Vesico-ureteric reflux in adult patients with spinal injury

OBJECTIVES: To review the incidence, aetiology, treatment and prognosis of vesico-ureteric reflux (VUR) in patients in a regional spinal injuries centre. PATIENTS AND METHODS: A retrospective review of radiological investigations revealed 34 of 447 (8%) patients with VUR on at least one study. The notes of these patients were examined to determine their management and outcome. RESULTS: Most patients developed VUR within 4 years of injury; the underlying intravesical pressure was high in half the patients studied. Patients were managed aggressively with a variety of medical and surgical techniques. The VUR of 15 patients resolved completely and in three patients there was some improvement. Renal function deteriorated in three patients as assessed by isotopic scanning. Two patients were transferred to our unit in end-stage renal failure associated with VUR and died within one year. CONCLUSIONS: VUR continues to be a problem in patients with spinal injury and remains potentially fatal through the effects of high transmitted pressure and infection. Renal failure does not always develop as a consequence of the combination of VUR and high intravesical pressure. No single aetiological factor for VUR was found. With active early treatment, the incidence of VUR can be minimized and long-term complications avoided.     

Intrarenal reflux

Seventy-six children with a total of 123 ureters showing vesico-ureteric reflux were reviewed in order to detect intrarenal reflux (pyelotubular backflow) occuring during micturating cystourethrography. This was found in 7 patients (9.2%). Five patients had unilateral and two bilateral intrarenal reflux. In only 7 out of the 9 kidneys with intrarenal reflux was it possible to outline the kidney contour precisely on excretion urography. In 3 cases renal damage corresponded exactly to the areas with intrarenal reflux. One kidney showed damage which did not correspond to the location of intrarenal reflux and 3 were without signs of damage. Renal damage of varying localization was found in 54 of the 123 kidneys with vesico-ureteric reflux and intrarenal reflux was present in 6 of these (11%). The significance of intrarenal reflux as a cause of renal damage and whether intrarenal reflux might be primary or secondary to the renal damage are discussed, and it is concluded that presence of intrarenal reflux is a definite indication for operation.     

Duodenogastric reflux potentiates the injurious effects of gastroesophageal reflux

Experimental studies have shown that the severity of esophageal mucosal injury in gastroesophageal reflux disease is related to the reflux of both gastric and duodenal juice. The purpose of this study was to determine whether duodenal juice potentiates esophageal injury in patients with reflux disease or, in fact, causes no harm allowing acid and pepsin to do the damage. A total of 148 consecutive patients who had no previous gastric or esophageal surgery underwent endoscopy and biopsy, manometry, and 24-hour esophageal pH and bilirubin monitoring. Esophageal injury was defined by the presence of erosive esophagitis, stricture, or biopsy-proved Barrett's esophagus. Exposure to duodenal juice, identified by the absorbance of bilirubin, was defined as an exposure time exceeding the ninety-fifth percentile measured in 35 volunteers. To separate the effects of gastric and duodenal juice, patients were stratified according to their acid exposure time. One hundred patients had documented acid reflux on pH monitoring, and in 63 of them it was combined with reflux of duodenal juice. Patients with combined reflux (50 of 63) were more likely to have injury than patients without combined reflux (22 of 37; P < 0.05). When the acid exposure time was greater than 10%, patients with injury (n = 40) had a greater exposure to duodenal juice (median exposure time 17.2% vs. 1.1%, P = 0.006) than patients without injury (n = 5), but there was no difference in their acid exposure (16.9% vs. 13.4%). Patients with dysplasia of Barrett's epithelium (n = 9) had a greater exposure to duodenal juice (median exposure time 30.2% vs. 7.2%, P = 0.04) compared to patients without complications (n = 25), whereas acid exposure was the same (16.4% vs. 15%). Duodenal juice adds a noxious component to the refluxed gastric juice and potentiates the injurious effects of gastric juice on the esophageal mucosa.     

Gastro-oesophageal reflux disease

Using emerging international guidelines, stringent procedures were used to develop and evaluate Canadian-French, German and UK translations/adaptions of the 50 item, parent-completed Child Health Questionnaire (CHQ-PF50). Multitrait analysis was used to evaluate the convergent and discriminant validity of the hypothesized item sets across countries relative to the results obtained for a representative sample of children in the US. Cronbach's alpha coefficient was used to estimate the internal consistency reliability for each of the health scales. Floor and ceiling effects were also examined. Seventy-nine percent of all the item-scale correlations achieved acceptable internal consistency (0.40 or higher). The tests of the item convergent and discriminant validity were successful at least 87% of the time across all scales and countries. Equal item variance was observed 90% of the time across all countries. The reliability coefficients ranged from a low of 0.43 (parental time impact, Canadian English) to a high of 0.97 (physical functioning index, Canadian French) across all scales (median 0.80). Negligible floor effects were observed across countries. Noteworthy ceiling effects were observed, as expected, for the hypothesized physical scales (mean effect 73%). Conversely, fewer ceiling effects were observed for the psychosocial scales (range 3-17% behaviour-parental emotional impact). The item-scaling results obtained in these pilot studies support the psychometric properties of the American-English CHQ-PF50 and its respective translations.     

Vesico-ureteral reflux in pediatrics

Vesico-ureteral reflux (VUR) is the most frequent uropathy involving 1-2% of children. Genetics, familiarity, race gender and age intervene in the pathogenesis of VUR. In particular, neonatal VUR seems to represent a specific entity. Different factors determine a renal damage due to RVU: direct action of VUR (back pression), urinary tract infection (UTI), inflammatory mechanisms and renal dysplasia. Micturing cystourethrography and nuclear cystography are currently performed for the diagnosis of VUR, being ultrasound examination aspecific. Functional parameters are now investigated in association with new morphologic studies. The strict relationship of VUR and UTI is discussed. The treatment (medical, surgical) of VUR is not well established, although some guidelines can be suggested. Finally an adequate support must be given to the family for an optimal management.     

Sialorrhea and gastroesophageal reflux

It is not unusual for patients who are pregnant or have a hiatal hernia to develop gatroesophageal reflux with the resultant symptoms of heartburn. This article reviews the role reflux plays in causing episodes of increased salivation. Stimulation of the esophagus by gastric acids excites and esophagosalivary reflex. A marked increase in salivary flow ensues, neutralizing the acid content of the esophagus. The dental practitioner is in a strategic position to be consulted about or recognize the existence of the esophagosalivary reflex and the consequent bouts of sialorrhea. Recognition mandates medical consultation.     

Gastroesophageal reflux disease--extraesophageal manifestations

Gastroesophageal reflux is often associated with symptoms of the respiratory tract. Chronic cough of unknown origin, laryngeal complaints and even non allergic asthma, resistant to steroid therapy, are suspicious of being reflux related. These extraesophageal manifestations can occur without typical reflux complaints, such as heartburn, and even without evident esophagitis. Therefore, prolonged pH-monitoring is essential to confirm the diagnosis. In some cases it will be adequate to start a therapeutic trial with proton pump inhibitors (PPI) to prove the causal connection between reflux and symptoms. The treatment of the extraesophageal manifestations of gastroesophageal reflux disease is identical with the management of reflux esophagitis. PPI are the treatment of choice. Sometimes higher doses of PPI are required. Fundoplication may be appropriate for selected patients.     

Gastroesophageal reflux in children

BACKGROUND: Gastroesophageal reflux is common in small children. It is important to recognise that its natural history and management differ from reflux in adults. OBJECTIVE: This article will summarise the clinical presentation, pathophysiology, appropriate investigations and therapy of reflux in small children. DISCUSSION: A small amount of regurgitation is common in infancy, and is only pathological if it results in harm. In children, reflux-induced injury can result from either acid exposure, nutrient loss or respiratory complications. Recognised presentations include heartburn, oesophagitis, infant irritability, dysphagia, haematemesis, stricture, growth failure, aspiration, apnoea and pneumonia. Excessive crying and irritable behaviour in infancy can be due to a variety of causes, but there is a fashionable tendency to assume that gastroesophageal reflux is a major factor. Regurgitation can be a symptom of other conditions such as infection or metabolic disturbance. It is important to carefully evaluate any infant with distressed behaviour to exclude a significant medical cause. Prolonged oesophageal pH monitoring is a very useful means of linking episodes of reflux with putative symptoms. The severity of gastroesophageal reflux tends to improve with age in infants and this should be considered when advising appropriate therapy, especially fundoplication.     

Duodenogastric reflux after choledochoduodenostomy

U937 cell growth in the presence of either chloramphenicol or ethidium bromide rapidly leads to respiratory deficiency. The novel finding of this report is that this response is paralleled by a specific increase in Se-dependent and independent glutathione peroxidase activities as well as of glutathione peroxidase and heme oxygenase mRNAs. Under the same experimental conditions, catalase activity and catalase mRNA do not show appreciable changes. These results can be explained by an increased formation of H2O2 at the early times of development of respiratory deficiency followed by induction of antioxidant enzymes.     

Reoperation after gastroesophageal reflux surgery

In a group of 19 patients reoperated after a primary operation on account of gastrooesophageal reflux the authors demonstrate that the reason for reoperation can be either a relapse of the reflux or also other complaints (most frequently dysphagia). The selection of a suitable operation is strictly individual. Cases of a short oesophagus are most difficult to resolve. The decisive factor is a correct surgical approach-laparotomy or thoracotomy.     

Gastroesophageal reflux and airway disease

Gastroesophageal reflux may cause a variety of airway diseases such as asthma, aspiration pneumonia, chronic bronchitis, posterior laryngitis, and ulceration or polyp formation on the vocal cords. Among these asthma seems most common and important clinically. Reflux not only may trigger and aggravate an episode of airway obstruction but also may contribute to nocturnal symptoms. Both clinical and experimental observations suggest that the pathogenetic mechanism may be a vagal reflux following stimulation of lower esophageal receptors and/or microaspiration of gastric acid into the trachea. Diagnosis is usually based on clinical history of asthma and symptoms of gastroesophageal reflux, but in some cases, diagnostic tests such as 24-hour esophageal pH monitoring may be necessary. General measures to avoid reflux and an H2-receptor antagonist together with supportive gastric medications may be the standard treatment. If symptoms persist, proton pump inhibitor may be helpful. Antireflux surgery may provide long-term improvements. Although surgical treatment is indicated only in patients with intractable esophagitis at present, it may be used more commonly through a laparoscopic approach in the near future.     

Duodenogastric reflux and stress ulcer

Duodenogastric reflux in 14 patients in an intensive care unit was compared with that in 12 healthy controls. In addition, intragastric bromsulphalein concentration was measured up to 60 minutes after intravenous administration. Reflux was much more frequent in the intensive-care patients and correlated with the incidence of gastric erosions and stress ulcers. Reflux is apparently one of three factors (in addition to ischaemia and HCl) which synergistically lead to stress-induced lesions of the gastric mucosa.