ESOPHAGEAL pH STUDIES IN ESOPHAGEAL DISEASE

1
ESOPHAGEAL pH STUDIES IN ESOPHAGEAL DISEASE

• General Thoracic Surgery
• Chapter 119

2
Gastroesophageal reflux disease(GERD)

• Continues to be a challenge to diagnosis.
• Classic symptoms Only 60 -- Heart-burn and
  regurgitation.
• Achalasia, cholelithiasis, gastritis, peptic
  ulcer, coronary artery disease All mimic
  typical symptoms with GERD.

3
Gastroesophageal reflux disease(GERD)

• Atypical symptoms include chest pain, hoarseness,
  recurrent sorethroat, dental caries,
  bronchospasm, wheezing, chronic cough, recurrent
  chest infection.
• Diagnosis include scintiscanning, barium
  radiography, acid-perfusion or Bernstein test,
  panendoscopy, present esophagitis.

4
Gastroesophageal reflux disease(GERD)

• The introduction of 24-hour esophageal pH
  monitoring provided a method to quantitate
  esophageal acid exposure.
• Greatest sensitivity and specificity for
  diagnosis of gastroesophageal reflux As the
  gold standard test.

5
(No Transcript)
6
Gastroesophageal reflux disease(GERD)

• Three main cause of increase exposure of
  esophagus to refluxed gastric contents
• (1) LES defective Most.
• (2) Inefficient esophageal clearance as low
  peristaltic amplitudes or increase ineffective
  contractions.
• (3)Gastric abnormal Decrease gastric empting.

7
Gastroesophageal reflux disease(GERD)

• In early disease, the reflux episode occurred in
  upright position.
• Bipositional reflux suggests more advanced
  disease and LES is severely impaired.
• Pure supine reflux is rare.
• Prolong reflux episodes suggest delayed
  esophageal clearance.

8
Bernstein test

• Acid-perfusion test Patient sitting with N-G
  tube 30 cm from nares, infusion normal saline 15
  min, 0.1 N HCL at rate of 6 ml/min until symptoms
  produced.
• The test is positive in two successive infusion
  periods acid induces pain and saline induces
  relief.
• Specificity 89, sensitivity is low because the
  pain induced by acid infusion does not correlate
  with the severity of esophagitis present.

9
Acid emptying test

• Measeure the esophageal emptying capacity.
• A bolus 15 ml of 0.1N HCl is introduced into
  esophagus 10 cm above the pH probe, patient
  repeat dry-swallows at 30-second intervals.
• In normal Distal esophagus is cleared of acid
  within 10 swallows.
• Prolonged clearance test indicates an impaired
  capacity of the esophagus to clear the irritant
  material.
• Lacks sensitivity.

10
24-hour esophageal pH monitoring

• Importance ofto detect an increased esophageal
  exposure to refluxed acidic gastric contents.
• patient with severe symptoms are found mild
  degree esophagitis in endoscope frequently.

11
24-hour esophageal pH monitoring

• Mucosa injury was greatest in the exposure of pH
  0-2.
• Normal The gastric pH is 1-2, esophageal pH
  4-7.
• Continuously measured esophageal pH below 4
  Became the commonly used threshold of determing a
  reflux episode.

12
24-hour esophageal pH monitoring

• False negativeduodenogastric reflux.
• Alkaline secretions neutralize gastric acid.
• If suspected, a probe measures bilirubin.
• Food in stomach can also neutralized gastric
  acid.
• Probe malfunction or misplacement.
• Medication use-- particularly proton pump
  inhibitors.

13
(No Transcript)
14
Analysis of data

• Analysis of pH tracing allowed calculation of the
  time that esophageal pH less than 4.
• This value dose not reflect how the exposure
  occurred, fig 119-3.
• It is necessary to know the number of times that
  esophageal drops below 4 and the duration of each
  episode.

15
(No Transcript)
16
Analysis of data

• Esophagel pH can fluctuate just above and below 4
  after a reflux episode fig 119-4.
• Six components of 24-hour pH record, table
  119-1,2.
• Graphically displayed, fig 119-5.

17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
Performance of the study

• All medication affect the pH should be stopped.
• PPI 2 week.
• H2-blocker 2 day.
• Antacid 12 hour.
• Promote gastrointestinal motility medication 2
  days.

21
Performance of the study

• Keep accurate diary.
• Document meal periods, any symptoms.
• Only water is allowed between meal.
• Eat normal-size meal.
• Avoid much carbonated beverages Because they
  have acidic pH and cause belching.

22
Performance of the study

• Sleep only at night.
• Avoid vigorous exercise.
• Avoid alcohol drinking, cigarette smoking.

23
Performance of the study

• Ideal probe to measure 24-hour pHSmall, firm,
  rapid response, minimally affect by temperature,
  no hysteresis effect, exhibit no drift,
  inexpensive, simple to calibrate, disposable or
  sterilizable Not exist.
• Two probesglass or antimony, fig 119-6,
• The probe should be calibrated in standard
  solutions at pH 1,4,7

24
(No Transcript)
25
Performance of the study

• Placement of probe Proper positioning of pH
  electrodes requires prior manometry.
• The probe must be placed 5 cm proximal to the
  upper border of LES, trans-nasally.

26
(No Transcript)
27
Esophageal pH monitoring in specific circumstances

• Unexplained chest pain.
• Recurrent pulmonary infection.
• Adult-onset asthma.
• Heartburn symptoms.

28
Unexplained chest pain

• 10 GERD with chest pain as the only symptoms
  (esophageal claudication).
• Exercise can induce reflux then exercise-induced
  chest pain.
• 24-hour pH monitoring is more sensitive.
• Ambulatory 24-hour esophageal manometry and pH
  monitoring.
• Occurred in nutcracker esophagus or diffuse
  esophageal spasm.

29
Recurrent or persistent respiratory symptoms

• Asthma, recurrent pneumonia especially in
  mid-lung field, severe bronchopulmonary disease
  in nonsmoker without obvious allergic triggers,
  onset bronchial asthma in late childhood or adult
  life.
• Endoscopic esophagitis appear less common.

30
Recurrent or persistent respiratory symptoms

• 45 of patient with reflux-induced respiratory
  disorder were found abnormalities in esophageal
  contractility

31
(No Transcript)
32
(No Transcript)
33
(No Transcript)
34
(No Transcript)
35
Achalasia

• Some with heart-burn symptoms.
• When regurgitate, they usually describe the
  material as bland tasting.
• No significant reflux of gastric contents up into
  the esophagus.

36
Achalasia

• 24-hour pH monitoring Fermentation of retained
  food material in esophageal can produce a slow
  decline in esophageal pH to less than 4.
• Distinguish between fermentation and reflux The
  percentage of time that pH less than 3
  Fermentation never produced a pH less than 3.

37
(No Transcript)
38
Bile

• Duodenogastric reflux is rare.
• Increase alkalinity in esophagus.
• Cannot distinguish between the effect of
  swallowed saliva.
• Second probe can positioned in stomach, acid
  reflux Drop in esophageal pH less than 4 and
  gastric pH remain less than 4.

39
Mixed reflux

• Esophageal pH decrease from 6 to 4-5 but gastric
  pH risen above 4.
• Alkaline reflux rise in esophageal pH above 7
  and gastric pH greater than 4

40
(No Transcript)