Top Posts 2016

The following posts are the ones that I think are most useful from 2016.

Gastroenterology:

Liver:

General:

Doctoring:

IBD:

Nutrition:

truth-johnpohl

Does Reflux Lead to Increased Aspiration Pneumonia?

This post’s title question turns out to be quite tricky.  According to a recent study (RL Rosen et al. JPGN 2016; 63: 210-17), reflux burden, even in children that aspirate did not correlate with increased hospitalization.

Here are the details:

Methods: Prospectively recruited cohort of 116 children who had both pH-impedance testing along with modified barium swallow. The authors considered pathologic reflux to have at least 73 episodes on pH-impedance or if pH<4 for >6% of study period.

Key findings:

  • There was no statistical correlation between pH-impedance study results and total number of admissions even with or without adjusting for aspiration status (and neurologic complications).

When the authors tried to reconcile these findings, they offered three competing potential explanations for these results:

  • Reflux has little impact on hospitalziations
  • Our methods for measuring reflux are not good
  • Even “normal” reflux can be a problem for those prone to complications; therefore, reflux burden is not consequential.

What is clear is that pH-impedance studies cannot predict which patients are at risk for increased complications.  This is supported by data showing that ‘reflux-related’ hospitalizations may not improve after fundoplication (Pediatrics 2006; 118: 2326-33; J Pediatr Surg 2008; 43: 59-63).  One particularly important limitation was that the cause of hospitalizations was determined by medical record review.

My take: A simple algorithm for preventing aspiration pneumonia does not exist.  Even the role of reflux testing is uncertain.

Related blog posts:

The accompanying article guaranteed that the pizza would pass through the body within 30 minutes.

The accompanying article guaranteed that the pizza would pass through the body within 30 minutes!!!

 

Linking Reflux and Tooth Erosion

Every now and then a dentist sends a kid to our GI practice due to eroded teeth because of concerns about reflux damaging the enamel.  While it is recognized that reflux may damage teeth, the exact frequency is unclear.  Other questions:

  • Which asymptomatic kids with poor dentition require GI evaluation?
  • What is the best way to evaluate these children?
  • If reflux is identified, how long should they remain on treatment? Forever?
  • How effective is reflux treatment in reducing tooth damage?

While none of these questions have been definitely answered, Rosen et al (JPGN 2016; 62: 309-13) show that acid reflux rather than nonacid reflux is predictive of tooth erosion. In this study, the authors used a prospective cohort of 27 children (age ≥3 years)–ALL of them were ON acid suppression (for >1 year) at the time of pH-MII testing.  Key findings:

  • Prevalence of tooth erosion was 10 or 27 (37%)
  • There was correlation with acid reflux episodes (& time in reflux) and tooth erosion, r=0.44, P=0.02
  • There was correlation with reflux index as well, r=0.54, P=0.004,  In the tooth erosion group, the mean reflux index was 7.3% compared with 1.6% in no dental erosion group.
  • There was no correlation with nonacid reflux with tooth erosion

The authors’ discussion highlights many prior relevant studies and indicates that a pH-metry study alone (rather than pH-MII) “may be adequate.” They note some of the limitations of this study which included a small number of patients and potential referral bias, as these children had suspected GERD.  In the methods section, the authors state that their standard practice, at the time of the study, was to maintain patients on prior acid suppression medication.  It would be useful to acknowledge that many experts, at this time, recommend doing pH-MII studies as well as standard pH studies off all acid suppression due to improved sensitivity/accuracy.

My take: This study shows that in the 10 children with tooth erosion who had suspected GERD, there was correlation with acid reflux but not with nonacid reflux.

Related blog post: Notes from PPI Webinar GutsandGrowth

Unrelated but interesting: Are medical errors really the 3rd leading cause of death in U.S.? Here’s NPR’s summary of a recent BMJ article which makes that claim: Only Heart Disease and Cancer Exceed Medical Errors As Cause of U.S. Death

Gibbs Gardens

Gibbs Gardens