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This study aims to compare pHmetric characteristics of diurnal and nocturnal supine reflux. We studied 500 consecutive individuals with clinical suspicion of gastroesophageal reflux disease (GERD) who underwent esophageal high-resolution manometry and prolonged ambulatory pH monitoring. Patients were classified with supine GERD pattern when the percentage of acid reflux time in the supine position was equal to or greater than 2.2%. Data on acid reflux in the supine position during daytime and nighttime recumbency were: (i) acid exposure time, (ii) number of reflux episodes, (iii) longest reflux episode, (iv) interval between the last meal and the supine position, (v) interval between the supine position and the first acid reflux episode, and (vi) reported symptoms. Of the 500 evaluated patients, 238 (48%) had GERD. Among these, supine pattern was observed in 134 (56%) patients, bipositional in 53 (23%), and orthostatic in 51 (21%). In patients with daytime recumbency, 112 (51% of 217) were pathological refluxers, with a mean DeMeester score of 45 ± 26. Total acid exposure time (P = 0.8) and reported Symptom Index (P = 0.2) did not differ depending on the period, whether diurnal or nocturnal. All other pHmetric parameters were lower during daytime recumbency. In conclusion, diurnal supine reflux has similar acid exposure time and temporal correlation between symptoms and reflux episodes as nocturnal supine reflux. Other pHmetric parameters are lower for diurnal supine reflux., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Gastroesophageal reflux disease (GERD) pathophysiology is multifactorial. Greater importance has been attributed to a defective lower esophageal sphincter (LES) in comparison to an altered transdiaphragmatic pressure gradient (TPG). This study aims to evaluate the role of the TPG and LES disfunction in GERD pathogenesis., Methods: Five hundred consecutive esophageal function tests from patients with clinically suspected GERD were reviewed. Patients were classified according to the pH monitoring in GERD positive or GERD negative. Abdominal pressure, thoracic pressure, TPG (abdominal-thoracic pressures), LES resting pressure (mid-respiratory, expiratory, and EGJ-CI), and LES retention pressure (LES resting pressure-TPG) were determined., Results: GERD was present in 296 (59%) individuals. GERD-positive patients were mostly males. LES resting pressure (by all parameters) and thoracic pressure were not different between groups. Abdominal pressure and TPG were higher in GERD-positive patients. LES retention pressure (by all parameters) was lower in GERD-positive patients. DeMeester score had a positive correlation with LES resting pressure, TPG, and LES retention pressure (by all parameters) but not with abdominal pressure and thoracic pressure., Conclusions: LES valvular competency as measured by absolute resting pressure was not reliable to predict GERD; however, it was associated with GERD severity. Relative LES pressure (LES retention pressure) predicted GERD presence and severity, but no parameter showed superiority. TPG plays an important role in the pathophysiology of GERD since it is related to GERD presence and severity; still TPG is altered mostly based on a higher abdominal pressure., (© 2022. The Society for Surgery of the Alimentary Tract.)

Background: To explore the agreement between clinical judgment and Guided Progression Analysis II (GPAII) in the evaluation of visual fields (VF) progression in patients with glaucoma. Methods: Three glaucoma experts and three general ophthalmologists were asked to rate the VF series by classifying them as progressive through the observation of the overview report. The agreement between clinical judgment and GPAII event analysis (EA) and trend analysis (TA) was assessed by Cohen statistic. The sensitivity and specificity of clinical judgment in detecting the presence of progression was evaluated considering the results of GPAII as the reference standard. Results: 66 VF series were included in the study. Glaucoma experts, general ophthalmologists, GPAII EA, and GPAII TA found progression in 39%, 38%, 15%, and 21% of the VF series (p < 0.05). The clinical judgment of glaucoma experts and general ophthalmologists was discordant with GPAII EA in 27.2% and 28.7% (k = 0.35, 95% CI 0.15−0.56 and k = 0.30, 95% CI 0.09−0.52) and with GPAII TA in 21.2% and 25.7% of the VF series examined (k = 0.51, 95% CI 0.31−0.72 and k = 0.41, 95% CI 0.18−0.62). Considering the GPAII EA and TA as reference standard, glaucoma experts showed a sensitivity of 90% and 92.8% and a specificity of 69.6% and 75%, while general ophthalmologists showed a sensitivity of 80% and 78.5% and a specificity of 69.6% and 73%. Conclusions: The agreement between clinical judgment and GPAII ranges from fair to moderate. Glaucoma experts showed better ability than general ophthalmologists in detecting VF progression., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The Chicago Classification is the most used classification for primary esophageal motility disorders (PEMD). This classification was recently updated to the 4.0 version. This opinion piece focuses on the possible implications for the treatment of PMED determined by the new classification. Chicago Classification 4.0 included two new concepts for the diagnosis of achalasia: (1) type III achalasia diagnosis demands 100% absent peristalsis defined as either failed peristalsis or spasm; (2) "inconclusive diagnosis of achalasia" was added as a possibility. Both may decrease unnecessary treatment. Esophagogastric junction outflow obstruction, distal esophageal spasm, and hypercontractile esophagus were only considered clinically significant when correlated to supportive testing and relevant clinical symptoms and in the absence of gastroesophageal reflux disease. This may decrease the surge of treatment, especially peroral endoscopic myotomy, based solely on manometric diagnosis.

Introduction: An increased transdiaphragmatic pressure gradient (TGP) is a main element for distal gastroesophageal reflux disease (GERD). The role of TGP for proximal reflux is still unclear. This study aims to evaluate the presence, severity, and importance of proximal reflux in relationship to the TGP, comparing healthy volunteers, obese individuals, and patients with chronic obstructive pulmonary disease (COPD)., Methods: We studied 114 individuals comprising 19 healthy lean volunteers, 47 obese individuals (mean body mass index 45 ± 7 kg/m 2 ), and 48 patients with COPD. All patients underwent high-resolution manometry and dual-channel esophageal pH monitoring. Esophageal motility, thoracic pressure (TP), abdominal pressure (AP), TGP, DeMeester score, and % of proximal acid exposure time (pAET) were recorded., Results: Pathologic distal GERD was found in 0, 44, and 57% of the volunteers, obese, and COPD groups, respectively. pAET was similar among groups, only higher for obese individuals GERD + as compared to obese individuals GERD - and COPD GERD -. pAET did not correlate with any parameter in healthy individuals, but it correlated with AP in the obese, TP in the COPD individuals, and TGP and DeMeester score in both groups. When all individuals were analyzed as a total, pAET correlated with AP, TGP, and DeMeester score. DeMeester score was the only independent variable that correlated with pAET., Conclusions: Our results show that (a) TGP is an important mechanism associated with distal esophageal acid exposure and this fact is linked with proximal acid exposure and (b) obesity and COPD both seem to be primary causes for GERD but not directly for proximal reflux.

Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract in the Western world. GERD pathophysiology is multifactorial. Different mechanisms may contribute to GERD including an increase in the transdiaphragmatic pressure gradient (TPG). The pathophysiology of GERD linked to TPG is not entirely understood. This review shows that TPG is an important contributor to GERD even when an intact esophagogastric barrier is present in the setting of obesity and pulmonary diseases.

Gastroesophageal reflux disease (GERD) is associated with different pulmonary diseases, including chronic obstructive pulmonary disease (COPD). Whether GERD is contributory to COPD severity remains unclear. This study aims to evaluate the contribution of GERD to the clinical manifestation of COPD based on ventilatory parameters and yearly clinical exacerbations. We studied 48 patients (56% females, age 66 years) with COPD. All patients underwent high-resolution manometry and esophageal pH monitoring. The patients were separated into two groups according to the presence of GERD. GERD was present in 21 (44%) patients. GERD + and GERD - groups did not differ in regard to gender, age, and body mass index. Pulmonary parameters were not different in the absence or presence of GERD. The number of yearly exacerbations was higher in patients GERD+. The severity of GERD (as measured by DeMeester score) correlated with the number of exacerbations. Our results show the following: 1) GERD does not influence pulmonary parameters and 2) GERD is associated with a higher number of annual clinical exacerbations. We believe GERD must be objectively tested in patients with COPD because the prevalence of GERD in these patients is underestimated when only symptoms are considered. GERD treatment might decrease the frequency of episodes of exacerbation.

Background:: The incidence of cholecystolithiasis is approximately 15% of the population. It is believed that between 30-40% of cholecystectomy patients have symptoms after surgery, being changes in bowel habits the most common among them., Aim:: 1) Defining the prevalence, and 2) identifying predictors of changes in bowel habits after laparoscopic cholecystectomy., Methods:: This is a retrospective cross-sectional study with an initial sample of 150 patients diagnosed with cholecystolithiasis operated between July and September 2014. Patients were submitted to a questionnaire about the presence of gastrointestinal symptoms and changes in stools consistency before and after the surgical procedure. They were divided into two groups (with or without changes in bowel habits) being combined with the following variables: high blood pressure, body mass index, hypothyroidism, adherence to postoperative dietary orientations, previous abdominal and bariatric surgery., Results:: The prevalence of changes in bowel habits in the study population was 35.1%. The association between it and gastrointestinal symptoms was demonstrated to be statistically significant (‰2=7.981; p=0.005), and people who did not have gastrointestinal symptoms had 2.34 times the odds of not presenting changes in bowel habits. None of the other investigated factors had shown to be a predictor of risk for post-cholecystectomy changes in bowel habits., Conclusion:: 1) There was a high prevalence of changes in bowel habits, and 2) there was association between changes in bowel habits and the presence of gastrointestinal symptoms., Racional:: A incidência da colecistopatia calculosa é de aproximadamente 15% da população brasileira. Acredita-se que entre 30-40% dos pacientes colecistectomizados apresentem sintomas pós-operatório, sendo a alteração do hábito intestinal o mais comum., Objetivo:: 1) Determinar a prevalência, e 2) identificar preditores de mudanças do hábito intestinal pós-colecistectomia videolaparoscópica., Métodos:: Estudo transversal retrospectivo com amostra inicial de 150 pacientes diagnosticados com colecistopatia calculosa, operados entre julho e setembro de 2014. Os pacientes foram submetidos a um questionário sobre a presença de sintomas gastrointestinais após a operação, e a alterações do aspecto das fezes antes e depois do procedimento. A amostra foi dividida em dois grupos (com ou sem mudanças do hábito intestinal) sendo realizadas associações com as seguintes variáveis: hipertensão arterial, IMC, hipotireoidismo, seguimento de dieta no pós-operatório, operação abdominal prévia e operação bariátrica., Resultados:: A prevalência de mudanças do hábito intestinal na população estudada foi de 35,1%. A associação entre elas e sintomas gastrointestinais demonstrou-se estatisticamente significativa (‰2=7,981; p=0,005), sendo que as pessoas que não apresentavam os sintomas tinham 2,34 vezes mais chances de não apresentarem mudanças do hábito intestinal. Nenhum dos demais fatores investigados demonstrou ser preditor de risco para mudanças do hábito intestinal pós-colecistectomia., Conclusões:: 1) Observou-se alta prevalência de mudanças do hábito intestinal, e 2) houve associação entre mudança do hábito intestinal e a presença de sintomas gastrointestinais.

Background: Chronic obstructive pulmonary disease (COPD) patients have a high incidence of gastroesophageal reflux disease (GERD) whose pathophysiology seems to be linked to an increased trans-diaphragmatic pressure gradient and not to a defective esophagogastric barrier. Inhaled beta agonist bronchodilators are a common therapy used by patients with COPD. This drug knowingly not only leads to a decrease in the lower esophageal sphincter (LES) resting pressure, favoring GERD, but also may improve ventilatory parameters, therefore preventing GERD., Aims: This study aims to evaluate the effect of inhaled beta agonist bronchodilators on the trans-diaphragmatic pressure gradient and the esophagogastric barrier., Methods: We studied 21 patients (mean age 67 years, 57 % males) with COPD and GERD. All patients underwent high-resolution manometry and esophageal pH monitoring. Abdominal and thoracic pressure, trans-diaphragmatic pressure gradient (abdominal-thoracic pressure), and the LES retention pressure (LES basal pressure-transdiaphragmatic gradient) were measured before and 5 min after inhaling beta agonist bronchodilators., Results: The administration of inhaled beta agonist bronchodilators leads to the following: (a) a simultaneous increase in abdominal and thoracic pressure not affecting the trans-diaphragmatic pressure gradient and (b) a decrease in the LES resting pressure with a reduction of the LES retention pressure., Conclusion: In conclusion, inhaled beta agonist bronchodilators not only increase the thoracic pressure but also lead to an increased abdominal pressure favoring GERD by affecting the esophagogastric barrier.