were compared to those in 14 healthy volunteers (HV) and 32 PPI responder NERD patients. SAP index for acid, weakly acidic and all reflux episodes was calculated using dedicated software. Values in our HV were also compared to those in a Belgian-French cohort of HV (1). Results: 14/28 non-responder patients, showing negative SAP and normal esophageal acid exposure time (AET), were classified as FH patients. The remaining 14 non responders (NERD PPI-resistant) presented pathological AET (6) and/or positive SAP (14) for acid and/or weakly acidic reflux. 1288 reflux episodes were analyzed in NERD PPIsensitive, 1213 in NERD non-responders and 719 in FH patients. Proportions of reflux categories, in each group, are in table. Frequency of reflux episodes (mean±SD) was 40±5.5 in HV, 51±23.7 in FH, 86.7±57 in PPI-resistant and 40±17 in PPI-sensitive patients. Data in our HV were similar to those previously published. Of the 126 symptoms reported by FH patients, 28 (22%) were associated with reflux episodes, 87% with proximal and 71% with liquid-gas (mixed) reflux. Conclusions: Compared to HV, FH patients appear to be characterized by increased frequency of mixed and proximal reflux episodes, which also account for the few reflux-associated symptoms. The improved accuracy of pH-impedance monitoring reveals a peculiar reflux pattern in FH patients, whose dynamic feature resemble those in NERD PPI-resistant patients. 1) Zerbib F et al APT 2005
T1678 Evaluation of Esophageal Mucosa Integrity “In Vivo”. Validation of Basal Intraluminal Impedance Measurements to Assess Non-Erosive Changes Induced by Esophageal Acid Exposure in Rabbit and Healthy Human Subjects Ricard Farré, Kathleen Blondeau, Dominique Clement, María Vicario, Lucia Cardozo, Michael Vieth, Veerle Mertens, Ans Pauwels, Marcel Jimenez, Jan F. Tack, Daniel Sifrim Esophageal intraluminal impedance is currently used for assessment of acid and non acid gastro-esophageal reflux. Between swallows and reflux, the esophageal basal impedance tracing is relatively stable. Severe esophagitis is associated with low basal impedance. We hypothesized that basal impedance measurements could be used to evaluate acid inducednon erosive changes in esophageal mucosa integrity in man.Methods: We performed basal impedance measurements before during and after esophageal acid perfusion in healthy subjects and rabbits. 8 healthy volunteers underwent impedance measurements during 30min esophageal perfusions at 5 cm above LES using saline solutions at pH 7.2, 2.0 and 1.0 in different days and random order. Subjects scored heartburn or pain during the perfusion using a visual analogue scale (VAS, range 0-10). 15 New Zealand rabbits were anesthetized and esophageal impedance was recorded during 30 min of esophageal perfusion with saline solutions at pH 7.2, 1.5 and 1.0. Thereafter, rabbits were sacrificed and the esophageal mucosa was mounted in Ussing chambers to determine transepithelial mucosa resistance (Rt). Finally, the mucosa was assessed with transmission electron microscopy to determine diameter of intercellular spaces.Results: In healthy subjects, basal impedance was 2900±147 Ω. During the perfusions, impedance dropped dramatically and after perfusions, impedance increased. After the control solution (pH 7.2), the recovery was complete. In contrast, after saline pH 2.0 and 1.0 the impedance remained lower a 21.9±6.5 % and 52.7±5.0 %, (p<0.0001) compared to control solution. The median symptom score was higher during perfusions with solutions pH 1.0 than with control and pH 2.0 solutions (4.5, 0 and 0 respectively, p<0.05). There was a correlation between symptom score and change in basal impedance (r=-0.51, p=0.009). In rabbits, basal impedance was 4457±270 Ω.. After perfusion with saline pH 1.5 and 1.0 this value remained lower a 39.1±7.0 % (p<0.05) and 63.9±6.5 % (p<0.0001) respectively, compared to control. Tissues analyzed In Vitro showed a reduction in Rt of 20 % (p<0.05) and 65 % (p<0.0001) respectively, compared to control. There was a positive correlation between In Vivo basal impedance and In Vitro Rt values (r=0.72 and p=0.0021). Tissue showed no erosions under light microscopy but both acidic solutions induced dilated intercellular spaces from 0,01 ± 0,002 μm (control) to 0.12 ± 0,02 μm and 0.28 ± 0,06 μm respectively.Conclusions: Basal esophageal impedance measurements might be used to evaluate individual changes in esophageal mucosa integrity after exposure to acid solutions in man.
* p<0.05 vs HV T1681 Relevance of the Dynamic Pattern of Reflux Episodes in Non-Erosive Reflux Disease (NERD) Patients With Non-Cardiac Chest Pain Mentore Ribolsi, Sara Emerenziani, Maria Chiara Addarii, Paola Balestrieri, Michele Cicala Introduction: Mechanisms underlying non-cardiac chest pain (NCCP) are not fully elucidated. Gastro-esophageal reflux disease (GERD) appears to be the most common cause, whilst impaired esophageal motility seems to play a limited role in symptom generation. NERD patients are characterized by a higher sensitivity to intra-esophageal stimuli. Since no data are available in these patients concerning the relationship between chemical, physical and dynamic properties of reflux episodes and NCCP, this represents the aim of the study. Methods: of consecutive NERD patients with symptoms responding to proton pump inhibitors (PPIs), those presenting NCCP as the major symptom, underwent, following a 3-week washout of PPIs or H2 antagonists, ambulatory pH-impedance monitoring following a stationary manometry. Patients with esophageal motor disorders were excluded from the analysis. Overall, 19 patients were analyzed and data were compared to those in 20 NERD patients with typical GERD symptoms (heartburn). Reflux episodes were identified and classified according to standardized criteria. Bolus clearance time (BCT), i.e., the time frame between reflux entry and exit, was calculated at 5 cm above the LES. Results: A total of 1289 reflux episodes were analyzed in NERD patients with NCCP and 1120 in heartburn patients. Reflux data are shown in table. Frequency of reflux episodes (mean and 95% CI) was: 69 (48-90) in NCCP patients and 56 (40-72) in heartburn patients. A total of 72 and 61 symptomatic reflux episodes were analyzed, respectively, in NCCP and heartburn patients. AET (mean and 95% CI) was 5.2% (2.1-7.8%) in NCCP patients and 7.8% (4.6-10.4%) in heartburn patients. Conclusions: In NCCP patients, the large majority of symptomatic refluxes are liquid-gas (mixed) and proximal, with clearing being prolonged compared to asymptomatic reflux episodes. Symptomatic refluxes in NCCP patients are more frequently
T1679 Increased Exhaled 8-Isoprostane Levels During Gastro-Esophageal Reflux With Respiratory Symptoms: Results of a Pilot Study Caroline Elie, Guillaume Gourcerol, Eric Verin, Essmaeel Essmaeel, Alain Lavoinne, Philippe R. Ducrotté, Anne-Marie Leroi, Frederic Ziegler Introduction An increased release in 8-isoprostane (8-IP) in the exhaled air is a marker of oxidative stress during inflammatory respiratory processes. The aim of this work was determine whether exhaled 8-IP levels were increased in patients suffering from gastro-esophageal reflux disease (GERD) with respiratory symptoms. Patient and methods Eight healthy controls (group 1) and 11 patients reporting GERD symptoms were investigated. GERD as well as
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AGA Abstracts
AGA Abstracts
T1677
Inspiratory Diaphragm Workout Improves GERD Symptoms and LES Function Miguel Souza, Tárcia N. Gomes, Ricardo B. Oliveira, Armênio A. Santos Crural diaphragm is an important component of LES. However, it is not know if improving diaphragmatic mechanics ameliorates LES function and GERD symptoms. We claim that the diaphragmatic component of LES is weakened in GERD, and that a diaphragmatic workout (DW) may enhance LES function and symptoms. METHODS. After local ethical committee approval, we studied 6 healthy (C) volunteers (age range: 20-41y, average age: 25.2y, 2 males), and 9 GERD volunteers (age range: 22-43y, average age: 36.3y, 6 males; 4 with grade LA A esophagitis, 1 with grade B, and 3 with NERD). Eight GERD volunteers enrolled in an inspiratory 5-days-a-week DW under progressive airway resistance (starting at 30% of maximal inspiratory pressure - maxIP - and increasing 5% every five days for 2 months). Each DW session consisted of 10 series of 15 inspirations. maxIP was measured with an analog vacuumeter, and inspiratory resistance was accomplished with an inspiratory resistive device (Threshold® IMT, Philips Respironics). Symptoms and functional studies (manometry and double-probe - 15 cm apart - ambulatory esophageal pH study) were done before and after the DW. A sleeve catheter was used to measure basal LES pressure (Pbasal), LES pressure increase after respiratory sinus arrhythmia maneuver (5-second inspiration and 5-second expiration, Prsa), and transient spontaneous relaxation (tLESR) after the first hour of a 200-mL chocolate-soya liquid meal (ADES, Unilever, Brazil). A frequency-based symptom score was attributed for heartburn and regurgitation (1-less than once a week, 2once a week, 3-two to 4 times a week, 4- more than 5 times a week). Healthy volunteers were submitted only to the manometric study. Data were presented in median and range, or mean and SEM, and analyzed as appropriate. RESULTS. GERD patients had a significantly (p=0.04) lower Pasr than controls (GERD: 151.7 ± 14.7 mmHg; C: 223.1 ± 30.9 mmHg). Pbasal were similar between GERD and controls (GERD: 32.6 ± 4.7 mmHg; C: 35.5 ± 2.3 mmHg). The number of tLESR decreased after DW [13.5/h (8-31) vs 25/h (16-38), p=0.04]. The sum of tLESR durations was shorter after DW (421.5 ± 61.9 minutes vs 814.9 ± 150.2 minutes, p=0.02). The score of heartburn and regurgitation decreased significantly after the DW [0 (0-10) vs 3 (1-4), p=0.001, and 0 (0-3) vs 1.5 (0-4), p=0.047, respectively]. Time pH < 4 (proximal esophagus, supine period) was shorter after DW but non-significantly (0.84 ± 0.81 minutes vs 1.79 ± 1.36 minutes, p=0.08). CONCLUSION. Voluntary diaphragmatic contraction seems important in the pathogenesis of GERD, and diaphragmatic workout improves both GERD symptoms and LES function.
T1680 Functional Heartburn Patients are Characterized by Increased Frequency and Perception of Liquid-Gas and Proximal Reflux Mentore Ribolsi, Sara Emerenziani, Paola Balestrieri, Maria Chiara Addarii, Michele Cicala Introduction: In functional heartburn (FH) patients, defined as poor or not responder to proton pump inhibitor (PPI) therapy, with normal pH-metric profile and negative symptomreflux association, the mechanisms of symptom production remain unclear. pH-impedance studies have identified the reflux pattern in non-erosive reflux disease (NERD) patients sensitive and non responder to PPIs, but no data are available in FH patients. Aim: To define the reflux pattern in FH patients. Methods: Of consecutive patients with recurrent typical GERD symptoms and no evidence of erosive esophagitis, those non responder (<50% improvement) to full or double dose PPI therapy (≥ 4 weeks), underwent, following a 3week washout of PPI or H2 antagonists, stationary manometry and ambulatory pH-impedance monitoring. Data were compared to those in 14 healthy volunteers (HV) and 32 PPI responder NERD patients. SAP index for acid, weakly acidic and all reflux episodes was calculated using dedicated software. Values in our HV were also compared to those in a Belgian-French cohort of HV (1). Results: 14/28 non-responder patients, showing negative SAP and normal esophageal acid exposure time (AET), were classified as FH patients. The remaining 14 non responders (NERD PPI-resistant) presented pathological AET (6) and/or positive SAP (14) for acid and/or weakly acidic reflux. 1288 reflux episodes were analyzed in NERD PPIsensitive, 1213 in NERD non-responders and 719 in FH patients. Proportions of reflux categories, in each group, are in table. Frequency of reflux episodes (mean±SD) was 40±5.5 in HV, 51±23.7 in FH, 86.7±57 in PPI-resistant and 40±17 in PPI-sensitive patients. Data in our HV were similar to those previously published. Of the 126 symptoms reported by FH patients, 28 (22%) were associated with reflux episodes, 87% with proximal and 71% with liquid-gas (mixed) reflux. Conclusions: Compared to HV, FH patients appear to be characterized by increased frequency of mixed and proximal reflux episodes, which also account for the few reflux-associated symptoms. The improved accuracy of pH-impedance monitoring reveals a peculiar reflux pattern in FH patients, whose dynamic feature resemble those in NERD PPI-resistant patients. 1) Zerbib F et al APT 2005
T1678 Evaluation of Esophageal Mucosa Integrity “In Vivo”. Validation of Basal Intraluminal Impedance Measurements to Assess Non-Erosive Changes Induced by Esophageal Acid Exposure in Rabbit and Healthy Human Subjects Ricard Farré, Kathleen Blondeau, Dominique Clement, María Vicario, Lucia Cardozo, Michael Vieth, Veerle Mertens, Ans Pauwels, Marcel Jimenez, Jan F. Tack, Daniel Sifrim Esophageal intraluminal impedance is currently used for assessment of acid and non acid gastro-esophageal reflux. Between swallows and reflux, the esophageal basal impedance tracing is relatively stable. Severe esophagitis is associated with low basal impedance. We hypothesized that basal impedance measurements could be used to evaluate acid inducednon erosive changes in esophageal mucosa integrity in man.Methods: We performed basal impedance measurements before during and after esophageal acid perfusion in healthy subjects and rabbits. 8 healthy volunteers underwent impedance measurements during 30min esophageal perfusions at 5 cm above LES using saline solutions at pH 7.2, 2.0 and 1.0 in different days and random order. Subjects scored heartburn or pain during the perfusion using a visual analogue scale (VAS, range 0-10). 15 New Zealand rabbits were anesthetized and esophageal impedance was recorded during 30 min of esophageal perfusion with saline solutions at pH 7.2, 1.5 and 1.0. Thereafter, rabbits were sacrificed and the esophageal mucosa was mounted in Ussing chambers to determine transepithelial mucosa resistance (Rt). Finally, the mucosa was assessed with transmission electron microscopy to determine diameter of intercellular spaces.Results: In healthy subjects, basal impedance was 2900±147 Ω. During the perfusions, impedance dropped dramatically and after perfusions, impedance increased. After the control solution (pH 7.2), the recovery was complete. In contrast, after saline pH 2.0 and 1.0 the impedance remained lower a 21.9±6.5 % and 52.7±5.0 %, (p<0.0001) compared to control solution. The median symptom score was higher during perfusions with solutions pH 1.0 than with control and pH 2.0 solutions (4.5, 0 and 0 respectively, p<0.05). There was a correlation between symptom score and change in basal impedance (r=-0.51, p=0.009). In rabbits, basal impedance was 4457±270 Ω.. After perfusion with saline pH 1.5 and 1.0 this value remained lower a 39.1±7.0 % (p<0.05) and 63.9±6.5 % (p<0.0001) respectively, compared to control. Tissues analyzed In Vitro showed a reduction in Rt of 20 % (p<0.05) and 65 % (p<0.0001) respectively, compared to control. There was a positive correlation between In Vivo basal impedance and In Vitro Rt values (r=0.72 and p=0.0021). Tissue showed no erosions under light microscopy but both acidic solutions induced dilated intercellular spaces from 0,01 ± 0,002 μm (control) to 0.12 ± 0,02 μm and 0.28 ± 0,06 μm respectively.Conclusions: Basal esophageal impedance measurements might be used to evaluate individual changes in esophageal mucosa integrity after exposure to acid solutions in man.
* p<0.05 vs HV T1681 Relevance of the Dynamic Pattern of Reflux Episodes in Non-Erosive Reflux Disease (NERD) Patients With Non-Cardiac Chest Pain Mentore Ribolsi, Sara Emerenziani, Maria Chiara Addarii, Paola Balestrieri, Michele Cicala Introduction: Mechanisms underlying non-cardiac chest pain (NCCP) are not fully elucidated. Gastro-esophageal reflux disease (GERD) appears to be the most common cause, whilst impaired esophageal motility seems to play a limited role in symptom generation. NERD patients are characterized by a higher sensitivity to intra-esophageal stimuli. Since no data are available in these patients concerning the relationship between chemical, physical and dynamic properties of reflux episodes and NCCP, this represents the aim of the study. Methods: of consecutive NERD patients with symptoms responding to proton pump inhibitors (PPIs), those presenting NCCP as the major symptom, underwent, following a 3-week washout of PPIs or H2 antagonists, ambulatory pH-impedance monitoring following a stationary manometry. Patients with esophageal motor disorders were excluded from the analysis. Overall, 19 patients were analyzed and data were compared to those in 20 NERD patients with typical GERD symptoms (heartburn). Reflux episodes were identified and classified according to standardized criteria. Bolus clearance time (BCT), i.e., the time frame between reflux entry and exit, was calculated at 5 cm above the LES. Results: A total of 1289 reflux episodes were analyzed in NERD patients with NCCP and 1120 in heartburn patients. Reflux data are shown in table. Frequency of reflux episodes (mean and 95% CI) was: 69 (48-90) in NCCP patients and 56 (40-72) in heartburn patients. A total of 72 and 61 symptomatic reflux episodes were analyzed, respectively, in NCCP and heartburn patients. AET (mean and 95% CI) was 5.2% (2.1-7.8%) in NCCP patients and 7.8% (4.6-10.4%) in heartburn patients. Conclusions: In NCCP patients, the large majority of symptomatic refluxes are liquid-gas (mixed) and proximal, with clearing being prolonged compared to asymptomatic reflux episodes. Symptomatic refluxes in NCCP patients are more frequently
T1679 Increased Exhaled 8-Isoprostane Levels During Gastro-Esophageal Reflux With Respiratory Symptoms: Results of a Pilot Study Caroline Elie, Guillaume Gourcerol, Eric Verin, Essmaeel Essmaeel, Alain Lavoinne, Philippe R. Ducrotté, Anne-Marie Leroi, Frederic Ziegler Introduction An increased release in 8-isoprostane (8-IP) in the exhaled air is a marker of oxidative stress during inflammatory respiratory processes. The aim of this work was determine whether exhaled 8-IP levels were increased in patients suffering from gastro-esophageal reflux disease (GERD) with respiratory symptoms. Patient and methods Eight healthy controls (group 1) and 11 patients reporting GERD symptoms were investigated. GERD as well as
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AGA Abstracts
AGA Abstracts
T1677