Reflux (Acid, Non-Acid, Mixed Types) in Neonates & How It May Also Apply to Adults

A study was published this month in the journal Pediatric Research which described reflux characteristics in neonates, but the findings can certainly be applied to adults as well.

What I found gratifying about this study was not so much that reflux was evaluated, but what measurements obtained by 24 hour pH-impedance were taken which apply just as much to adults as neonates. Just exactly what was measured and what did the study find (at least in neonates suspected of having reflux)?

• Only 54% of reflux events was associated with symptoms

• Defined by physical characteristics of reflux events:

• 51.3% were liquid
• 29.1% were gas
• 19.6% were mixed

• Defined by chemical characteristics of the reflux events:

• 48.5% were acidic
• 51.5% were non-acidic

• Defined by how high the reflux traveled away from the stomach:

• 79.2% reached the throat/mouth level
• 20.8% stayed in the chest level

Although these findings are specific for neonates, adults experience similar problems, though precise numbers are probably different and need more study.

Laryngopharyngeal reflux is when reflux reaches the throat level. Depending on the chemical characteristics of the reflux (acid vs non-acid as well as how high it goes), the symptoms may be quite variable. NON-acid reflux is considered "silent" and patients may not experience any symptoms of heartburn. Rather, common symptoms include:

• Phlegmy throat
• Chronic cough
• Swollen sensation in the throat (globus)
• Chronic throat-clearing

These results point out another issue... Common medications used to treat reflux (zantac, pepcid, nexium, prilosec, prevacid, etc) only treats ACID reflux. Not NON-acid reflux.

As such, other modalities must be pursued to address symptomatic non-acid reflux beyond medications involving lifestyle changes including diet as well as surgery.

Whether it be babies or adults, characterization of the spatial-temporal-physical-chemical nature of reflux events as defined by pH-impedance methods offers the best chance of evaluating and treating symptoms due to reflux.

Or in more simplistic terms...

NOT ALL REFLUX IS ACID!!!

NOT ALL REFLUX CAUSES HEARTBURN!!!

Reference:
Significance of gastroesophageal refluxate in relation to physical, chemical, and spatiotemporal characteristics in symptomatic intensive care unit neonates. Pediatr Res. 2011 Aug;70(2):192-8.

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Fauquier Hospital Now Offers 24 Hour Multichannel pH and Impedance Testing for Reflux!

As far as we know, Virginia Hospital Center's Heartburn Center in Arlington, VA and now Fauquier Hospital are the only places in Northern Virginia that offers 24 hour Multichannel Intraluminal Impedance (MII) testing to look for non-acidic reflux. Oftentimes, this test is combined with pH probe testing and manometry to measure the more traditional acid reflux as well as esophageal motility.  These tests are important when working up patients with symptoms of chronic cough, globus, phlegmy throat, and/or throat clearing when all other reflux measurements/testing have come back normal.

The testing is performed by placing a catheter through the nose and into the stomach AND leaving it in place for 24 hours. Patients often ask what this looks like... so here's a few pictures!

Here are the contact information for the locations that provide 24 hour Multichannel pH and Impedance testing:

Gastroenterology Associates
(in association with Fauquier Hospital)
402 Hospital Drive
Warrenton, VA 20186
Phone: (540) 347-2470
Website

Virginia Hospital Center
Phone: (703) 717-4373
Fax: (703) 717-4374
Director: Kevin Gillian, MD, FACS
Nurse Coordinator: Susan McNeill-Smith, RN
Website

Some over-the-counter medications used to treat relux are listed below:

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What a 24 Hour Multichannel pH and Impedance Testing Looks Like

I often order a special test called "24 hour Multichannel pH and Impedance Testing" when working up patients with symptoms of chronic cough, globus, phlegmy throat, and/or throat clearing.

This test measures any non-acid and well as acid reflux along with muscle contractility of the esophagus continuously over a 24 hour period of time.

The catch is that a catheter needs to be placed through the nose and into the stomach AND left in place for 24 hours. Patients often ask what this looks like... so here's a picture!

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