Background
Acid exposure time (AET) is considered the most useful parameter to predict response of reflux‐related heartburn to medical or surgical treatment. However, recent studies showed high rates ...of heartburn response to proton pump inhibitor (PPI) therapy in patients with normal AET.
We aimed to compare the efficacy of postreflux swallow‐induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) with AET in linking PPI‐responsive heartburn to reflux.
Methods
Off‐therapy impedance‐pH tracings from 425 patients, 317 with PPI‐responsive and 108 with PPI‐refractory heartburn were blindly re‐analyzed. Demographic and endoscopic characteristics, conventional impedance‐pH variables, PSPW index, and MNBI were assessed with multivariate logistic regression to identify factors independently associated with PPI responsiveness. Prediction models were developed to assess the strength of reflux linkage with factors independently associated with PPI responsiveness by calculating the area under the curve (AUC) at receiver‐operating‐characteristic (ROC) analysis.
Key Results
At multivariate logistic regression analysis, AET, MNBI, and PSPW index were the only factors independently associated with PPI responsiveness, abnormal values found in 60%, 76%, and 92% of PPI‐responsive cases (P<.017). At ROC analysis, PSPW index (AUC:.794, P=.002) and MNBI (AUC: 0.742, P=.003), both separately and combined (AUC: 0.811, P<.001) linked reflux with PPI‐responsiveness better than AET (AUC: 0.687).
Conclusions & Inferences
AET, PSPW index, and MNBI are independently associated with PPI‐responsive heartburn. PSPW index and MNBI can link PPI‐responsive heartburn to reflux better than AET and should become part of the standard analysis of impedance‐pH tracings.
The diagnostic sensitivity of acid exposure time (AET) is limited. Postreflux swallow‐induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) can increase the diagnostic yield of impedance‐pH monitoring. AET, PSPW index, and MNBI were the only variables independently associated with heartburn response to PPIs. PSPW index and MNBI were significantly more efficient than AET in linking PPI‐responsive heartburn with reflux. Routine assessment of impedance‐pH tracings should include calculation of PSPW index and MNBI in order to increase our ability to establish a direct relationship between PPI‐responsive heartburn and reflux.
Background
On‐therapy impedance‐pH monitoring in proton pump inhibitor (PPI)‐refractory gastroesophageal reflux disease (GERD) yielded conflicting results. We aimed to assess the diagnostic value of ...postreflux swallow‐induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) in PPI‐refractory heartburn.
Methods
On‐therapy impedance‐pH tracings from 189 consecutive patients with PPI‐refractory heartburn were blindly reviewed. Patients were subdivided into refractory reflux esophagitis (RRE), healed reflux esophagitis (HRE), non‐erosive reflux disease (NERD), and functional heartburn (FH) according to endoscopic and conventional impedance‐pH findings. The diagnostic accuracy of PSPW index and MNBI in separating NERD from FH was assessed with receiver‐operating‐characteristic (ROC) analysis. Objectively documented persistent reflux remission at 3‐year follow‐up in 53 patients who underwent laparoscopic fundoplication served to evaluate PSPW index and MNBI as independent predictors of PPI‐refractory GERD confirmed by positive surgical outcome.
Key Results
Median PSPW index and MNBI values were significantly lower in 39 RRE (16%; 1145 Ω) than in 41 HRE (25%; 1741 Ω) and in 68 NERD (29%; 2374 Ω) patients, and in all three GERD subgroups compared to 41 FH cases (67%; 3488 Ω) (P<.008). At ROC analysis, comparing NERD to FH the area under the curve was 0.886 with PSPW index and 0.677 with MNBI (P=.005). PSPW index was an independent predictor of PPI‐refractory GERD (odds ratio 0.6983, P=.012).
Conclusions & Inferences
At on‐therapy impedance‐pH monitoring, PSPW index and MNBI efficiently distinguish PPI‐refractory NERD from FH. The PSPW index represents an independent predictor of PPI‐refractory GERD.
On‐therapy impedance‐pH monitoring establishes the relationship between PPI‐refractory heartburn and reflux. Post‐reflux swallow‐induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) were highly efficient in distinguishing PPI‐refractory non‐erosive reflux disease (NERD) from functional heartburn (FH) and refractory reflux esophagitis (RRE) from healed reflux esophagitis (HRE). Abnormal PSPW index and MNBI characterize reflux‐related PPI‐refractory heartburn.
Background
Recently, it has been suggested that low esophageal basal impedance may reflect impaired mucosal integrity and increased acid sensitivity. We aimed to compare baseline impedance levels in ...patients with heartburn and pathophysiological characteristics related to functional heartburn (FH) divided into two groups on the basis of symptom relief after proton pump inhibitors (PPIs).
Methods
Patients with heartburn and negative endoscopy were treated with esomeprazole or pantoprazole 40 mg daily for 8 weeks. According to MII‐pH (off therapy) analysis, patients with normal acid exposure time (AET), normal reflux number, and lack of association between symptoms and refluxes were selected; of whom 30 patients with a symptom relief higher than 50% after PPIs composed Group A, and 30 patients, matched for sex and age, without symptom relief composed Group B. A group of 20 healthy volunteers (HVs) was enrolled. For each patient and HV, we evaluated the baseline impedance levels at channel 3, during the overnight rest, at three different times.
Key Results
Group A (vs Group B) showed an increase in the following parameters: mean AET (1.4 ± 0.8% vs 0.5 ± 0.6%), mean reflux number (30.4 ± 8.7 vs 24 ± 6.9), proximal reflux number (11.1 ± 5.2 vs 8.2 ± 3.6), acid reflux number (17.9 ± 6.1 vs 10.7 ± 6.9). Baseline impedance levels were lower in Group A than in Group B and in HVs (p < 0.001).
Conclusions & Inferences
Evaluating baseline impedance levels in patients with heartburn and normal AET could achieve a better understanding of pathophysiology in reflux disease patients, and could improve the distinction between FH and hypersensitive esophagus.
Background
High‐resolution manometry (HRM) provides information on esophagogastric junction (EGJ) morphology, distinguishing three different subtypes. Data on the correlation between EGJ subtypes and ...impedance‐pH detected reflux patterns are lacking. We aimed to correlate the EGJ subtypes with impedance‐pH findings in patients with reflux symptoms.
Methods
Consecutive patients with suspected gastroesophageal reflux disease (GERD) were enrolled. All patients underwent HRM and impedance‐pH testing off‐therapy. EGJ was classified as: Type I, no separation between the lower esophageal sphincter (LES) and crural diaphragm (CD); Type II, minimal separation (>1 and <2 cm); Type III, ≥2 cm separation. We measured esophageal acid exposure time (AET), number of total reflux episodes and symptom association analysis.
Key Results
We enrolled 130 consecutive patients and identified 46.2% Type I EGJ, 38.5% Type II, and 15.4% Type III patients. Type III subjects had a higher number of reflux episodes (61 vs 45, p < 0.03, vs 25, p < 0.001), a greater mean AET (12.4 vs 4.2, p < 0.02, vs 1.5, p < 0.001) and a greater positive symptom association (75% vs 72%, p = 0.732 vs 43.3%, p < 0.02) compared with Type II and I patients, respectively. Furthermore, Type II subjects showed statistically significant (overall p < 0.01) increased reflux when compared with Type I patients. Type III and II EGJ morphologies had a more frequent probability to show a positive multichannel intraluminal impedance pH monitoring than Type I (95% vs 84% vs 50%, p < 0.001).
Conclusions & Inferences
Increasing separation between LES and CD can cause a gradual and significant increase in reflux. EGJ morphology may be useful to estimate an abnormal impedance‐pH testing in GERD patients.
Esophagogastric junction (EGJ) morphology can play an important role in defense mechanism against reflux. Defining EGJ morphology with high‐resolution manometry (HRM) may be useful to predict an abnormal impedance‐pH testing in GERD. This study aims to establish a correlation between EGJ subtypes and different reflux parameters, detected during impedance‐pH monitoring in GERD patients. EGJ morphology is depicted at HRM by evaluating the position of lower esophageal sphincter (LES) and crural diaphragm (CD). EGJ subtypes are classified as: Type I, no separation detectable between LES and CD; Type II, presence of minimal separation (>1 and <2 cm) between LES and CD; Type III, presence of separation ≥2 cm. Reflux parameters determined at impedance‐pH monitoring are total number of reflux, total esophageal acid exposure time (AET) and symptom‐reflux events association analysis. Our findings demonstrated that a gradual and significant increase in terms of esophageal AET, total number of reflux episodes and positive reflux‐symptom association are observed when the separation between LES and CD becomes wider (Type II and III EGJ morphology). EGJ morphology may be useful to estimate an abnormal impedance‐pH testing in patients with reflux symptoms. However, reflux monitoring remains mandatory to confirm the diagnosis of GERD.
Background
Multiple rapid swallowing (MRS) during high‐resolution manometry (HRM) is increasingly utilized as provocative test to assess esophageal peristaltic reserve. The aim of this study was to ...evaluate the correlation between MRS response and impedance and pH (MII‐pH) parameters in endoscopy negative heartburn (ENH) patients.
Methods
We enrolled consecutive ENH patients, who underwent HRM and MII‐pH study, with a selected MII‐pH profile: abnormal MII‐pH (pH+/MII+); normal MII‐pH (pH−/MII−). HRM was performed with 10 wet swallows (WS) and one MRS. Mean distal contractile integral (DCI) during WS and MRS were calculated. MII‐pH parameters including acid exposure time (AET), reflux events, baseline impedance levels (BI) and the efficacy of chemical clearance evaluated with the postreflux swallow‐induced peristaltic wave (PSPW) index were measured.
Key Results
We analyzed 103 patients: 49 MII+/pH+ (27 male), and 54 MII−/pH− (19 male). Mean age was similar between the two groups. As expected, mean AET and number of refluxes were higher in pH+/MII+ (p < 0.05). HRM was normal in all selected patients. Mean DCI‐WS was similar between two groups (p = n.s.). Mean DCI‐MRS‐ was higher in MII−/pH− vs MII+/pH+ (p < 0.05). The increase in DCI‐MRS was inversely correlated with AET (−0.699; p < 0.001) and directly correlated with BI values (0.631; p < 0.001) and PSPW index (0.626; p < 0.001).
Conclusions & Inferences
Following MRS, patients with abnormal impedance‐pH test showed suboptimal contraction response as compared with those with normal impedance‐pH test. Moreover, MRS response was inversely correlated with AET and directly correlated with BI values and PSPW index.
We evaluate two different groups of endoscopy negative heartburn patients that were classified with impedance and pH test in: pH+/MII+ and pH−/MII−. They underwent high‐resolution manometry with low volume multiple rapid swallow (MRS). The main results of our study were the following: (i) post‐MRS contractile DCI and MRS/WS ratio were lower in MII+/pH+ patients as compared with MII−/pH− (considered as control group); (ii) an inverse correlation between esophageal motor response after DCI‐MRS and MRS/WS ratio with AET was found; (iii) a direct correlation between DCI‐MRS and MRS/WS ratio with BI values and PSPW index were observed.
Background
A short‐course of proton pump inhibitors (PPIs) is often used to confirm gastroesophageal reflux disease (GERD). However, some patients with PPI responsive heartburn do not seem to have ...evidence of GERD on impedance‐pH monitoring (MII‐pH). The aim of the study was to evaluate patients with reflux symptoms and a negative endoscopy, who well respond to PPIs with MII‐pH.
Methods
We enrolled 312 patients with GERD symptoms and negative endoscopy: 144 reported well‐controlled symptoms after 8‐week PPIs and 155 were non‐responders. Symptom relief was evaluated with GERD Impact Scale and visual analog scale score. All patients underwent MII‐pH off‐therapy. Thirteen patients were excluded from analysis. Patients were grouped as follows: non‐erosive reflux disease (NERD; increased acid exposure time, AET); hypersensitive esophagus (HE; normal AET, positive symptom association, SI/SAP); MII‐pH‐/PPI+ (normal AET, negative SI/SAP) in the responder group; MII‐pH‐/PPI‐ in non‐responders.
Key Results
MII‐pH in PPI responders (symptom relief during PPI therapy > 75%) showed: 79/144 NERD (54.9%); 37/144 HE (25.7%); 28/144 MII‐pH‐/PPI+ (19.4%). MII‐pH‐/PPI+ patients reported the same symptom relief when compared with NERD and HE. In non‐responder (symptom relief during PPI therapy < 50%) group, 27/155 patients were NERD (17.4%); 53/155 were HE (34.2%); 75/155 were MII‐pH‐/PPI‐ (48.4%). NERD diagnosis was significantly higher in responder group (p < 0.01).
Conclusions & Inferences
In a substantial subgroup of patients responding to PPI with typical reflux symptoms, the diagnosis of GERD cannot be confirmed with pH‐impedance monitoring. Proton pump inhibitor response and presence of typical symptoms are thus not reliable predictors of the diagnosis and antireflux surgery should always be preceded by reflux monitoring.
Summary
A wide variety of pieces of evidence has suggested that obesity is associated with a significant increase in the risk for gastroesophageal reflux disease (GERD) symptoms and its ...complications. The aim of this study was to evaluate the effect of weight loss on reflux symptoms in overweight/obese patients with proven GERD. We enrolled overweight/obese patients with typical GERD symptoms and erosive esophagitis. At baseline, patients underwent detailed reflux symptoms evaluation and anthropometric assessment, and were divided into two treatment groups: group A received proton pump inhibitor (PPI) and a personalized hypocaloric diet and aerobic exercise; and group B received PPI and a ‘standard of care diet’. The dietetic treatment was considered effective if at least 10% of weight loss was achieved within 6 months. All patients were evaluated in terms of anthropometric data, GERD symptoms, and PPI use. In group A, mean body mass index (BMI) decreased from 30.3 ± 4.1 to 25.7 ± 3.1 (P < 0.05), and mean weight decreased from 82.1 ± 16.9 kg to 69.9 ± 14.4 kg (P < 0.05). In group B, there was no change in BMI and weight. Symptom perception decreased (P < 0.05) in both groups during PPI therapy, but a higher improvement was recorded in group A. In group A, PPI therapy was completely discontinued in 27/50 of the patients, and halved in 16/50. Only 7/50 continued the same PPI dosage. In group B, 22/51 halved the therapy and 29/51 maintained full dosage of therapy, but none was able to discontinue PPI due to a symptom recurrence. Overall, weight loss of at least 10% is recommended in all patients with GERD in order to boost the effect of PPI on reflux symptom relief and to reduce chronic medication use.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
SUMMARY
Gastroesophageal reflux disease (GERD) is a common disorder of the upper gastrointestinal tract which is typically characterized by heartburn and acid regurgitation. These symptoms are ...widespread in the community and range from 2.5% to more than 25%. Economic analyses showed an increase in direct and indirect costs related to the diagnosis, treatment and surveillance of GERD and its complications. The aim of this review is to provide current information regarding the natural history of GERD, taking into account the evolution of its definition and the worldwide gradual change of its epidemiology. Present knowledge shows that there are two main forms of GERD, that is erosive reflux disease (ERD) and non-erosive reflux disease (NERD) and the latter comprises the majority of patients (up to 70%). The major complication of GERD is the development of Barrett esophagus, which is considered as a pre-cancerous lesion. Although data from medical literature on the natural history of this disease are limited and mainly retrospective, they seem to indicate that both NERD and mild esophagitis tend to remain as such with time and the progression from NERD to ERD, from mild to severe ERD and from ERD to Barrett's esophagus may occur in a small proportion of patients, ranging from 0 to 30%, 10 to 22% and 1 to 13% of cases, respectively. It is necessary to stress that these data are strongly influenced by the use of powerful antisecretory drugs (PPIs). Further studies are needed to better elucidate this matter and overcome the present limitations represented by the lack of large prospective longitudinal investigations, absence of homogeneous definitions of the various forms of GERD, influence of different treatments, clear exclusion of patients with functional disorders of the esophagus.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Background
Multiple rapid swallows (MRS) is a provocative test for assessment of contraction reserve, however reproducibility on repetitive MRS is incompletely understood. Our aim was to determine ...the optimal number of MRS sequences for consistent assessment of contraction reserve.
Methods
One hundred and fifty‐nine consecutive patients (79 IEM and 80 normal motility) who underwent high‐resolution manometers were enrolled. Ten single swallows (SS) and 10 MRS were performed. Gold standard for evaluation of the contraction reserve was the ratio between the mean DCI of 10 MRS and the mean DCI of 10 SS (MRS/SS DCI ratio). Rates of false negatives and false positives were calculated for increasing numbers of MRS sequences, using either mean DCI or the MRS with the highest DCI.
Key Results
According to the gold standard, 50 IEM and 50 normal motility patients had contraction reserve. With progressively increasing numbers of MRS sequences, contraction reserve was detected using mean MRS DCI within three and four MRS sequences in IEM and normal motility respectively, whereas two and three MRS sequences were needed using the MRS sequence with the highest DCI. False positives were much higher with highest DCI method compared with mean DCI, (22% vs 9% respectively in IEM; 24% vs 9% in normal motility) when three MRS sequences were considered.
Conclusions & Inferences
At least three MRS are needed to reliably assess contraction reserve. The mean DCI of the three MRS sequences is the best variable to utilize as evidence of contraction reserve.
One or two multiple rapid swallows (MRS) are usually performed to characterize contraction reserve. Reproducibility of contraction reserve on repetitive MRS sequences is incompletely understood. With 10 MRS as gold standard, the rate of false positives and false negatives for contraction reserve was high with one or two MRS sequences; three and four MRS sequences detected contraction reserve reliably in IEM and normal motility patients respectively. At least three MRS are needed in order to assess contraction reserve.
Background
The role of esophagogastric junction contractile integral (EGJ‐CI) as assessed by high‐resolution manometry (HRM) is unclear. We aimed to correlate the EGJ‐CI with impedance‐pH findings in ...gastro‐esophageal reflux disease (GERD) patients.
Methods
Consecutive patients with GERD symptoms were enrolled. All patients underwent upper endoscopy, HRM, and impedance‐pH testing. The EGJ‐CI was calculated using the distal contractile integral tool box during three consecutive respiratory cycles. The value was then divided by the duration of these cycles. A value below 13 was considered as a defective EGJ‐CI. We also assessed EGJ morphology, esophageal acid exposure time (AET), number of reflux episodes (NRE), and symptom association analysis (SAA). A positive impedance‐pH monitoring was considered in case of abnormal AET and/or NRE and/or positive SAA.
Key Results
Among 130 patients we enrolled, 91 had GERD (abnormal AET and/or elevated NRE and/or positive SAA) and 39 had functional heartburn (FH) (negative endoscopy, normal AET, normal NRE, and negative SAA). The GERD patients had a lower median value of EGJ‐CI (11 3.1–20.7 vs 22 9.9–41, p < 0.02) compared to FH patients. Patients with a defective EGJ‐CI had, more frequently, a positive impedance‐pH monitoring or esophageal mucosal lesions at endoscopy (p < 0.05 and p < 0.05, respectively) than patients with a normal EGJ‐CI. An EGJ‐CI cut‐off value of 5 mmHg cm yielded the optimal performance in identifying GERD at impedance‐pH (sensitivity 89%–specificity 63%).
Conclusions & Inferences
A defective EGJ‐CI at HRM is clearly associated with evidence of GERD at impedance‐pH monitoring. Evaluating EGJ‐CI may be useful to predict an abnormal impedance‐pH testing.
Esophagogastric junction (EGJ) plays an important role in defense mechanisms against reflux. Defining EGJ vigor with high‐resolution manometry (HRM) may be useful to predict an abnormal impedance‐pH testing in reflux disease. This study aims to establish a correlation between EGJ‐contractile integral (EGJ‐CI) and different reflux parameters, detected during impedance‐pH monitoring in GERD patients. Esophagogastric junction contractile integral is calculated at HRM enclosing the upper and lower margins of the EGJ in a DCI toolbox, during three consecutive respiratory cycles and referenced to gastric pressure. The value computed with the DCI tool in mmHg*s*cm is then divided by the duration of the three respiratory cycles (in seconds) yielding EGJ‐CI units of mmHg*cm. The value below 13 is established in a series of normal volunteers as a defective EGJ‐CI. Reflux parameters determined at impedance‐pH monitoring are total number of reflux, total esophageal acid exposure time (AET), and symptom association. Our findings show that, when a defective EGJ‐CI is present, a gradual and significant increase IN reflux can be present.
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