Advantage of multichannel intraluminal impedance in the diagnosis of aerophagia: A case report

Advantage of multichannel intraluminal impedance in the diagnosis of aerophagia: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Advantage of multichannel intraluminal impedance in the diagnosis of aerophagia: A case report Aya Tanaka, Takayuki Fujii, Hiroto Katami, Ryuichi Shimono This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4588668/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Sep, 2024 Read the published version in BMC Pediatrics → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Aerophagia is caused by the swallowing of excessive air and is associated with various gastrointestinal symptoms. Aerophagia is diagnosed based on the observation of the occurrence of excessive air swallowing or ingestion; however, it tends to be difficult and often delayed. Early recognition and diagnosis of aerophagia are required to avoid unnecessary diagnostic investigations or serious clinical complications. Given that multichannel intraluminal impedance–pH measurement can discriminate gas, liquid, and mixed swallows, it can be useful for the diagnosis of aerophagia. Case presentation: A 7-year-old girl presented to us with vomiting, and abdominal radiography showed dilatation of the stomach and intestine with no signs of mechanical obstruction. After successful conservative treatment, her symptoms recurred. Along with frequent visible and audible air swallowing, computed tomography (CT) revealed a severely dilated stomach with organoaxial volvulus. Multichannel intraluminal impedance–pH measurement was performed for further exploration. Patients showed numerous air swallows, particularly in the daytime during the 24-h recording period. She was diagnosed with aerophagia complicated by gastric volvulus. Given that she had a mental disorder and psychological counseling was difficult, laparoscopic anterior gastropexy and gastrostomy were performed to correct the gastric volvulus and desufflator. Conclusions: In addition to clinical symptoms, multichannel intraluminal impedance–pH measurement may help more accurately and objectively diagnose aerophagia. Further studies of air swallowing patterns may be useful for understanding the pathophysiological mechanism of aerophagia. case report aerophagia multichannel intraluminal impedance gastric volvulus Figures Figure 1 Figure 2 Figure 3 Background Aerophagia in children is defined by the Rome IV criteria as all of the following signs and symptoms: excessive air swallowing, abdominal distension caused by intraluminal air that increases during the day, repetitive belching and/or increased flatus, and repetitive belching or increased flatus occurring for a minimum of 2 months after appropriate evaluation [ 1 ]. Aerophagia has been observed in 8.8% of the institutionalized mentally handicapped population [ 2 ]. Until recently, studying air swallowing objectively for a prolonged period was difficult. With esophageal multichannel intraluminal impedance (MII) monitoring, evaluating swallowing frequencies and discriminating normal swallows from air swallows has become possible [ 3 ]. This study aimed to assess the advantage of MII–pH measurement for the diagnosis of aerophagia. Case presentation A 7-year-old girl with mental retardation caused by chromosome 4 q34-pter partial monosomy and chromosome 7 p21-pter partial trisomy was referred to us with vomiting. Plain abdominal radiography showed stomach dilation following vomiting (Fig. 1 a), and the intestines had no signs of mechanical obstruction (Fig. 1 b) in a while. After successful conservative treatment, her symptoms recurred. Along with frequent visible and audible air swallowing, CT revealed a severely dilated stomach with organoaxial volvulus. MII–pH measurement was conducted for further exploration. The study protocol was approved by the Kagawa University Ethics Review Board (No. H26-137). The patient was examined after informed consent was obtained from her parents. In this case, 24-h MII–pH measurement was performed using Sleuth recording devices (Sandhill Scientific System, Denver, CO, USA). The position of the MII–pH catheter was confirmed by X-ray imaging. Impedance data were automatically evaluated using the BioVIEW analysis software program, and each tracing was manually reviewed. An air swallow was defined as a peak superior to 1000 ohms above the baseline moving in the antegrade direction and measured in the most distal impedance segment (Fig. 2 ) [ 4 ]. During the 24-h recording period, the patient showed numerous air swallows, particularly the daytime but less at night time (Fig. 3 ). A gastric air reflux or a gastric belch was defined as a rapid rise of > 3000 ohms in the retrograde direction over at least two consecutive impedance sites that moved toward the mouth. She also belched repetitively. Abnormal gastroesophageal reflux (GER) was not observed, and her pH reflux index, bolus exposure index, and number of total reflux episodes were 0%, 1.2%, and 20times, respectively. She was diagnosed with aerophagia complicated with gastric volvulus. Because she had mental retardation, psychological counseling was difficult. After conservative treatment, she had repeated gastric volvulus. Therefore, laparoscopic anterior gastropexy and gastrostomy were conducted to correct the gastric volvulus and desufflator. Thereafter, she was free of symptoms, and plain abdominal X-ray imaging did not show dilatation of the stomach after surgery. Discussion and conclusions In most of the reported cases, the correct diagnosis of pediatric aerophagia was initially missed [ 5 – 7 ]. Early recognition and correct diagnosis help alleviate parents’ or patient’s anxiety and prevent unnecessary testing, treatments, and hospital admissions [ 2 , 5 , 7 ]. In some cases, severe aerophagia causes massive bowel distention and can result in ileus, volvulus, and intestinal necrosis or perforation [ 5 ]. Confirming the excessive volume of air objectively has been difficult. Recently, combined MII–pH measurement has become increasingly important for evaluating GER or esophageal function [ 8 , 9 ]. MII detects GER episodes based on changes in electrical resistance to the flow of an electrical current between a pair of electrodes placed on the MII probe when a liquid, semisolid, or gas bolus moves between them. By detecting reflux regardless of the pH value and distinguishing swallowing (antegrade flow) from authentic GER (retrograde flow), the combination of esophageal pH monitoring and impedance measurement offers several advantages over standard pH monitoring. In addition, it can accurately detect the height of the refluxate. Moreover, it can determine whether the refluxate is a liquid, gas, or a mixture of both liquid and gas [ 10 , 11 ]. Esophageal MII monitoring can evaluate swallowing frequencies and discriminate normal swallows from air swallows [ 3 ]. In this case, MII monitoring helped us diagnose our case as aerophagia. MII monitoring may be useful as a diagnostic tool for aerophagia. For obvious ethical reasons, no controlled study is conducted in pediatric populations. Given that only small reports evaluate aerophagia using MII monitoring [ 3 , 7 , 12 ], more studies are needed to evaluate the diagnostic value of MII in children with aerophagia. Effective reassurance and explanation of symptoms to the parents and child are essential in the treatment of aerophagia. Often, during the visit, the clinician can help the child become aware of air swallowing. Eating slowly, avoiding chewing gum and drinking carbonated beverages, and using psychotherapeutic strategies for the alleviation of anxiety may be helpful [ 2 ]. In the present case, overdistended transverse colon and distended stomach caused by aerophagia have also been considered important predisposing factors to the development of gastric volvulus. Such distended intestines, particularly the distended transverse colon, further promoted the volvulation of the stomach. Thus, the vicious circle caused by gastric volvulus and pathologic aerophagia contributed to the progression of abdominal distension, resulting in persistent gastrointestinal tract distention. The treatment of chronic gastric volvulus depends on symptomatology [ 13 ]. Those with persistent and severe symptoms should undergo gastropexy [ 13 , 14 ]. Some recent studies have reported the usefulness of laparoscopic gastropexy, which is a minimally invasive technique, in patients with chronic gastric volvulus [ 15 ]. Although gastropexy could not treat aerophagia, laparoscopic gastropexy combined with gastrostomy is a good indication for chronic gastric volvulus complicated by pathologic aerophagia. As our patient had mental retardation and recurrent symptoms, psychological counselling seemed to be difficult and surgical treatment was selected. MII–pH measurement can provide objective evidence of excessive air swallowing and repetitive belching, which can be useful for the diagnosis of aerophagia. Thus, more studies are needed to understand the pathophysiological mechanisms of aerophagia. Abbreviations GER gastroesophageal reflux MII multichannel intraluminal impedance CT computed tomography IV four Declarations Ethics approval and consent to participate; The study protocol was approved by the Kagawa University Ethics Review Board (No. H26-137). The patient was examined after informed consent was obtained from her parents. Consent for publication; The study protocol was approved by the Kagawa University Ethics Review Board (No. H26-137). The patient was examined after informed consent was obtained from her parents. Availability of data and materials; The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests; The authors declare that they have no competing interests Funding; The authors declare that they have no funding Authors’ contributions Study conception and design: AT and RS Acquisition of data: AT, TF, and HK Analysis and interpretation of data: AT and RS Drafting of manuscript: AT and RS Critical revision: AT and RS Acknowledgments The authors thank Dr D. Sifrim for his experienced advice in the analysis of MII–pH waveform. References Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016;150:1456–68. Loening-Baucke V. Aerophagia as cause of gaseous abdominal distention in a toddler. J Pediatr Gastroenterol Nutr. 2000;31:204–7. Hemmink GJM, Weusten BLAM, Bredenoord AJ, Timmer R, Smout AJPM. Areophagia: Excessive air swallowing demonstrated by esophageal impedance monitoring. Clin Gastroenterol Hepatol. 2009;7:1127–9. Kessing BF, Bredenoord AJ, Smout AJP. Mechanisms of gastric and supragastric belching: A study using concurrent high-resolution manometry and impedance monitoring. Neurogastroenterol Motil. 2012;24:e573–9. Hwang JB, Choi WJ, Kim JS, Lee SY, Jung CH, Lee YH, et al. Clinical features of pathologic childhood aerophagia: Early recognition and essential diagnostic criteria. J Pediatr Gastroenterol Nutr. 2005;41:612–6. Morabito G, Romeo C, Romano C. Functional aerophagia in children: A frequent, atipical disorder. Case Rep Gastroenterol. 2014;8:123–8. Halb C, Pomerleau M, Faure C. Multichannel intraesophageal impedance pattern of children with aerophagia. Neurogastroenterol Motil. 2014;26:1010–4. Sifrim D, Castell D, Dent J, Kahrilas PJ. Gastro-oesophageal reflux monitoring: Review and consensus report on detection and definition of acid, non-acid, and gas reflux. Gut. 2004;53:1024–31. Agrawal A, Castell DO. Clinical importance of impedance measurements. J Clin Gastroenterol. 2008;42:579–83. van Wijk MP, Benninga MA, Omari TI. Role of the multichannel intraluminal impedance technique in infants and children. J Pediatr Gastroenterol Nutr. 2009;48:2–12. Mousa HM, Rosen R, Woodley FW, Orsi M, Armas D, Faure C, et al. Esophageal impedance monitoring for gastroesophageal reflux. J Pediatr Gastroenterol Nutr. 2011;52:129–39. Bredenoord AJ, Weusten BLAM, Sifrim D, Timmer R, Smout AJPM. Aerophagia, gastric, and supragastric belching: A study using intraluminal electrical impedance monitoring. Gut. 2004;53:1561–5. Al-Salem AH. Acute and chronic gastric volvulus in infants and children: Who should be treated surgically? Pediatr Surg Int. 2007;23:1095–9. Porcaro F, Mattioli G, Romano C. Pediatric gastric volvulus: Diagnostic and clinical approach. Case Rep Gastroenterol. 2013;7:63–8. Komoro H, Matoba K, Kaneko M. Laparoscopic gastropexy for chronic gastric volvulus complicated by pathologic aerophagia in a boy. Pediatr Int. 2005;47:701–3. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 28 Sep, 2024 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 04 Jul, 2024 Reviews received at journal 04 Jul, 2024 Reviews received at journal 03 Jul, 2024 Reviewers agreed at journal 25 Jun, 2024 Reviewers agreed at journal 25 Jun, 2024 Reviewers invited by journal 25 Jun, 2024 Editor invited by journal 25 Jun, 2024 Editor assigned by journal 19 Jun, 2024 Submission checks completed at journal 19 Jun, 2024 First submitted to journal 16 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4588668","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":322877377,"identity":"66717763-9935-4b24-8526-6f33461bc38c","order_by":0,"name":"Aya Tanaka","email":"","orcid":"","institution":"Kagawa University","correspondingAuthor":false,"prefix":"","firstName":"Aya","middleName":"","lastName":"Tanaka","suffix":""},{"id":322877378,"identity":"78bc5309-734f-4e93-91d7-74e7b57141cb","order_by":1,"name":"Takayuki Fujii","email":"","orcid":"","institution":"Kagawa 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obstruction.\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4588668/v1/18507cf5b85b9e449e5512f3.jpg"},{"id":60529971,"identity":"7f3b0c91-141f-4c2d-9658-561ad50f0d43","added_by":"auto","created_at":"2024-07-17 20:01:13","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":54093,"visible":true,"origin":"","legend":"\u003cp\u003eAir swallow.\u003c/p\u003e\n\u003cp\u003eA peak of impedance superior to 1000 ohms above the baseline moving in the antegrade direction and measured in the most distal impedance segment.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4588668/v1/9b79c71849aaad6c926e9dcd.jpg"},{"id":60530799,"identity":"aacdc0e3-7d9a-4e9c-b97c-11d2173f6838","added_by":"auto","created_at":"2024-07-17 20:09:13","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":172818,"visible":true,"origin":"","legend":"\u003cp\u003eMII waveform during the 24-h recording period.\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4588668/v1/68889739cfafc1f7e336e31e.jpg"},{"id":65627118,"identity":"ccf45ed7-0277-49ed-a827-c639c23029f7","added_by":"auto","created_at":"2024-09-30 16:12:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":542183,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4588668/v1/81c6fb3b-f09c-46d7-b0fa-d6887e6c7889.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Advantage of multichannel intraluminal impedance in the diagnosis of aerophagia: A case report","fulltext":[{"header":"Background","content":"\u003cp\u003eAerophagia in children is defined by the Rome IV criteria as all of the following signs and symptoms: excessive air swallowing, abdominal distension caused by intraluminal air that increases during the day, repetitive belching and/or increased flatus, and repetitive belching or increased flatus occurring for a minimum of 2 months after appropriate evaluation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Aerophagia has been observed in 8.8% of the institutionalized mentally handicapped population [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Until recently, studying air swallowing objectively for a prolonged period was difficult. With esophageal multichannel intraluminal impedance (MII) monitoring, evaluating swallowing frequencies and discriminating normal swallows from air swallows has become possible [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This study aimed to assess the advantage of MII\u0026ndash;pH measurement for the diagnosis of aerophagia.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 7-year-old girl with mental retardation caused by chromosome 4 q34-pter partial monosomy and chromosome 7 p21-pter partial trisomy was referred to us with vomiting. Plain abdominal radiography showed stomach dilation following vomiting (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea), and the intestines had no signs of mechanical obstruction (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb) in a while. After successful conservative treatment, her symptoms recurred. Along with frequent visible and audible air swallowing, CT revealed a severely dilated stomach with organoaxial volvulus. MII\u0026ndash;pH measurement was conducted for further exploration.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe study protocol was approved by the Kagawa University Ethics Review Board (No. H26-137). The patient was examined after informed consent was obtained from her parents.\u003c/p\u003e \u003cp\u003eIn this case, 24-h MII\u0026ndash;pH measurement was performed using Sleuth recording devices (Sandhill Scientific System, Denver, CO, USA). The position of the MII\u0026ndash;pH catheter was confirmed by X-ray imaging. Impedance data were automatically evaluated using the BioVIEW analysis software program, and each tracing was manually reviewed. An air swallow was defined as a peak superior to 1000 ohms above the baseline moving in the antegrade direction and measured in the most distal impedance segment (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. During the 24-h recording period, the patient showed numerous air swallows, particularly the daytime but less at night time (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A gastric air reflux or a gastric belch was defined as a rapid rise of \u0026gt;\u0026thinsp;3000 ohms in the retrograde direction over at least two consecutive impedance sites that moved toward the mouth. She also belched repetitively. Abnormal gastroesophageal reflux (GER) was not observed, and her pH reflux index, bolus exposure index, and number of total reflux episodes were 0%, 1.2%, and 20times, respectively. She was diagnosed with aerophagia complicated with gastric volvulus. Because she had mental retardation, psychological counseling was difficult. After conservative treatment, she had repeated gastric volvulus. Therefore, laparoscopic anterior gastropexy and gastrostomy were conducted to correct the gastric volvulus and desufflator. Thereafter, she was free of symptoms, and plain abdominal X-ray imaging did not show dilatation of the stomach after surgery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion and conclusions","content":"\u003cp\u003eIn most of the reported cases, the correct diagnosis of pediatric aerophagia was initially missed [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Early recognition and correct diagnosis help alleviate parents\u0026rsquo; or patient\u0026rsquo;s anxiety and prevent unnecessary testing, treatments, and hospital admissions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In some cases, severe aerophagia causes massive bowel distention and can result in ileus, volvulus, and intestinal necrosis or perforation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Confirming the excessive volume of air objectively has been difficult. Recently, combined MII\u0026ndash;pH measurement has become increasingly important for evaluating GER or esophageal function [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. MII detects GER episodes based on changes in electrical resistance to the flow of an electrical current between a pair of electrodes placed on the MII probe when a liquid, semisolid, or gas bolus moves between them. By detecting reflux regardless of the pH value and distinguishing swallowing (antegrade flow) from authentic GER (retrograde flow), the combination of esophageal pH monitoring and impedance measurement offers several advantages over standard pH monitoring. In addition, it can accurately detect the height of the refluxate. Moreover, it can determine whether the refluxate is a liquid, gas, or a mixture of both liquid and gas [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Esophageal MII monitoring can evaluate swallowing frequencies and discriminate normal swallows from air swallows [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In this case, MII monitoring helped us diagnose our case as aerophagia. MII monitoring may be useful as a diagnostic tool for aerophagia.\u003c/p\u003e \u003cp\u003eFor obvious ethical reasons, no controlled study is conducted in pediatric populations. Given that only small reports evaluate aerophagia using MII monitoring [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], more studies are needed to evaluate the diagnostic value of MII in children with aerophagia.\u003c/p\u003e \u003cp\u003eEffective reassurance and explanation of symptoms to the parents and child are essential in the treatment of aerophagia. Often, during the visit, the clinician can help the child become aware of air swallowing. Eating slowly, avoiding chewing gum and drinking carbonated beverages, and using psychotherapeutic strategies for the alleviation of anxiety may be helpful [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In the present case, overdistended transverse colon and distended stomach caused by aerophagia have also been considered important predisposing factors to the development of gastric volvulus. Such distended intestines, particularly the distended transverse colon, further promoted the volvulation of the stomach. Thus, the vicious circle caused by gastric volvulus and pathologic aerophagia contributed to the progression of abdominal distension, resulting in persistent gastrointestinal tract distention. The treatment of chronic gastric volvulus depends on symptomatology [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Those with persistent and severe symptoms should undergo gastropexy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Some recent studies have reported the usefulness of laparoscopic gastropexy, which is a minimally invasive technique, in patients with chronic gastric volvulus [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Although gastropexy could not treat aerophagia, laparoscopic gastropexy combined with gastrostomy is a good indication for chronic gastric volvulus complicated by pathologic aerophagia. As our patient had mental retardation and recurrent symptoms, psychological counselling seemed to be difficult and surgical treatment was selected.\u003c/p\u003e \u003cp\u003eMII\u0026ndash;pH measurement can provide objective evidence of excessive air swallowing and repetitive belching, which can be useful for the diagnosis of aerophagia. Thus, more studies are needed to understand the pathophysiological mechanisms of aerophagia.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGER\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003egastroesophageal reflux\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMII\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emultichannel intraluminal impedance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecomputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003efour\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate;\u0026nbsp;\u003c/strong\u003eThe study protocol was approved by the Kagawa University Ethics Review Board (No. H26-137). The patient was examined after informed consent was obtained from her parents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication;\u0026nbsp;\u003c/strong\u003eThe study protocol was approved by the Kagawa University Ethics Review Board (No. H26-137). The patient was examined after informed consent was obtained from her parents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials;\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests;\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding;\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception and design: AT and RS\u003c/p\u003e\n\u003cp\u003eAcquisition of data: AT, TF, and HK\u003c/p\u003e\n\u003cp\u003eAnalysis and interpretation of data: AT and RS\u003c/p\u003e\n\u003cp\u003eDrafting of manuscript: AT and RS\u003c/p\u003e\n\u003cp\u003eCritical revision: AT and RS\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Dr D. Sifrim for his experienced advice in the analysis of MII\u0026ndash;pH waveform.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016;150:1456\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoening-Baucke V. Aerophagia as cause of gaseous abdominal distention in a toddler. J Pediatr Gastroenterol Nutr. 2000;31:204\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHemmink GJM, Weusten BLAM, Bredenoord AJ, Timmer R, Smout AJPM. Areophagia: Excessive air swallowing demonstrated by esophageal impedance monitoring. Clin Gastroenterol Hepatol. 2009;7:1127\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKessing BF, Bredenoord AJ, Smout AJP. Mechanisms of gastric and supragastric belching: A study using concurrent high-resolution manometry and impedance monitoring. Neurogastroenterol Motil. 2012;24:e573\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHwang JB, Choi WJ, Kim JS, Lee SY, Jung CH, Lee YH, et al. Clinical features of pathologic childhood aerophagia: Early recognition and essential diagnostic criteria. J Pediatr Gastroenterol Nutr. 2005;41:612\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorabito G, Romeo C, Romano C. Functional aerophagia in children: A frequent, atipical disorder. Case Rep Gastroenterol. 2014;8:123\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalb C, Pomerleau M, Faure C. Multichannel intraesophageal impedance pattern of children with aerophagia. Neurogastroenterol Motil. 2014;26:1010\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSifrim D, Castell D, Dent J, Kahrilas PJ. Gastro-oesophageal reflux monitoring: Review and consensus report on detection and definition of acid, non-acid, and gas reflux. Gut. 2004;53:1024\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgrawal A, Castell DO. Clinical importance of impedance measurements. J Clin Gastroenterol. 2008;42:579\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Wijk MP, Benninga MA, Omari TI. Role of the multichannel intraluminal impedance technique in infants and children. J Pediatr Gastroenterol Nutr. 2009;48:2\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMousa HM, Rosen R, Woodley FW, Orsi M, Armas D, Faure C, et al. Esophageal impedance monitoring for gastroesophageal reflux. J Pediatr Gastroenterol Nutr. 2011;52:129\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBredenoord AJ, Weusten BLAM, Sifrim D, Timmer R, Smout AJPM. Aerophagia, gastric, and supragastric belching: A study using intraluminal electrical impedance monitoring. Gut. 2004;53:1561\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Salem AH. Acute and chronic gastric volvulus in infants and children: Who should be treated surgically? Pediatr Surg Int. 2007;23:1095\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePorcaro F, Mattioli G, Romano C. Pediatric gastric volvulus: Diagnostic and clinical approach. Case Rep Gastroenterol. 2013;7:63\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKomoro H, Matoba K, Kaneko M. Laparoscopic gastropexy for chronic gastric volvulus complicated by pathologic aerophagia in a boy. Pediatr Int. 2005;47:701\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"case report, aerophagia, multichannel intraluminal impedance, gastric volvulus","lastPublishedDoi":"10.21203/rs.3.rs-4588668/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4588668/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Aerophagia is caused by the swallowing of excessive air and is associated with various gastrointestinal symptoms. Aerophagia is diagnosed based on the observation of the occurrence of excessive air swallowing or ingestion; however, it tends to be difficult and often delayed. Early recognition and diagnosis of aerophagia are required to avoid unnecessary diagnostic investigations or serious clinical complications. Given that multichannel intraluminal impedance–pH measurement can discriminate gas, liquid, and mixed swallows, it can be useful for the diagnosis of aerophagia.\u003c/p\u003e\n\u003cp\u003eCase presentation: A 7-year-old girl presented to us with vomiting, and abdominal radiography showed dilatation of the stomach and intestine with no signs of mechanical obstruction. After successful conservative treatment, her symptoms recurred. Along with frequent visible and audible air swallowing, computed tomography (CT) revealed a severely dilated stomach with organoaxial volvulus. Multichannel intraluminal impedance–pH measurement was performed for further exploration. Patients showed numerous air swallows, particularly in the daytime during the 24-h recording period. She was diagnosed with aerophagia complicated by gastric volvulus. Given that she had a mental disorder and psychological counseling was difficult, laparoscopic anterior gastropexy and gastrostomy were performed to correct the gastric volvulus and desufflator.\u003c/p\u003e\n\u003cp\u003eConclusions: In addition to clinical symptoms, multichannel intraluminal impedance–pH measurement may help more accurately and objectively diagnose aerophagia. Further studies of air swallowing patterns may be useful for understanding the pathophysiological mechanism of aerophagia.\u003c/p\u003e","manuscriptTitle":"Advantage of multichannel intraluminal impedance in the diagnosis of aerophagia: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-17 20:01:08","doi":"10.21203/rs.3.rs-4588668/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-04T21:04:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-04T20:14:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-03T21:06:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50549883737066342735572942490163930982","date":"2024-06-25T17:17:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186434246595731988061980492877314433845","date":"2024-06-25T16:41:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-25T16:40:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-25T12:30:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-19T11:31:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-19T11:31:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2024-06-16T06:31:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7f36eb18-1fa9-41ff-8972-209ac14d91cc","owner":[],"postedDate":"July 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-30T16:00:02+00:00","versionOfRecord":{"articleIdentity":"rs-4588668","link":"https://doi.org/10.1186/s12887-024-05081-7","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2024-09-28 15:57:05","publishedOnDateReadable":"September 28th, 2024"},"versionCreatedAt":"2024-07-17 20:01:08","video":"","vorDoi":"10.1186/s12887-024-05081-7","vorDoiUrl":"https://doi.org/10.1186/s12887-024-05081-7","workflowStages":[]},"version":"v1","identity":"rs-4588668","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4588668","identity":"rs-4588668","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}