小児 24 時間食道インピーダンス pH モニタリング(MII-pH) …

1 24 pH (MII-pH) pH (Gastroesophageal Reflux Disease : GERD) pH GER pH ( MII-pH) MII-pH 2012 (ESPGHAN) (EURO-PIG) MII-pH 1) 2015 MII-pH ESPGHAN MII-pH MII-pH MII-pH MII-pH (pH<4), (pH>4) ( )

2 PH GER pH GER MII-pH pH GER GER GER MII-pH GER : ( , , ) ( , ) MII-pH pH GER GER 3 1) Sandhill sleuth ZepHhrTM MII-pH 2016 2 pH Sandhill ( <75 cm), (ZIN-BS-51) 1ch pH (75 cm < <150 cm), (CZPN-BG-57 ZPN-BG-07) (2ch pH) ( >150 cm), (ZAN-BG-44) (2ch pH) pH (ZIN-BS-51)

3 PH MII 2cm pH (CZPN-BG-57 ZPN-BG-07) (ZAN-BG-44) 2) (H2 ) 3 3) MII-pH pH Sandhill pH 10 pH 4) MII-pH pH MII-pH pH Strobel formula (LES) [ x body length [cm]+5] MII-pH Strobel formula MII-pH MII-pH pH pH/ 5)

4 PH GER 24 MII-pH GER 6) GER GER MII-pH GER GER ( / ) / 3. PC PC (BioViewTM) pH pH (AutoSCANTM) acid/weakly acidic//weakly alkaline acid/nonacid gas-only reflux 2) MII-pH : 94%.

5 74% 3) ( ) 4) Sandhill 1. 500 GER pH 5) 2. AutoSCANTM AutoSCANTM over-diagnosis 3. Proximal reflux 4. gastric belch supragastric belch 5. Color contour MII-pH Definition of reflux parameters Liquid MII-reflux episode: decrease in impedance with 50% feom baseline Acid MII reflux: with a pH: with a pH < Non-acid reflux: with a pH Weakly acid reflux: with a pH but < Weakly alkaline reflux: with a pH Gas MII-reflux episode: sharp increase of impedance >3000ohm Mean bolus clearance time: time needed for a bolus to be cleared from the esophagus Bolus exposure index: the percentage of time that a bolus is present in the esophagus Mean acid clearance time.

6 Time needed for acid to be cleared from the esophagus (previously known as the reflux index) Bolus-liquid reflux 50 The end of a reflux episode 50% Gas reflux 2 50% >5000 Ohm 6) Mixed reflux liquid gas reflux GER 1. Symptom Index (SI) GER / GER 5 50% GER SI SI 2. Symptom sensitivity index (SSI) GER / GER GER 5 GER 10% GER SSI 3.

7 Symptom association probability (SAP): 2 GER(+) (+), GER(+) (-),GER(-) (+),GER(-) (-) Fisher 95% SAP GER GER SAP Number of Total reflux Number of Acid Non-acid reflux Number of Proximal reflux 3) Acid exposure time (Reflux Index) Bolus exposure index Acid clearance time Bolus clearance time GER SI, SSI, SAP MII-pH GERD MII-pH (G-PIG) 700 MII-pH GERD 7) Symptom index (SI) 50% 70 100 ( 2) ( ) ( ) MII-pH MII-pH pH GER MII-pH PPI Rumination syndrome MII-pH MII-pH MII-pH MII-pH ( )

8 PH MII-pH Comparison between pH monitoring and impedance Parameter pH monitoring MII-pH Acid GER Yes Yes Nonacid GER Blind Yes Superimposed acid reflux Blind Yes Gas reflux Blind Yes Height of reflux 1 or 2 levels 6 levels Chemical clearance Yes Yes Bolus clearance Blind Yes Postprandial GER Blind Yes GER=gastroesophageal reflux; MII= multiple intraluminal impedance ( ) Mousa .(2014) 95 6) ( ) ( ) Median 95 percentile Median 95 percentile Percentage of AGER ( ) AGER frequency ( ) 20 48 14 55 Number of proximal AGER episodes ( ) 14 44 7 43 Percentage of NAGER ( ) 1 NAGER frequency( ) 32 67 6 34 Number of proximal NAGER episodes ( ) 22 57 3 20 Percentage of GER ( ) GER frequency ( ) 54 93 21 71 Mean GER BCT ( ) 13 20 15 32 AGER: acid GER, NAGER: non-acid GER BCT: bolus contact time(seconds) Published adult normal values of 24-hour MII-pH Reference No.

9 Subjects Country Acid reflux WAR AlkR Total no. reflux MACT MBCT BEI (%) Shay et al 60 United States 18 (59) 9 (26) 0 (1) 30 (73) 23s 11s ( ) Zerbib et al 68 France and Belgium 22 (50) 11 (33) 3 (15) 44 (75) 34s 11s (2) Zentilin et al 25 Italy 18 (51) 14 (38) 4 (18) 16 (48) 28s 12s Number are presented as median (95th percentile). AlkR=weakly alkaline, BEI= bolus exposure index; MACT=mean acid clearance time; MBCT=mean bolus clearance time; MII=multiple intraluminal impedance; reported; WAR=weakly acidic reflux 11 GER Events Detected During 24-Hour Stationary Impedance-pH Recordings in 21 Healthy Preterm Neonates Total Reflux, n/24h Acid Reflux, % Weakly Acidic, % Volume Exposure, %/24h Reflux-Related Acid Exposure, %/24h Total Acid Exposure, %24h Median 71 95th percentile 98 Acid and Weakly Acidic Reflux Episodes During Fasting and Feeding Periods in 21 Healthy Preterm Neonates Fasting Feeding Acid Reflux, n/h Weakly Acidic Reflux, n/h Reflux-Related Acid Exposure, % Total Acid Exposure, % Acid Reflux, n/h Weakly Acidic Reflux, n/h Reflux-Related Acid Exposure, % Total Acid Exposure.

10 % Median 95th percentile 1. Wenzl TG, Benninga MA, Loots CM, Salvatore S, Vandenplas Y, Indications, methodology, and interpretation of combined esophageal impedance-pH monitoring in children: ESPGHAN EURO-PIG standard protocol. J Pediatr Gastroenterol Nutr. 2012 ;55:230-234 2. Loots CM, Benninga MA, Davidson GP, Omari TI. Addition of pH-impedance monitoring to standard pH monitoring increases the yield of symptom association analysis in infants and children with gastroesophageal reflux. J Pediatr. 2009;154:248-252. 3. Loots CM, van Wijk MP, Blondeau K, Dalby K, Peeters L, Rosen R, Salvatore S, Wenzl TG, Vandenplas Y, Benninga MA, Omari TI. Interobserver and intraobserver variability in pH-impedance analysis between 10 experts and automated analysis.