Background
Hypersensitive esophagus (HE) is defined by endoscopy-negative heartburn with a normal acid exposure time but positive symptom association probability (SAP) and/or symptom index (SI) on ...impedance–pH monitoring, and proton pump inhibitor (PPI) responsiveness. Functional heartburn (FH) is distinguished by negative SAP/SI and PPI refractoriness. The clinical value of SAP and SI has been questioned. We aimed to investigate whether impairment of chemical clearance and of mucosal integrity, expressed by the postreflux swallow-induced peristaltic wave (PSPW) index and the mean nocturnal baseline impedance (MNBI), characterize HE independently of SAP and SI.
Methods
Impedance–pH tracings from PPI-responsive endoscopy-negative patients, 125 with nonerosive reflux disease and 108 with HE, distinguished by an abnormal and a normal acid exposure time, and from 70 patients with FH were retrospectively selected and blindly reviewed.
Results
The mean PSPW index and MNBI were significantly lower in nonerosive reflux disease (30 %, 1378 Ω) than in HE (51 %; 2274 Ω) and in both of them as compared with FH (76 %; 3445 Ω) (
P
= 0.0001). Both the PSPW index (adjusted odds ratio 0.863,
P
= 0.001) and the MNBI (adjusted odds ratio 0.998,
P
= 0.001) were independent predictors of HE; with their combined assessment, the area under the curve on receiver operating characteristic analysis was 0.957. SAP and/or SI was positive in 67 of the 108 HE patients (62 %), whereas the PSPW index and/or MNBI was abnormal in 99 of the 108 HE patients (92 %;
P
< 0.0001).
Conclusions
HE is characterized by impairment of chemical clearance and mucosal integrity, which explains the increased reflux perception. When SAP and SI afford uncertain results, the PSPW index and MNBI should be analyzed.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Summary
Background
Artificial intelligence (AI) has recently been applied to endoscopy and questionnaires for the evaluation of oesophageal diseases (ODs).
Aim
We performed a systematic review with ...meta‐analysis to evaluate the performance of AI in the diagnosis of malignant and benign OD.
Methods
We searched MEDLINE, EMBASE, EMBASE Classic and the Cochrane Library. A bivariate random‐effect model was used to calculate pooled diagnostic efficacy of AI models and endoscopists. The reference tests were histology for neoplasms and the clinical and instrumental diagnosis for gastro‐oesophageal reflux disease (GERD). The pooled area under the summary receiver operating characteristic (AUROC), sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR) and diagnostic odds ratio (DOR) were estimated.
Results
For the diagnosis of Barrett's neoplasia, AI had AUROC of 0.90, sensitivity 0.89, specificity 0.86, PLR 6.50, NLR 0.13 and DOR 50.53. AI models’ performance was comparable with that of endoscopists (P = 0.35). For the diagnosis of oesophageal squamous cell carcinoma, the AUROC, sensitivity, specificity, PLR, NLR and DOR were 0.97, 0.95, 0.92, 12.65, 0.05 and DOR 258.36, respectively. In this task, AI performed better than endoscopists although without statistically significant differences. In the detection of abnormal intrapapillary capillary loops, the performance of AI was: AUROC 0.98, sensitivity 0.94, specificity 0.94, PLR 14.75, NLR 0.07 and DOR 225.83. For the diagnosis of GERD based on questionnaires, the AUROC, sensitivity, specificity, PLR, NLR and DOR were 0.99, 0.97, 0.97, 38.26, 0.03 and 1159.6, respectively.
Conclusions
AI demonstrated high performance in the clinical and endoscopic diagnosis of OD.
Artificial intelligence in the diagnosis of oesophageal diseases: systematic review with meta‐analysis.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Background
Chronic cough significantly impairs the quality of life. Although various studies focused on MNBI as assessed in the distal esophagus, scarce data are available on the clinical value of ...proximal measurements.
Aim
To investigate the role of proximal MNBI in the workup of patients with chronic cough and its ability to predict PPI response.
Methods
Demographic, clinical, endoscopy findings, impedance‐pH and HRM tracings from consecutive cough patients were evaluated. MNBI was calculated at proximal and distal esophagus.
Results
One hundred and sixty four patients were included. In addition to traditional variables, when considering also the PSPW index or MNBI at 3 cm or 15 cm, the proportion of patients with pathological impedance‐pH monitoring significantly increased. 70/164 patients were responders, while 94 (57.3%) were non‐responder to double PPI dose (p < 0.05). Patients with pathologic MNBI at 3 cm and/or 15 cm as well as those with pathologic PSPW index were characterized by a significantly higher proportion of responders than that observed among patients with normal impedance‐pH variables (p < 0.001). The proportion of responders with pathological MNBI at 15 cm was significantly higher than the proportion of responders with pathological MNBI at 3 cm (82.8% vs. 64.3%, p < 0.05). At multivariable model, pathological MNBI at both 3 cm and 15 cm as well as PSPW index were associated with PPI responsiveness. The strongest association with PPI response was observed for MNBI at 15 cm.
Conclusions
The assessment of MNBI at proximal esophagus increases the diagnostic yield of impedance‐pH monitoring and may represent a useful predictor of PPI responsiveness in the cumbersome clinical setting of suspected reflux‐related cough.
Ambulatory impedance‐pH monitoring has improved the diagnosis of GERD in patients with chronic cough. The assessment of MNBI at proximal esophagus increases the diagnostic yield of impedance‐pH monitoring and may represent a useful predictor of PPI responsiveness in the cumbersome clinical setting of suspected reflux‐related cough.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Summary
Background
A hierarchical approach for gastro‐oesophageal reflux disease (GERD) diagnosis by impedance‐pH monitoring was proposed by the Lyon Consensus, based on acid exposure time (AET) and ...supportive impedance metrics.
Aims
To establish the clinical value of Lyon Consensus criteria in the work‐up of patients with proton pump inhibitory (PPI)‐refractory heartburn.
Methods
Expert review of off‐therapy impedance‐pH tracings from unproven GERD patients with PPI‐refractory heartburn prospectively evaluated at referral centers. Impedance metrics, namely total reflux episodes, postreflux swallow‐induced peristaltic wave index, and mean nocturnal baseline impedance, were assessed. Expert review of on‐therapy preoperative impedance‐pH tracings from a separate cohort of surgically treated erosive/nonerosive GERD cases.
Results
Off‐therapy, normal, inconclusive, and abnormal AET was found in 59%, 17%, and 23% of 317 cases. Supportive evidence of GERD was provided by abnormal impedance metrics in up to 22% and 62% of cases in the normal and inconclusive AET groups, respectively. Adding the cases with inconclusive AET and abnormal impedance metrics to the abnormal AET group, a significant increase in GERD evidence was observed (from 23% to 37% of cases, p < 0.0002). At the on‐therapy presurgical evaluation, abnormal/inconclusive AET and supraphysiological values of impedance metrics showed ongoing reflux in 21% and 90% of 96 cases, respectively (p < 0.00001); a relationship between on‐therapy ongoing reflux and PPI‐refractory heartburn was confirmed by the favorable surgical outcome at 3‐year follow‐up, 88% of cases being in persistent off‐PPI heartburn remission.
Conclusions
Impedance‐pH monitoring, off‐ and on‐therapy, is of high clinical value in the work‐up of patients with PPI‐refractory heartburn.
In patients with proton pump inhibitory (PPI)‐refractory heartburn and inconclusive acid exposure time, gastro‐oesophageal reflux disease (GERD) evidence can be afforded by off‐therapy impedance metrics. In proven GERD cases, PPI‐refractory heartburn can be related to ongoing reflux by on‐therapy impedance metrics, a relationship confirmed by positive surgical outcome at 3‐year follow‐up.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
5.
Indications and interpretation of esophageal function testing Gyawali, C. Prakash; Bortoli, Nicola; Clarke, John ...
Annals of the New York Academy of Sciences,
December 2018, 2018-Dec, 2018-12-00, 20181201, Volume:
1434, Issue:
1
Journal Article
Peer reviewed
Esophageal symptoms are common, and can arise from mucosal, motor, functional, and neoplastic processes, among others. Judicious use of diagnostic testing can help define the etiology of symptoms and ...can direct management. Endoscopy, esophageal high‐resolution manometry (HRM), ambulatory pH or pH‐impedance manometry, and barium radiography are commonly used for esophageal function testing; functional lumen imaging probe is an emerging option. Recent consensus guidelines have provided direction in using test findings toward defining mechanisms of esophageal symptoms. The Chicago Classification describes hierarchical steps in diagnosing esophageal motility disorders. The Lyon Consensus characterizes conclusive evidence on esophageal testing for a diagnosis of gastroesophageal reflux disease (GERD), and establishes a motor classification of GERD. Taking these recent advances into consideration, our discussion focuses primarily on the indications, technique, equipment, and interpretation of esophageal HRM and ambulatory reflux monitoring in the evaluation of esophageal symptoms, and describes indications for alternative esophageal tests.
Esophageal symptoms are common, and can arise from mucosal, motor, functional, and neoplastic processes, among others. This review focuses primarily on the indications, technique, equipment, and interpretation of esophageal high‐resolution manometry (HRM) and ambulatory reflux monitoring in the evaluation of esophageal symptoms, and describes indications for alternative esophageal tests. This image demonstrates a reflux episode on pH impedance monitoring, followed by the patient's recording of a heartburn event.
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BFBNIB, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
On‐therapy impedance‐pH monitoring is recommended in patients with documented GERD and PPI‐refractory heartburn in order to establish whether the unremitting symptom is reflux‐related or ...not.
Aims
To define on‐PPI cut‐offs of impedance‐pH metrics allowing proper interpretation of on‐therapy impedance‐pH monitoring.
Methods
Blinded expert review of impedance‐pH tracings performed during double‐dosage PPI, prospectively collected from 150 GERD patients with PPI‐refractory heartburn and 45 GERD patients with PPI‐responsive heartburn but persisting extra‐esophageal symptoms. Acid exposure time (AET), number of total refluxes (TRs), post‐reflux swallow‐induced peristaltic wave (PSPW) index, and mean nocturnal baseline impedance (MNBI) were assessed. On‐PPI cut‐offs were defined and evaluated with ROC analysis and the area under curve (AUC).
Results
All the four impedance‐pH metrics significantly differed between PPI‐refractory and PPI‐responsive heartburn cases. At ROC analysis, AUC was 0.73 for AET, 0.75 for TRs, 0.81 for PSPW index, and 0.71 for MNBI; best cut‐offs were ≥1.7% for AET, ≥45 for TRs, ≤36% for PSPW index, and ≤ 1847 Ω for MNBI; AUC of such cut‐offs was 0.66, 0.71, 0.73, and 0.68, respectively. Analysis of PSPW index and MNBI added to assessment of AET and TRs significantly increased the yield of on‐therapy impedance‐pH monitoring in the PPI‐refractory cohort (97% vs. 83%, p < 0.0001). Notably, suboptimal acid suppression as shown by AET ≥1.7% was detected in 43% of 150 PPI‐refractory cases.
Conclusions
We have defined on‐PPI cut‐offs of impedance‐pH metrics by which comprehensive assessment of impedance‐pH tracings, including analysis of PSPW index and MNBI can efficiently characterize PPI‐refractory GERD and support treatment escalation.
This study establishes on‐PPI cut‐offs of impedance‐pH metrics. Adopting such cut‐offs, on‐PPI impedance‐pH monitoring can demonstrate a cause‐and‐effect relationship between reflux and PPI‐refractory heartburn in most patients with documented GERD. Comprehensive assessment of tracings including analysis of PSPW index and MNBI increases the clinical value of on‐PPI impedance‐pH monitoring.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Background
Microscopic esophagitis (ME) is common in patients with non-erosive reflux disease (NERD), and dilation of intercellular spaces (DIS) has been regarded as the potential main mechanism of ...symptom generation. We aimed to compare these histological abnormalities in healthy volunteers (HVs) and patients with erosive esophagitis (EE), NERD, and functional heartburn (FH).
Methods
Consecutive patients with heartburn prospectively underwent upper endoscopy and impedance-pH off-therapy. Twenty EE patients and fifty-seven endoscopy-negative patients (NERD), subclassified as 22 with pH-POS (positive for abnormal acid exposure), 20 with hypersensitive esophagus (HE; normal acid/symptom association probability SAP+ or symptom index SI+), and 15 with FH (normal acid/SAP-/SI-/ proton pump inhibitor PPI test-), were enrolled. Twenty HVs were also included. In each patient/control, multiple specimens (
n
= 5) were taken from the distal esophagus and histological alterations were evaluated. ME was diagnosed when the global histological score was >0.35.
Results
The prevalence of ME was higher (
p
< 0.0001) in EE (95 %), pH-POS (77 %), and HE (65 %) NERD patients than in FH patients (13 %) and HVs (15 %). Also, basal cell hyperplasia (
p
< 0.0023), DIS (
p
< 0.0001), and papillae elongation (
p
< 0.0002) showed similar rates of prevalence in the above populations (
p
< 0.0001). ME, including each histological lesion, had similar low frequencies in FH and HVs (
p
= 0.9990). Considering the histological abnormalities together, they permitted us to clearly differentiate EE and NERD from FH and HVs (
p
< 0.0001 and
p
< 0.0001, respectively).
Conclusions
The lack of ME in the esophageal distal biopsies of FH patients indicates a limited role of these histological abnormalities in symptom generation in them. ME can be considered as an accurate and reliable diagnostic marker for distinguishing FH patients from GERD patients and has the potential to be used to guide the correct therapy.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
LINKED CONTENT
This article is linked to Frazzoni et al and Rogers & Gyawali papers. To view these articles, visit https://doi.org/10.1111/apt.16371 and https://doi.org/10.1111/apt.16393
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Available for:
BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Background
Hiatus hernia (HH) contributes to development of gastroesophageal reflux disease, Barrett's esophagus and esophageal adenocarcinoma. This study was aimed to investigate the influence of HH ...on reflux patterns and distal esophageal mucosal integrity in non‐erosive reflux disease (NERD).
Methods
We retrospectively analyzed PPI‐refractory NERD patients referred to three tertiary referral centers who underwent high‐resolution manometry and off‐PPI 24‐h impedance‐pH monitoring (with or without bile spectrophotometry). Patients with HH ≥2 cm (HH group, n = 42) or no HH (non‐HH group, n = 40) with similar esophageal acid exposure time (AET 6%–12%) were included.
Key Results
Age, gender, BMI, esophageal motility, AET, and esophageal clearance were similar between the two groups. The HH group had higher numbers of total reflux episodes (p = 0.015) with similar proportion of acid/non‐acid reflux compared with the non‐HH group. Mean nocturnal baseline impedance (MNBI) in the distal esophagus was significantly lower in the HH group than the non‐HH group at both 5 cm (p = 0.002) and 3 cm (p = 0.015) above the lower esophageal sphincter. Multivariable regression analysis showed that HH, less non‐acid reflux and lower post‐reflux swallow‐induced peristaltic wave index (PSPWI) were independently associated with lower MNBI. Among 31 patients tested with bile spectrophotometry, the HH group had significantly longer bile exposure time than the non‐HH group (p = 0.011), and bile reflux inversely and significantly correlated with MNBI (rho = −0.75, p < 0.001).
Conclusions and Inferences
Hiatus hernia, less non‐acid reflux and lower PSPWI were associated with lower MNBI. HH impairs distal esophageal mucosal integrity, the mechanism of which we speculate to be through excessive bile reflux.
In patients with similar acid burden and similar motor function, the presence of a hiatus hernia, less non‐acid reflux and lower post‐reflux swallow‐induced peristaltic wave index led to greater impairment of distal esophageal mucosal integrity compared with no hernia. HH impairs distal esophageal mucosal integrity possibly through excessive bile reflux.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
A low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet (LFD) is a possible therapy for irritable bowel syndrome (IBS). This study investigates the short- and ...long-term efficacy and nutritional adequacy of an LFD and the patients' long-term acceptability. Patients' adherence and ability to perceive the "trigger" foods were also evaluated. Seventy-three IBS patients were given an LFD (T0) and after 2 months (T1), 68 started the reintroduction phase. At the end of this period (T2), 59 were advised to go on an Adapted Low-FODMAP Diet (AdLFD) and 41 were evaluated again after a 6-24 month follow-up (T3). At each time, questionnaires and Biolectrical Impedance Vector Analysis (BIVA) were performed. The LFD was effective in controlling digestive symptoms both in the short- and long-term, and in improving quality of life, anxiety and depression, even if some problems regarding acceptability were reported and adherence decreased in the long term. The LFD improved the food-related quality of life without affecting nutritional adequacy. When data collected at T0 were compared with those collected at T2, the perception of trigger foods was quite different. Even if some problems of acceptability and adherence are reported, an LFD is nutritionally adequate and effective in improving IBS symptoms also in the long term.
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