Spontaneous Reflux During Videoesophagram: Its Clinical Significance and Correlation with Ph Monitoring
Shahin Ayazi1, Steven R. Demeester1, James M. Halls2, Florian Augustin*1, Joerg Zehetner1, Arzu Oezcelik1, Helen J. Sohn1, John C. Lipham1, Jeffrey a. Hagen1, Tom R. Demeester1
1Surgery, University of Southern California, Los Angeles, CA; 2Radiology, University of Southern California, Los Angeles, CA
Introduction: The significance of provoked reflux during a barium swallow is unclear, but spontaneous reflux is thought to be more reliably linked to gastroesophageal reflux disease (GERD). The aim of this study was to determine the relationship between spontaneous reflux events during a videoesophagram and gastroesophageal reflux disease.Material and methods: Records were reviewed of all patients with GERD symptoms who underwent videoesophagram within 2 weeks of 24 hour esophageal pH monitoring between January and July 2008. Patients with previous foregut surgery and those that had their pH monitoring on acid-suppression medication were excluded. The videoesophagrams were reviewed by an experienced radiologist. Spontaneous reflux was defined as the reflux of barium from the abdominal or herniated stomach back into the esophagus through the gastroesophageal junction (GEJ). The occurrence and characteristics of the spontaneous reflux episodes were compared to the findings from ambulatory esophageal pH monitoring.Results: The Study population consisted of 92 patients (49 males and 43 females). Seventy percent (64/92) had a radiologic hiatal hernia. The median number of spontaneous reflux was 3 (IQR: 2-3.5). At least one reflux episode occurred in 41 patients (45%). In 95% of the patients with spontaneous reflux the reflux episodes occurred in the upright position and in 80% of these patients it was confined to the distal third of the esophagus. In 8 patients the refluxed barium went up to the mid esophagus or higher. Ninety five percent of spontaneous reflux episodes occurred in patients with hiatal hernia and only 2 patients without a hiatal hernia had spontaneous reflux episodes. Patients with spontaneous reflux were more likely to have an abnormal composite pH score (78% vs. 53%, p=0.016). All of the 8 patients with spontaneous reflux to or above the mid esophagus had an abnormal composite pH score. The finding of spontaneous reflux during a videoesophagram had a 78% positive predictive value and a 73% negative predictive value for an abnormal composite pH score on ambulatory pH monitoring. The number of spontaneous reflux events did not improve the predictive value for an abnormal composite score.Conclusion: Seventy eight percent of patients with spontaneous reflux on videoesophagram have an abnormal composite pH score on ambulatory pH monitoring. Reflux to the level of the mid or proximal esophagus was always associated with an abnormal composite pH score.
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