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Martinucci I, Savarino EV, Pandolfino JE, Russo S, Bellini M, Tolone S, Tutuian R, Roman S, Furnari M, Frazzoni M, Macchia L, Savarino V, Marchi S, de Bortoli N. Vigor of peristalsis during multiple rapid swallows is inversely correlated with acid exposure time in patients with NERD. Neurogastroenterol Motil 2016; 28:243-50. [PMID: 26661383 DOI: 10.1111/nmo.12719] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/06/2015] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- I Martinucci
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - E V Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - J E Pandolfino
- Gastroenterology Unit, Department of Internal Medicine, Northwest University, Chicago, IL, USA
| | - S Russo
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - M Bellini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - S Tolone
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy
| | - R Tutuian
- Gastroenterology Unit, University Hospital of Bern, Bern, Switzerland
| | - S Roman
- Digestive Physiology, Hospices Civil de Lyon and Lyon I University, Lyon, France
| | - M Furnari
- Division of Gastroenterology, Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - M Frazzoni
- Gastroenterology Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - L Macchia
- Gastroenterology Unit, University Hospital of Bern, Bern, Switzerland
| | - V Savarino
- Division of Gastroenterology, Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - S Marchi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - N de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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de Bortoli N, Martinucci I, Savarino E, Franchi R, Bertani L, Russo S, Ceccarelli L, Costa F, Bellini M, Blandizzi C, Savarino V, Marchi S. Lower pH values of weakly acidic refluxes as determinants of heartburn perception in gastroesophageal reflux disease patients with normal esophageal acid exposure. Dis Esophagus 2016; 29:3-9. [PMID: 25212408 DOI: 10.1111/dote.12284] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Multichannel impedance pH monitoring has shown that weakly acidic refluxes are able to generate heartburn. However, data on the role of different pH values, ranging between 4 and 7, in the generation of them are lacking. The aim of this study was to evaluate whether different pH values of weakly acidic refluxes play a differential role in provoking reflux symptoms in endoscopy-negative patients with physiological esophageal acid exposure time and positive symptom index and symptom association probability for weakly acidic refluxes. One hundred and forty-three consecutive patients with gastroesophageal reflux disease, nonresponders to proton pump inhibitors (PPIs), were allowed a washout from PPIs before undergoing: upper endoscopy, esophageal manometry, and multichannel impedance pH monitoring. In patients with both symptom index and symptom association probability positive for weakly acidic reflux, each weakly acidic reflux was evaluated considering exact pH value, extension, physical characteristics, and correlation with heartburn. Forty-five patients with normal acid exposure time and positive symptom association probability for weakly acidic reflux were identified. The number of refluxes not heartburn related was higher than those heartburn related. In all distal and proximal liquid refluxes, as well as in distal mixed refluxes, the mean pH value of reflux events associated with heartburn was significantly lower than that not associated. This condition was not confirmed for proximal mixed refluxes. Overall, a low pH of weakly acidic reflux represents a determinant factor in provoking heartburn. This observation contributes to better understand the pathophysiology of symptoms generated by weakly acidic refluxes, paving the way toward the search for different therapeutic approaches to this peculiar condition of esophageal hypersensitivity.
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Affiliation(s)
- N de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - I Martinucci
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - E Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - R Franchi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - L Bertani
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - S Russo
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - L Ceccarelli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - F Costa
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - M Bellini
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - C Blandizzi
- Division of Pharmacology and Chemotherapy, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - V Savarino
- Division of Gastroenterology, Department of Internal Medicine DIMI, University of Genova, Genoa, Italy
| | - S Marchi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
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de Bortoli N, Martinucci I, Savarino EV, Frazzoni M, Tutuian R, Tolone S, Piaggi P, Furnari M, Russo S, Bertani L, Macchia L, Savarino V, Marchi S. Manually calculated oesophageal bolus clearance time increases in parallel with reflux severity at impedance-pH monitoring. Dig Liver Dis 2015; 47:1027-32. [PMID: 26362613 DOI: 10.1016/j.dld.2015.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/05/2015] [Accepted: 08/15/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Oesophageal clearance has been scarcely studied. AIMS Oesophageal clearance in endoscopy-negative heartburn was assessed to detect differences in bolus clearance time among patients sub-grouped according to impedance-pH findings. METHODS In 118 consecutive endoscopy-negative heartburn patients impedance-pH monitoring was performed off-therapy. Acid exposure time, number of refluxes, baseline impedance, post-reflux swallow-induced peristaltic wave index and both automated and manual bolus clearance time were calculated. Patients were sub-grouped into pH/impedance positive (abnormal acid exposure and/or number of refluxes) and pH/impedance negative (normal acid exposure and number of refluxes), the former further subdivided on the basis of abnormal/normal acid exposure time (pH+/-) and abnormal/normal number of refluxes (impedance+/-). RESULTS Poor correlation (r=0.35) between automated and manual bolus clearance time was found. Manual bolus clearance time progressively decreased from pH+/impedance+ (42.6s), pH+/impedance- (27.1s), pH-/impedance+ (17.8s) to pH-/impedance- (10.8s). There was an inverse correlation between manual bolus clearance time and both baseline impedance and post-reflux swallow-induced peristaltic wave index, and a direct correlation between manual bolus clearance and acid exposure time. A manual bolus clearance time value of 14.8s had an accuracy of 93% to differentiate pH/impedance positive from pH/impedance negative patients. CONCLUSIONS When manually measured, bolus clearance time reflects reflux severity, confirming the pathophysiological relevance of oesophageal clearance in reflux disease.
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Affiliation(s)
- Nicola de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.
| | - Irene Martinucci
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Edoardo V Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Radu Tutuian
- Gastroenterology Unit, University Hospital of Bern, Switzerland
| | - Salvatore Tolone
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy
| | - Paolo Piaggi
- Obesity Research Center, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Salvatore Russo
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Lorenzo Bertani
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Lorenzo Macchia
- Gastroenterology Unit, University Hospital of Bern, Switzerland
| | - Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Santino Marchi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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de Bortoli N, Furnari M, Tolone S, Savarino E. A More In-depth Evaluation of Impedance-pH Could Assist in Distinguishing Reflux-related From Reflux-unrelated Heartburn. J Neurogastroenterol Motil 2015; 21:621-2. [PMID: 26351254 PMCID: PMC4622147 DOI: 10.5056/jnm15085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy.,GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy
| | - Manuele Furnari
- astroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy.,GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy
| | - Salvatore Tolone
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy.,GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.,GISE, Gruppo Italiano per lo Studio dell'Esofago, Italy
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Tolone S, de Cassan C, de Bortoli N, Roman S, Galeazzi F, Salvador R, Marabotto E, Furnari M, Zentilin P, Marchi S, Bardini R, Sturniolo GC, Savarino V, Savarino E. Esophagogastric junction morphology is associated with a positive impedance-pH monitoring in patients with GERD. Neurogastroenterol Motil 2015; 27:1175-82. [PMID: 26010058 DOI: 10.1111/nmo.12606] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 04/29/2015] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- S Tolone
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy
| | - C de Cassan
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - N de Bortoli
- Division of Gastroenterology, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - S Roman
- Digestive Physiology, Hospices Civils de Lyon, Lyon I University and Labtau, INSERM 1032, Lyon, France
| | - F Galeazzi
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - R Salvador
- U.O. Chirurgia Generale, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - E Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - M Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - P Zentilin
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - S Marchi
- Division of Gastroenterology, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - R Bardini
- U.O. Chirurgia Generale, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - G C Sturniolo
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - V Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - E Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Association between baseline impedance values and response proton pump inhibitors in patients with heartburn. Clin Gastroenterol Hepatol 2015; 13:1082-8.e1. [PMID: 25499991 DOI: 10.1016/j.cgh.2014.11.035] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 11/03/2014] [Accepted: 11/24/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Esophageal impedance measurements have been proposed to indicate the status of the esophageal mucosa, and might be used to study the roles of the impaired mucosal integrity and increased acid sensitivity in patients with heartburn. We compared baseline impedance levels among patients with heartburn who did and did not respond to proton pump inhibitor (PPI) therapy, along with the pathophysiological characteristics of functional heartburn (FH). METHODS In a case-control study, we collected data from January to December 2013 on patients with heartburn and normal findings from endoscopy who were not receiving PPI therapy and underwent impedance pH testing at hospitals in Italy. Patients with negative test results were placed on an 8-week course of PPI therapy (84 patients received esomeprazole and 36 patients received pantoprazole). Patients with more than 50% symptom improvement were classified as FH/PPI responders and patients with less than 50% symptom improvement were classified as FH/PPI nonresponders. Patients with hypersensitive esophagus and healthy volunteers served as controls. In all patients and controls, we measured acid exposure time, number of reflux events, baseline impedance, and swallow-induced peristaltic wave indices. RESULTS FH/PPI responders had higher acid exposure times, numbers of reflux events, and acid refluxes compared with FH/PPI nonresponders (P < .05). Patients with hypersensitive esophagus had mean acid exposure times and numbers of reflux events similar to those of FH/PPI responders. Baseline impedance levels were lower in FH/PPI responders and patients with hypersensitive esophagus, compared with FH/PPI nonresponders and healthy volunteers (P < .001). Swallow-induced peristaltic wave indices were similar between FH/PPI responders and patients with hypersensitive esophagus. CONCLUSIONS Patients with FH who respond to PPI therapy have impedance pH features similar to those of patients with hypersensitive esophagus. Baseline impedance measurements might allow for identification of patients who respond to PPIs but would be classified as having FH based on conventional impedance-pH measurements.
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Martinucci I, de Bortoli N, Savarino E, Piaggi P, Bellini M, Antonelli A, Savarino V, Frazzoni M, Marchi S. Esophageal baseline impedance levels in patients with pathophysiological characteristics of functional heartburn. Neurogastroenterol Motil 2014; 26:546-55. [PMID: 24433456 DOI: 10.1111/nmo.12299] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 12/06/2013] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- I Martinucci
- Division of Gastroenterology, University of Pisa, Pisa, Italy
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