Clinical Diagnosis Of Gastroesophageal Reflux In Critically Ill Patients

Aim:1.To analyze the results of24h esophageal pH and bile monitoring in critically ill patients and investigate the feasibility of the method for clinical diagnosis.2.By cultivating the gastric colonization bacteria and the oropharyngeal colonization bacteria for the critically ill patients and the lower respiratory tract bacteria for the pulmonary infection patients and conducting the classification of bacteria and phenotype analysis, the homogeneity of the gastric colonization bacteria and the oropharyngeal colonization bacteria and the lower respiratory tract bacteria is investigated. If the homogeneity is proved, the relevance of bacteria’homology and gastroesophageal reflux will be investigated and the existence of stomach-pharynx-lower respiratory tract reverse infection, of the critically ill patients will be verified to provide further evidence for the diagnosis of gastroesophageal reflux.Methods:41critically ill patients who were transferred to Intensive Care Unit during March2009to September2010in Zhuzhou NO.1hospital were selected. The diagnosis of all these cases, with APACHEII score more than18in the first day, were confirmed based on a variety of severe diseases diagnostic criteria. Among the41cases,34cases were male and7cases were female, with the average age of63.9±2.4years old and the following basic disease:13with trauma,12with chronic obstructive pulmonary disease,6with cerebral hemorrhage,5with severe pancreatitis,5with shock, endotracheal intubation with mechanical ventilation in36cases. All patients in ICU were orally intubated from the beginning of the study. Collected gastric and oropharyngeal specimens, lower respiratory tract specimens when patients admitted to the ICU, and then every24h in7:00AM collection of lower respiratory tract specimens, gastric and oropharyngeal specimens,the deadline is1week after patient admission to the ICU.Bacteriological examination was made in the samples of lower espiratory tract, gastric fluid and pharyngeal wab by means of semi-quantitative cultivation. All cases underwent24h dynamic esophageal pH and bile reflux monitoring within72hours after admitting to the ICU. Forty one patients with symptoms of reflux such as acid reflux, heartburn, chest pain, coughing which clinical diagnosis of gastroesophageal reflux(GER) as control group.23cases was male and female was18, average age of52.8±1.9years old. Each group underwent24h dynamic esophageal pH and bile reflux monitoring were not used the PPIs and H2RA medicine before study. All the experimental data were processed and analyzed by SPSS13.0statistic software package.Results:1. In this study group, there had32(78.1%) abnormal gastroesophageal reflux patients.Acid reflux in4cases (9.8%), bile reflux in13cases (31.7%), mixed reflux in15patients (36.5%) and no reflux in9patients (21.9%). In the control group,abnormal gastroesophageal reflux was confirmed in all cases.Acid reflux in17cases (41.5%), bile reflux in2cases (4.9%), mixed reflux in22patients (53.6%). It’s obvious that the incidence of bile reflux is higher than that of acid reflux in this group while in the control group, although the frequency of the reflux is less(x=13.9,P<0.001), the time is longer, especially the longest reflux time is significantly increased, which are of obvious difference compared with the control group(P<0.05).2.542strain specimen were isolated in gastric juice (168), oropharynx (183)and lower respiratory tract (191). Gram-Negative bacillus cultures were found in430of542(79.3%) patients in critically ill patients. Among those430, there were bacillus cultures Bacillus coli(23.4%), Pseudomonas aeruginosa(20.8%) and baumanii (16.4%) are the major Gram-Negative bacillus.3.10in41critically ill patients had26strain (including Bacillus coli10strain, Pseudomonas aeruginosa5strain, baumanii4strain, sewer Bacillus coli5strain, enterococcus faecalis2strain) were isolated from gastric suction which were coincidence to oropharynx and lower respiratory tract.4. The detection rate of pathologic reflux group and no reflux group the intragastric colonization difference had no statistically significant (x=0.26, P>0.05), The incidence of pathological reflux group and no reflux group the reverse colonization difference was of no statistically significant (x=0.37, P>0.05).Conclusions:1.24h dynamic esophageal pH and bile monitoring can be appied not only in the diagnosis of GERD in general patients, but also in the clinical diagnosis in critically ill patients.2. Critically ill patients had high incidence of GER (78.0%), which were mainly to bile reflux and mixed reflux with longer reflux time than general patients. A significantly difference of the reflux characteristics between general patients and critically ill patients can be found.3. Critically ill patients sufferd stomach bacterial colonization, a major of Gram-negative bacilli, due to high pH value of gastric fluid and the other reasons.4. There were consistency between the oropharynx, lower respiratory tract isolated bacteria and stomach colonization bacteria in critically ill patients, which gives the possibility of the existence of the homology of those two. There were higher existence of the homology bacteria in patients who suffered GER than those didn’t suffered GER, which showed the possibillty of the stomach-pharynx-lower respiratory tract reverse infection and the reverse infection is relate to GER.