Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring

Altered esophageal sensory-motor function in patients with persistent symptoms after Nissen fundoplication

BACKGROUND

The pathophysiology of persistent gastroesophageal reflux disease (GERD) symptoms after antireflux surgery is unclear. We assessed esophageal sensorimotor function in patients with GERD before and after Nissen fundoplication (NF).

METHODS

Sensory and biomechanical properties were evaluated before surgery using impedance planimetry in 17 GERD patients and 16 healthy volunteers. All patients underwent standard laparoscopic NF. Eight GERD patients with persistent symptoms after surgery underwent repeat evaluations at least 12 months after surgery.

RESULTS

At baseline, GERD patients had lower thresholds for first perception (P < .001), discomfort (P < .001), and pain (P < .001) compared with controls. The esophagus was more reactive (P = .001) and less distensible (P = .04) in patients than controls. After NF, in patients with persistent symptoms, the sensory thresholds were unchanged (P > .05) but esophageal wall reactivity decreased (P = .001), and distensibility improved (P = .025).

CONCLUSIONS

NF improves esophageal biomechanical dysfunction but not the underlying hypersensitivity. Visceral hypersensitivity of the esophagus may explain persistent symptoms after NF.

Contribution of sensitivity, volume and tone to visceral perception in the upper gastrointestinal tract in man: emphasis on testing

Upper gastrointestinal (GI) symptoms occur frequently in the general population, making them among the most common indications responsible for patients consulting the healthcare system. Consequently, understanding and characterization of the upper GI symptoms is important for the diagnosis and assessment of organ dysfunction. In practice, assessment of clinical symptoms is difficult and it is still to a large extent unclear how sensitivity, volume and tone contribute to visceral perception in the upper GI tract. The goal of advanced research in upper GI symptoms is to obtain a better understanding of the mechanisms involved in transduction, transmission, and perception under normal and pathophysiological conditions. An important step towards this goal is understanding the information provided by and the inherent limitations of the currently available measuring techniques. This article focuses on the sensory testing of the oesophagus, and methods and concepts used to assess the relation between gastric volumes or tone and upper GI symptoms. It also summarizes the contributions of these techniques towards identifying the components responsible for the generation of upper GI symptoms.

Multichannel intraluminal impedance and pH-metry for investigation of symptomatic gastroesophageal reflux disease

BACKGROUND

Combined multichannel intraluminal impedance and pH-metry (MII-pH) is a technique that enables monitoring of gastroesophageal reflux independent of its acidity.

AIM

To investigate the utility of MII-pH in the clinical investigation of patients with gastroesophageal reflux disease (GERD) symptoms.

METHODS

32 consecutive patients underwent 24-hour ambulatory MII-pH. 16 patients were on PPI (PPI+) therapy and 16 were taking no acid-suppressive medication (PPI-). We investigated the pattern of reflux by means of acid and nonacid reflux and the relation to typical and atypical symptoms. In addition, we investigated the symptom association by using the symptom index.

RESULTS

Symptom-related acid reflux was higher in the PPI+ group (33 vs. 25%) and symptom-related nonacid reflux was higher in the PPI- group (36 vs. 21%). The association between type of symptoms and the association to reflux is highly significant (p < 0.001) in the PPI- group. In this group the association of acid reflux is more likely to correlate with typical symptoms and the association of nonacid reflux is more likely to be associated with atypical symptoms.

CONCLUSIONS

These data show that nonacid reflux can be associated with symptoms in patients with GERD symptoms. The diagnostic value of MII-pH is independent of PPI therapy.

Technology review: Esophageal impedance monitoring

Intraluminal impedance monitoring is a new technique that can be used to detect the flow of liquids and gas through hollow viscera. In combination with manometry, it is used for esophageal function testing and while manometry provides information on contractile activity, impedance provides information on esophageal bolus transit. This is especially useful in patients with nonobstructive dysphagia. However, impedance monitoring appears to be less suitable for the evaluation of patients with achalasia. When used in combination with esophageal pH monitoring, impedance monitoring makes gastroesophageal reflux monitoring more complete because it allows recognition of both acidic and weakly acidic reflux episodes. The results of several studies suggest that impedance-pH monitoring is useful in the evaluation of patients with PPI-resistant typical reflux symptoms, chronic unexplained cough, excessive belching, and rumination.

Impedance-pH monitoring in proton pump inhibitor resistant patients: ready for clinical application?

Impedance‐pH monitoring represents a useful tool for studies and clinical research in oesophageal disorders, and may hold promise for the group of patients dissatisfied with their antireflux treatment

Review article: complete gastro-oesophageal reflux monitoring - combined pH and impedance

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.