Background
An international group of experts evaluated and revised recommendations for ambulatory reflux monitoring for the diagnosis of gastro‐esophageal reflux disease (GERD).
Methods
Literature ...search was focused on indications and technical recommendations for GERD testing and phenotypes definitions. Statements were proposed and discussed during several structured meetings.
Key Results
Reflux testing should be performed after cessation of acid suppressive medication in patients with a low likelihood of GERD. In this setting, testing can be either catheter‐based or wireless pH‐monitoring or pH‐impedance monitoring. In patients with a high probability of GERD (esophagitis grade C and D, histology proven Barrett's mucosa >1 cm, peptic stricture, previous positive pH monitoring) and persistent symptoms, pH‐impedance monitoring should be performed on treatment. Recommendations are provided for data acquisition and analysis. Esophageal acid exposure is considered as pathological if acid exposure time (AET) is greater than 6% on pH testing. Number of reflux episodes and baseline impedance are exploratory metrics that may complement AET. Positive symptom reflux association is defined as symptom index (SI) >50% or symptom association probability (SAP) >95%. A positive symptom‐reflux association in the absence of pathological AET defines hypersensitivity to reflux.
Conclusions and Inferences
The consensus group determined that grade C or D esophagitis, peptic stricture, histology proven Barrett's mucosa >1 cm, and esophageal acid exposure greater >6% are sufficient to define pathological GERD. Further testing should be considered when none of these criteria are fulfilled.
The consensus group proposes to define pathological GERD as at least one of the following criteria: Grade C or D esophagitis, peptic stricture, Barrett's mucosa >1 cm and esophageal acid exposure >6%. Number of reflux episodes and baseline impedance should be considered as exploratory tools for further research.
Background and aims: Empiric proton pump inhibitor (PPI) trials have become increasingly popular leading to gastroenterologists frequently evaluating gastro-oesophageal reflux disease (GORD) patients ...only after they have “failed” PPI therapy. Combined multichannel intraluminal impedance and pH (MII-pH) monitoring has the ability to detect gastro-oesophageal reflux (GOR) episodes independent of their pH and evaluate the relationship between symptoms and all types of GOR. Using this technique, we aimed to characterise the frequency of acid and non-acid reflux (NAR) and their relationship to typical and atypical GOR symptoms in patients on PPI therapy. Methods: Patients with persistent GORD symptoms referred to three centres underwent 24 hour combined MII-pH monitoring while taking PPIs at least twice daily. Reflux episodes were detected by impedance channels located 3, 5, 7, 9, 15, and 17 cm above the lower oesophageal sphincter (LOS) and classified into acid or non-acid based on pH data from 5 cm above the LOS. A positive symptom index (SI) was declared if at least half of each specific symptom events were preceded by reflux episodes within five minutes. Results: A total of 168 patients (103 (61%) females and 65 (39%) males; mean age 53 (range 18–85) years) underwent combined MII-pH monitoring while taking PPIs at least twice daily. One hundred and forty four (86%) patients recorded symptoms during the study day and 24 (15%) patients had no symptoms during testing. Sixty nine (48%) symptomatic patients had a positive SI for at least one symptom (16 (11%) with acid reflux and 53 (37%) with NAR) and 75 (52%) had a negative SI. A total of 171 (57%) typical GORD symptoms were recorded, 19 (11%) had a positive SI for acid reflux, 52 (31%) for NAR, and 100 (58%) had a negative SI. One hundred and thirty one (43%) atypical symptoms were recorded, four (3%) had a positive SI for acid reflux, 25 (19%) had a positive SI for NAR, and 102 (78%) had a negative SI. Conclusion: Combined MII-pH identifies the relation of reflux of all types to persistent symptoms and the importance of NAR in patients taking PPIs.
Introduction:Functional dyspepsia and non-erosive reflux disease (NERD) are prevalent gastrointestinal conditions with accumulating evidence regarding an overlap between the two. Still, patients with ...NERD represent a very heterogeneous group and limited data on dyspeptic symptoms in various subgroups of NERD are available.Aim:To evaluate the prevalence of dyspeptic symptoms in patients with NERD subclassified by using 24 h impedance-pH monitoring (MII-pH).Methods:Patients with typical reflux symptoms and normal endoscopy underwent impedance-pH monitoring off proton pump inhibitor treatment. Oesophageal acid exposure time (AET), type of acid and non-acid reflux episodes, and symptom association probability (SAP) were calculated. A validated dyspepsia questionnaire was used to quantify dyspeptic symptoms prior to reflux monitoring.Results:Of 200 patients with NERD (105 female; median age, 48 years), 81 (41%) had an abnormal oesophageal AET (NERD pH-POS), 65 (32%) had normal oesophageal AET and positive SAP for acid and/or non-acid reflux (hypersensitive oesophagus), and 54 (27%) had normal oesophageal AET and negative SAP (functional heartburn). Patients with functional heartburn had more frequent (p<0.01) postprandial fullness, bloating, early satiety and nausea compared to patients with NERD pH-POS and hypersensitive oesophagus.Conclusion:The increased prevalence of dyspeptic symptoms in patients with functional heartburn reinforces the concept that functional gastrointestinal disorders extend beyond the boundaries suggested by the anatomical location of symptoms. This should be regarded as a further argument to test patients with symptoms of gastro-oesophageal reflux disease in order to separate patients with functional heartburn from patients with NERD in whom symptoms are associated with gastro-oesophageal reflux.
Aliment Pharmacol Ther 2011; 34: 476–486
Summary
Background Limited data are available regarding the frequency of oesophageal motility and bolus transit abnormalities in subgroups of patients with ...gastro‐oesophageal reflux disease (GERD).
Aim To assess oesophageal motility and bolus transit in endoscopically defined GERD subgroups.
Methods Patients (N = 755) with typical reflux symptoms underwent upper endoscopy, conventional or impedance oesophageal manometry and/or impedance‐pH testing. They were divided into: erosive oesophagitis (EO; N = 340), Barrett Oesophagus (BO; N = 106), non‐erosive reflux disease (NERD; endoscopy−, abnormal pH and/or SAP/SI+; N = 239) and functional heartburn (FH; endoscopy−, normal pH and SAP/SI−; N = 70). Manometric patterns and bolus transit were defined according to previously published criteria.
Results Increasing GERD severity was associated with decreased lower oesophageal sphincter resting pressure (P < 0.05) and distal oesophageal amplitude (P < 0.01), higher prevalence of hiatal hernia (P < 0.01) and increased prevalence of ineffective oesophageal motility (P < 0.01). Patients with EO and BO had a significantly lower percentage of complete bolus transit compared with NERD and FH (P < 0.01). Overall, abnormal bolus transit (ABT) for liquid swallows was found in 12% of FH, 20% of NERD, 54% of EO and 56% of BO (P < 0.01). Combined impedance‐manometry showed abnormal oesophageal function in 4% of FH, 4% of NERD, 22% of EO and 21% of BO patients with normal oesophageal manometry.
Conclusions Oesophageal motility abnormalities increase in parallel with the severity of GERD from NERD to EO and BO. Bolus transit abnormalities in severe reflux disease underscore the importance of impaired oesophageal function in the development of mucosal injury.
Background Esophageal motility abnormalities include a series of manometric findings that differ to a significant degree from findings in normal, asymptomatic volunteers.
Methods Current review ...summarizes conventional and high‐resolution esophageal manometry criteria used to define and characterize esophageal hypertensive motility abnormalities.
Key Results In the conventional esophageal manometry classification scheme hypertensive esophageal motility abnormalities include nutcracker esophagus (average distal contraction amplitude >180mmHg), hypertensive lower esophageal sphincter (average resting LES pressure >45mmHg) and poorly relaxing lower esophageal sphincter (average LES residual pressure >8mmHg). The new, high resolution esophageal manometry scheme includes in the group of hypertensive peristaltic disorders hypertensive peristalsis (“nutcracker esophagus”: mean DCI >5000 mmHg*sec*cm) and hypercontractile esophagus (“jackhammer esophagus”: at least one contraction with DCI > 8,000 mmHg*sec*cm) and defines a separate group for disorders with impaired esophageal‐gastric junction relaxation (mean integrated residual (LES) pressure >15mmHg).
Conclusions & Inferences Hypertensive motility disorders represent a heterogeneous condition subdivided into hypercontractile esophagus and hypertensive peristalsis. Further studies are required to determine the clinical relevance of this new classification.
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 large proportion of age‐related fecal incontinence is attributed to weakness or degeneration of the muscles composing the anal continence organ. However, the individual role of these ...muscles and their functional interplay remain poorly understood.
Methods
This study employs a novel technique based on the combination of MR imaging and FLIP measurements (MR‐FLIP) to obtain anatomical and mechanical information simultaneously. Unlike previous methods used to assess the mechanics of the continence organ, MR‐FLIP allows inter‐individual comparisons and statistical analysis of the sphincter morpho‐mechanical parameters. The anatomy as well as voluntary and involuntary mechanical properties of the anal continence organ were characterized in 20 healthy senior volunteers.
Results
Results showed that the external anal sphincter (EAS) forms a funnel‐like shape with wall thickness increasing by a factor of 2.5 from distal (6 ± 0 mm) to proximal (15 ± 3 mm). Both voluntary and involuntary mechanical properties in this region correlate strongly with the thickness of the muscle. The positions of least compliance and maximal orifice closing were both located toward the proximal EAS end. In addition, maximal contraction during squeeze maneuvers was reached after 2 s, but high muscle fatigue was measured during a 7 s holding phase, corresponding to about 60% loss of the energy produced by the muscles during the contraction phase.
Conclusions
This work reports baseline parameters describing the morpho‐mechanical condition of the sphincter muscle of healthy elderly volunteers. New parameters were also proposed to quantify the active properties of the muscles based on the mechanical energy associated with muscle contraction and fatigue. This information could be used to assess patients suffering from AI or for the design of novel implants.
The mechanisms by which continence is maintained remain poorly understood. Therefore, we report a first statistical analysis of the involuntary (compliance) and voluntary (muscle work) mechanical properties of the healthy continence organ along the anal canal.
This work presents baseline parameters for implant design and proposes new mechanical biomarkers for quantifying continence. In addition, this study provides evidence that the proximal segment of the anal canal plays a prominent role in mechanically maintaining continence.
Summary
Background : Omeprazole controls acid but not non‐acid reflux. The GABA B agonist baclofen decreases acid reflux through the inhibition of transient lower oesophageal sphincter relaxations ...(TLESRs) and should similarly decrease non‐acid reflux. Using combined multichannel intraluminal impedance and pH (MII/pH), we compared acid and non‐acid reflux after placebo and baclofen.
Methods : Nine healthy volunteers and nine heartburn patients underwent two 2‐h studies of combined MII/pH in right lateral decubitus after a refluxogenic meal in random order: on placebo and after baclofen 40 mg p.o. Tracings were analysed for acid and non‐acid reflux episodes, re‐reflux and symptoms in the heartburn patients.
Results : In normal subjects baclofen significantly reduced the median number of episodes of acid (7 vs. 1, P = 0.02), non‐acid (2 vs. 0, P = 0.005), and all reflux combined (10 vs. 2, P = 0.006); re‐reflux was not reduced (0 vs. 0, P = N.S.). In heartburn patients, baclofen significantly decreased the median number of episodes of acid (15 vs. 6, P = 0.004), non‐acid (4 vs. 2, P = 0.003), re‐reflux (2 vs. 0, P = 0.02), and all reflux combined (23 vs. 8, P = 0.004); it also reduced the median number of acid‐related (9 vs. 1, P = 0.008) and non‐acid‐related (1 vs. 0, P = 0.04) symptoms.
Conclusions : Baclofen reduces post‐prandial acid and non‐acid reflux and their associated symptoms. GABA B agonists may have a role in treating GERD.
Summary
Gastroesophagel reflux disease (GERD) is a common condition encountered in clinical practice. Over the years there has been a continuous interaction between the understanding of the disease, ...the diagnostic tools and treatments of GERD. The use of proton pump inhibitor (PPI) trials by primary care physicians as diagnostic tool in patients with symptoms suspected to be due to GERD has led to a shift in the type of patients referred to specialists. Currently, gastrointestinal specialists are frequently asked to evaluate patients with persistent reflux symptoms despite acid suppressive therapy. In these patients symptoms can be associated with reflux (both acid and non‐acid) or not associated with reflux.
While conventional pH monitoring can quantify esophageal acid exposure and evaluate the association between symptoms and acid reflux, it cannot reliably detect reflux episodes with a pH >4 (i.e. non‐acid reflux). Detecting reflux episodes by changes in intraluminal resistance to alternating current (i.e. impedance), combined multichannel intraluminal impedance and pH (MII‐pH) monitoring offers the opportunity to detect both acid and non‐acid reflux episodes and to evaluate the relationship between symptoms and reflux. We believe that MII‐pH monitoring has become the new ‘‘gold standard’’ for clarifying the mechanisms of persistent symptom on PPI therapy.
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