Gastroesophageal pH step-up inaccurately locates proximal border of lower esophageal sphincter

A SIGE-SINGEM-AIGO technical review on the clinical use of esophageal reflux monitoring

Patients with esophageal symptoms potentially associated with gastroesophageal reflux disease such as heartburn, regurgitation, chest pain, or cough represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal reflux monitoring in clinical practice is: (1) to accurately define reflux burden, (2) to segregate patients according to reflux monitoring results as true GERD, reflux hypersensitivity and functional heartburn, and (3) to establish a treatment plan. With this in mind, in the last decade, investigations and technical advances, with the introduction of impedance-pH monitoring and wireless pH capsule, have enhanced our understanding and management of GERD. The following recommendations were discussed and approved after a comprehensive review of the medical literature pertaining to reflux testing techniques and their recent application. This review created under the auspices of the Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE), Società Italiana di Neuro-Gastro-Enterologia e Motilità (SINGEM) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying reflux studies in the most fruitful manner within the context of their patients with esophageal symptoms.

Lower oesophageal sphincter identification for gastro-oesophageal reflux monitoring: The step-up method revisited with use of basal impedance

Background

Oesophageal manometry is the gold standard for accurate positioning of multichannel intraluminal impedance pH (MII-pH) monitoring. The pH step-up method is not as accurate as oesophageal manometry and needs patients to be off proton pump inhibitor (PPI) therapy.

Objective

This study aimed to evaluate the feasibility of the impedance step-up method for lower oesophageal sphincter (LOS) localisation.

Methods

A total of 100 patients who underwent 24-hour MII-pH monitoring were enrolled. High-resolution manometry (HRM) was performed before MII-pH monitoring in order to locate the LOS by a different operator. The impedance step-up was defined as an increase of ≥50% with respect to gastric baseline. Lin's concordance correlation coefficient (ρ_c ) with 95% Bland-Altman limits of agreement (LOA) and Spearman's rho correlation coefficient were used when appropriate.

Results

The median impedance step-up was on average 0.8 cm caudal to the manometric upper border of the LOS. Agreement between two step-up impedance performances and inter-observer agreement were excellent (ρ_c  = 0.98 and 0.95), although the LOA ranges were wide (-2.4 to 4.0 cm). Impedance step-up performances were similar between patients off and on PPI.

Conclusions

We have described an alternative new method for pH impedance probe positioning using impedance step-up. Although less accurate than HRM in locating the LOS, it has excellent intra- and inter-observer agreement.

British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring

These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry (HRM) and oesophageal impedance monitoring. The guidelines were developed by a guideline development group of patients and representatives of all the relevant professional groups using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. A systematic literature search was performed and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool was used to evaluate the quality of evidence and decide on the strength of the recommendations made. Key strong recommendations are made regarding the benefit of: (i) HRM over standard manometry in the investigation of dysphagia and, in particular, in characterising achalasia, (ii) adjunctive testing with larger volumes of water or solids during HRM, (iii) oesophageal manometry prior to antireflux surgery, (iv) pH/impedance monitoring in patients with reflux symptoms not responding to high dose proton pump inhibitors and (v) pH monitoring in all patients with reflux symptoms responsive to proton pump inhibitors in whom surgery is planned, but combined pH/impedance monitoring in those not responsive to proton pump inhibitors in whom surgery is planned. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG.

Accuracy of the Air Flow Sphincter Locator system in identifying the lower esophageal sphincter for placement of pH catheters

The Air Flow Sphincter Locator (AFSL) is marketed as an alternative method to manometry for localizing the lower esophageal sphincter (LES) for pH probe placement. Such a system is desirable due to the additional time, cost, and discomfort associated with dual nasal intubation, but its accuracy has never been assessed. To assess the accuracy of the AFSL in localizing the LES. Fifty consecutive outpatients presenting for pH and manometry studies were included. The upper border of the LES was determined using HRM and the AFSL by two technicians independently. LES locations measured by technicians using AFSL versus manometry, as well as the manometrically determined LES locations by technicians versus MDs were compared. Differences in LES locations determined by HRM as read by MDs versus technicians were small; none were >3 cm, and 92% were within 2 cm. Comparison between LES locations determined by technicians using HRM versus the AFSL revealed that 52% had a difference of 2-3cm and 32% had a difference of >3 cm. Hiatal hernia was associated with a difference in LES location of >3 cm. Excluding patients with hiatal hernia, nonetheless, still produced a >3 cm difference in 24% of studies. Prior reports have suggested that a difference greater than +/-3 cm in pH probe placement is considered unacceptable for clinical studies. Based on our study, the AFSL placed the LES outside of this range in 32% of patients, and may be particularly inaccurate in the setting of a hiatal hernia. This suggests that the device may not be an acceptable alternative to manometry in determining LES location for pH probe placement.

Determination of pH turning point with pH mapping of the gastroesophageal junction: an alternative technique to orientate esophageal pH monitoring

Manometric location of the lower esophageal sphincter (LES) has been mandatory before esophageal pH monitoring, despite costs and discomfort related with esophageal manometry. The aims of the study were: (i) to map the pH of the gastroesophageal junction (GEJ) to determine a pH turning point (PTP) and its relation with LES; and (ii) to test the feasibility of this technique to orientate esophageal pH monitoring. We studied 310 adult patients who underwent esophageal manometry and pH monitoring off acid-suppressive therapy. GEJ pH mapping was carried out by step-pulling the pH sensor from 5 cm below to 5 cm above LES, and a PTP was determined when pH changed from below to above 4, in centimeters from the nostril. Thirty-six patients referred only for pH monitoring were studied with pH sensor placed at 5 cm above the PTP. Out of 310 patients, a PTP was found in 293 (94.5%): inside LES in 86.3%, into the stomach in 8.2% and in the esophageal body in 5.5% of patients. The median distance between PTP and place where pH sensor monitored reflux was 8 cm. Among 36 patients who performed pH monitoring without LES manometry, there was no gastric monitoring during reflux testing. In adult patients investigated off acid suppressive therapy, GEJ pH mapping with reflux monitoring 5 cm above the PTP can be an alternative technique to perform esophageal pH monitoring when LES manometry is not available. Additional studies are needed before the widespread use of GEJ pH mapping in the clinical practice.

Estudo prospectivo comparativo de duas modalidades de posicionamento do sensor de phmetria esofágica prolongada: por manometria esofágica e pela viragem do Ph

RACIONAL: Por padronização aceita internacionalmente, posiciona-se o sensor distal de pHmetria esofágica a 5 cm acima da borda superior do esfíncter inferior do esôfago, localizado por manometria esofágica. Porém, vários autores sugerem técnicas alternativas de posicionamento que prescindem da manometria. Dentre essas, destaca-se a da viragem do pH, tema este controverso pela sua duvidosa confiabilidade. OBJETIVO: Avaliar a adequação do posicionamento do sensor distal de pHmetria pela técnica de viragem do pH, considerando-se a presença, o tipo e o grau de erro de posicionamento que tal técnica proporciona, e também estudar a influência da posição adotada pelo paciente durante a técnica da viragem. MÉTODOS: Foram estudados de modo prospectivo, durante o período de 1 ano, 1.031 pacientes. Durante entrevista clínica, foram registrados os dados demográficos e as queixas clínicas apresentadas. Todos foram submetidos a manometria esofágica para localização do esfíncter inferior do esôfago e a técnica da viragem do pH. A identificação do ponto de viragem foi realizada de dois modos distintos, caracterizando dois grupos de estudo: com o paciente sentado (grupo I - 450 pacientes) e com o paciente em decúbito dorsal horizontal (grupo II - 581 pacientes). Após a identificação do ponto de viragem, o sensor distal de pHmetria era posicionado na posição padronizada, baseada na localização manométrica do esfíncter. Registrava-se onde seria posicionado o sensor de pH se fosse adotada a técnica da viragem. Para avaliação da adequação do posicionamento, considerou-se que o erro é representado pela diferença (em centímetros) entre a localização padronizada (manométrica) e a localização que seria adotada caso fosse empregada a técnica da viragem. Considerou-se que o erro seria grosseiro se fosse maior que 2 cm. Analisou-se também o tipo de erro mais freqüente (se acima ou abaixo da posição padronizada). Foram incluídos todos pacientes que aceitaram participar da pesquisa e excluídos os casos nos quais não se identificou acidificação intragástrica. RESULTADOS: Se fosse adotada a técnica da viragem, haveria erro no posicionamento do sensor em 945 pacientes (91,6%), portanto, o sensor seria posicionado na posição padronizada em apenas 86 (8,4%) casos. Em relação à caracterização do grau de erro, haveria erro considerado grosseiro em 597 (63,2%) pacientes. Em relação ao tipo de erro, o sensor seria posicionado abaixo do local padronizado em 857 (90,7%) casos. Não houve diferença significante entre os dois grupos de estudo em relação a nenhum dos parâmetros analisados, indicando que a posição adotada pelo paciente durante a manobra da viragem não interfere no erro inerente à técnica. CONCLUSÕES: 1. O posicionamento do sensor distal de pHmetria pela técnica da viragem do pH não é confiável. 2. A técnica da viragem proporciona margem de erro expressiva. 3. O tipo de erro mais comum que tal modalidade técnica proporciona é o posicionamento mais distal do sensor, que pode superestimar a ocorrência de refluxo. 4. Não há influência da posição adotada pelo paciente durante a realização da técnica da viragem do pH na eficiência do método.

pH Testing: the basics

Esophageal pH testing, first described more than 3 decades ago, has become incorporated in the diagnostic armamentarium of most gastroenterologists. Using commercially available sophisticated equipment and software, the procedure is easy to perform and the analysis of the signals is automated. Nevertheless, users of esophageal pH testing must remain aware of the technical pitfalls that may stand in the way of the acquisition of meaningful results. Esophageal pH monitoring provides quantitative information about the exposure of the distal esophagus to acid. The technique makes it also possible, however, to quantify the correlation between symptom episodes and reflux events. In clinical practice, the latter is often more relevant than information on esophageal acid exposure.

High-resolution manometry

Recently, high-resolution oesophageal manometry was added to the armamentarium of researchers and gastroenterologists. Current studies suggest that the yield of high-resolution oesophageal manometry is higher than that of conventional pull-through manometry and is at least comparable to that of sleeve sensor manometry. Probably the most important advantage of solid-state high-resolution manometry is that it makes oesophageal manometry faster and easier to perform. Topographic plotting of high-resolution manometry signals facilitates their interpretation. It is concluded that high-resolution manometry is a promising technique for the evaluation of oesophageal motor function. Further studies will have to determine whether high-resolution manometry is superior to conventional manometry in the diagnostic work-up of patients with oesophageal symptoms.

Accurate positioning of the 24-hour pH monitoring catheter: Agreement between manometry and pH step-up method in two patient positions

AIM: To investigate the agreement between esophageal manometry and pH step-up method in two different patient positions.

METHODS: Eighteen subjects were included in the study. First, the distance from the nose to the proximal border of the lower esophageal sphincter (LES) was measured manometrically. Then a different investigator, who was blinded to the results of the first study, measured the same distance using the pH step-up method, with the patient in both upright and supine positions. An assessment of agreement between the two techniques was performed.

RESULTS: In the supine position, the measurement of only one subject was outside the range accepted for correct positioning (≤ 3 cm distal or proximal to the LES). In the upright position, errors in measurement were recognized in five subjects. Bland-Altman plots revealed good agreement between measurements obtained manometrically and by the pH-step up method with the patient in the supine position.

CONCLUSION: In the case of nonavailability of manometric detection device, the pH step-up method can facilitate the positioning of the 24 h pH monitoring catheter with the patient in the supine position. This should increase the use of pH-metry in clinical practice for subjects with suspected gastroesophageal reflux disease if our results are supported by further studies.

Esophageal acid exposure in healthy adults in Taiwan: experience with pH step-up method by dual-channel pH-metry

Esophageal acid exposure is common in normal subjects. The aim of this study was to investigate proximal and distal esophageal acid exposure in asymptomatic volunteers using dual-channel esophageal pH-metry with probe positioning by pH step-up. A total of 21 healthy subjects (9 male; mean age, 51 years) underwent 24-hour ambulatory esophageal pH recording with the pH step-up method using a two-channel pH probe, a portable digital data recorder, and computerized data analysis. All reflux episodes, episodes longer than 5 minutes, longest reflux episode, duration of acidity (pH <4), and percentage of time with acidity were analyzed. The 95th percentile for reflux parameters assessed in the distal/proximal esophagus were: total reflux episodes, 100/34; episodes greater than 5 minutes, 2.9/0; longest reflux episode, 16.6/2.95 minutes; duration of acidity, 87.95/15.5 minutes; and percentage of time with acidity, 7.0%/1.3%. Proximal and distal acid exposure were well correlated. Results showed that neither gender nor age influenced reflux parameters and that asymptomatic volunteers might experience some gastroesophageal reflux.

Catheter-based pH monitoring: use in evaluation of gastroesophageal reflux disease symptoms (on and off therapy)

Tube-based ambulatory pH testing has rapidly evolved in the past 3 decades to become the standard by which other diagnostic approaches to gastroesophageal reflux disease are judged. Acid exposure 5 cm above the manometrically determined lower esophageal sphincter is the standard for documentation of pathologic acid exposure of the distal esophagus. Proximal esophageal or hypopharyngeal monitoring is an evolving technique that may shed light on patients with supraesophageal symptoms. The ability to simultaneously monitor esophageal and gastric acidity (usually in patients with persistent symptoms despite therapy) is another advantage of this technique. Whether the new system that allows simultaneous pH and impedance monitoring and the system that uses an implantable tubeless monitoring capsule will supplant this older but well-established technology remains to be determined.

Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease

Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published in 1995 and updated in 1999. These and other guidelines undergo periodic review. Advances continue to be made in the area of GERD, leading us to review and revise previous guideline statements. GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. These guidelines were developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee, and approved by the Board of Trustees. Diagnostic guidelines address empiric therapy and the use of endoscopy, ambulatory reflux monitoring, and esophageal manometry in GERD. Treatment guidelines address the role of lifestyle changes, patient directed (OTC) therapy, acid suppression, promotility therapy, maintenance therapy, antireflux surgery, and endoscopic therapy in GERD. Finally, there is a discussion of the rare patient with refractory GERD and a list of areas in need of additional study.

Lower esophageal sphincter pressure in patients with gastroesophageal reflux diseases and posture and time patterns

Gastroesophageal reflux disease is caused predominantly by lower esophageal sphincter insufficiency. Reports suggest that it is possible to distinguish between two main mechanisms causing reflux: low basal sphincter pressure leading to free reflux, mostly occurring at night in the supine position, and increased transient lower esophageal sphincter relaxations with normal or increased resting pressure leading to reflux during the day in an upright position. Lower esophageal sphincter pressure (LESP)-- s determined by stationary pull-through manometry--was compared to profiles of acidic reflux measured by 24-h pH monitoring in 207 patients with proven gastroesophageal reflux disease. Differences in LESP were not significant among patients with reflux predominantly during the day in an upright position and those with reflux predominantly at night in a supine position (16.1 +/- 7.4 mmHg versus 15.1 +/- 7.8 mmHg; t-test: P = 0.355). For both patterns of LESP, there was a slight negative correlation with the amount of acidic reflux (determined as a percentage of time with pH < 4). Pearson correlation coefficients were -0.196 for upright refluxers and -0.137 for bipositional/supine refluxers (P = 0.006 and P = 0.049, respectively). As there are no differences in LESP with regard to posture or time patterns of acidic reflux it seems unlikely that upright reflux is associated with increased LESP, whereas supine reflux manifests due to a hypotensive LESP. Alternatively, it may be concluded that stationary pull-through manometry is inadequate for determining the cause of gastroesophageal reflux disease and is therefore of limited use in its routine diagnosis.

pH probe positioning for 24-hour pH-metry by manometry or pH step-up

OBJECTIVES

Before pH measurement, manometry is recommended for precise pH probe positioning. We investigated whether the pH probe could be positioned accurately by the pH difference between the oesophagus and the stomach (pH step-up).

METHODS

Dual-channel 24-h pH-metry with probes positioned 5 cm above either the manometrically determined upper lower oesophageal sphincter margin or the pH step-up was performed in healthy volunteers and reflux patients. To determine the pH step-up, the pH probe was pulled back from the stomach until a sudden rise to pH greater than four occurred. Probe position, reflux episodes and the fraction of the time pH was less than four were compared using the Wilcoxon test for difference and the Hodges-Lehman estimate inclusive confidence interval for equivalence. The pH step-up method was evaluated further during proton pump inhibitor therapy and after drug discontinuation.

RESULTS

The pH probe was positioned 2 cm and 1 cm closer to the stomach by the pH step-up method in the volunteers and reflux patients, respectively. A small increase in upright reflux episodes but not in supine reflux episodes was registered by the probe positioned by pH step-up. No significant differences in the fraction of the time pH was less than four were obtained between the two probes. The Hodges-Lehman calculation proved equivalence for both methods of probe positioning for 24-h pH-metry. During proton pump inhibitor therapy, no pH step-up was detectable in three volunteers and in one patient. On the first day after discontinuing therapy, the pH step-up method yielded clear-cut results again.

CONCLUSION

The pH probe for diagnostic 24-h pH-metry and, with some limitations, also for 24-h pH-metry for therapy control, can be positioned accurately by the pH step-up method.

Ineffective motility is not a marker for gastroesophageal reflux disease

OBJECTIVE

Previous studies have suggested that ineffective esophageal motility (IEM) may be a marker for gastroesophageal reflux disease (GERD), particularly supraesophageal reflux disease. We evaluated the relationship between esophageal acid exposure and esophageal body motility in patients undergoing both esophageal manometry and 24-h pH metry in the absence of antisecretory therapy.

METHODS

We conducted a retrospective database review of 84 patients (mean age 47 yr, 46% male) evaluated in our GI physiology laboratory. The indication for testing was recorded and characterized as esophageal or supraesophageal. Abnormal esophageal acid exposure was defined as a distal esophageal pH <4 for more than 4.2% of the total monitoring time (>6.3% upright, >1.2% supine) or a proximal esophageal acid exposure time of greater than 1.1% total (>1.3% upright, 0% supine). IEM was defined as more than two of 10 ineffective peristaltic waves.

RESULTS

Seventy-two patients had esophageal-presenting symptoms, and 12 had supraesophageal symptoms. The prevalence of abnormal esophageal acid exposure was similar in patients with esophageal and supraesophageal symptoms (69% vs 92%, p = 0.17). Abnormal motility was identified in 26 patients (31%). IEM was the most common motility disturbance (77%, 20 patients). The frequency of motility disorders was similar in patients with and without abnormal esophageal acid exposure (30% vs 35%, p = 0.79), in patients with esophageal or supraesophageal symptoms (32% vs 25%, p = 0.75, for all patients; 30% vs 27%, p = 1.00, for patients with abnormal esophageal acid exposure), and among upright, supine, and combined refluxers (33%, 9%, and 35%, p = 0.26).

CONCLUSIONS

IEM does not stand alone as a significant marker for the presence of GERD in general or supraesophageal reflux disease in particular.

The prevalence of constipation in institutionalized people with intellectual disability

Constipation is a common problem in people with intellectual disability (ID). Laxatives are frequently prescribed with disappointing results. The prevalence of constipation was investigated in a random population of 215 people with ID (IQ < 50) and constipation was correlated with clinical symptoms. All subjects were scored for bowel habits. Constipation was defined as having a bowel movement less than three times a week or the necessity of using laxatives more than three times a week. Further possible accompanying factors were evaluated. The control subjects were defined as individuals who did not use laxatives. Subjects with constipation were defined as patients and were compared to subjects without constipation (controls). One hundred and forty-nine out of 215 cases (69.3%) showed constipation. Constipation was significantly correlated with non-ambulancy, cerebral palsy, the use of anticonvulsive medication or benzodiazepines, H2-receptor antagonists or proton pump inhibitors, food refusal, and an IQ < 35. Fifty-eight per cent of the patients used bisacodyl or magnesium oxide, 39% lactulose, 13% sodiumlaurylsulphoacetate/sodium citrate/sorbitol and only 10% were given sodium phosphate enemas. Faecal soiling was found in 15% of subjects, while manual evacuation of faeces was performed in nearly 7% of cases. Constipation was randomly demonstrated in almost 70% of the population with ID. Subjects with the above-mentioned accompanying factors are especially at risk for constipation. Contrary to the general population, constipation in people with ID is associated with little use of phosphate enemas, microlax, a low incidence of faecal soiling and manual evacuation of faeces, suggesting an aetiology without distal faecal impaction. The regimen and effect of therapy has to be studied to define adequate treatment schedules.

Esophageal pH monitoring: are you sure that the electrode is properly placed?

OBJECTIVE

A crucial methodological aspect of ambulatory 24-h esophageal pH monitoring is electrode placement. Lower esophageal sphincter (LES) location is recommended for standard electrode positioning. The aim of the present study was to evaluate prospectively whether LES manometric location and intragastric pH acid confirmation suffice to guarantee that the pH electrode is properly placed.

METHODS

We evaluated data from 402 consecutive patients undergoing esophageal pH monitoring. LES location was determined by manometry, and the pH electrode was introduced until a pH recording <3 was obtained. Subsequently, it was positioned 5 cm above the proximal LES border. Thereafter, adequate catheter placement and absence of bends or loops were checked by fluoroscopy. Patients with bent or rolled catheters were instructed to have breakfast immediately, and catheter placement was checked again by fluoroscopy.

RESULTS

When checked by fluoroscopy, the catheter was properly placed in 383 patients (95.3%). In the other 19 (4.7%), it was not located in the distal part of the esophagus owing to bending or rolling: 14 in the esophagus and five in the pharynx. After breakfast, 14 of the 19 malpositioned catheters were properly positioned whereas five remained bent or rolled. Those bent in the esophagus were more prone to unbending (12 of 14) than those bent or rolled in the pharynx (two of five).

CONCLUSIONS

After LES location by manometry and demonstration of acid pH during the pH step-up technique, the pH electrode was properly placed in more than 95% of cases. Nevertheless, it cannot be completely guaranteed that the pH catheter will not bend or roll, and the pH electrode will not be malpositioned. Eating immediately after electrode placement resolves this problem in the majority (75%) of cases. Therefore, we recommend that patients undergoing esophageal pH-metric studies be instructed to eat as soon as possible after electrode placement to minimize these possible pitfalls.

Accurate placement of the esophageal pH electrode for 24-hour pH monitoring using a combined pH/manometry probe

OBJECTIVE

Accurate placement of a pH electrode requires manometric localization of the lower esophageal sphincter (LES). Combined manometry/pH devices using water-perfused tubes attached to pH catheters and the use of an electronic "LES locator" have been reported. We investigated whether accurate placement of pH probes can be achieved using such a probe, and whether this may reduce the need for the performance of the usual stepwise pull-back manometry.

METHODS

Thirty consecutive patients (15 men, 15 women; median age, 56 yr; interquartile range, 42-68 yr) referred for manometry and pH testing were included in the study. The localization of the LES was determined with standard esophageal manometry. After that, a second 3-mm pH electrode with an internal perfusion port was passed into the stomach. Using this catheter, a single stepwise pull-through manometry was performed and the LES position was noted. LES location, mean pressure, and length obtained with standard manometry were compared to data from the combined pH/manometry catheter. Additionally the time necessary to perform each of the procedures was noted and the patient's discomfort caused by the catheter was evaluated using a standardized questionnaire.

RESULTS

The LES location with the pH/manometry probe was proximal to that with standard manometry in 19 patients (63%), the same in nine patients (30%), and distal in two patients (7%). The differences were <2 cm in 29 of 30 (97%) patients. The LES location with the pH/manometry probe required a median of 6.5 min (interquartile range: 3.5-8.5 min) versus a median of 21.5 min (interquartile range: 14.5-26.5 min) for standard manometry (p < 0.0001). In addition, LES evaluation using the combined pH/manometry probe provided accurate data on the resting pressure, as well as overall and intraabdominal length of the LES. All patients tolerated the combination probe better than the standard manometry probe (p < 0.001).

CONCLUSIONS

Placement of the esophageal electrode for 24-h esophageal pH monitoring using a combined pH/manometry probe is accurate. The technique is simple, time-saving, and convenient for the patients. Because it is possible to accurately evaluate the LES using this technique, it may even replace conventional manometry before pH probe placement.

Standards for oesophageal manometry. A position statement from the Gruppo Italiano di Studio Motilità Apparato Digerente (GISMAD)

Manometry is an important tool in the diagnosis of oesophageal motility, disorders, but proper instruments and methods are needed to obtain useful clinical information. The authors reviewed the minimal technical requirements, operative aspects, which information the final report should contain as well as indications and contraindications of the text itself. Technical requirements: At least a three-channel, multiple-lumen catheter perfused with a pneumo-hydraulic capillary infusion system which ensures deltaP/deltaT>150-200 mmHg/sec.; data should be recorded at a sampling rate of > or =8 Hz to study the oesophageal body and lower oesophageal sphincter; lower oesophageal sphincter tonic (pressure) and phasic activity (relaxations) and oesophageal body amplitude and peristaltic activity should be recorded. The final report must contain the patient's details, the indication for the test and a manometric diagnosis. Indications for manometry: Dysphagia (after ruling out any organic pathology); non- cardiac chest pain (after ruling out any cardiopulmonary involvement); systemic collagenosis (to investigate oesophageal involvement); gastro-oesophageal reflux disease (if surgery is planned). Contraindications are limited to: pharyngeal or upper oesophageal obstructions, oesophageal bullous disorder, cardiac conditions in which vagal stimulation may not be tolerated, severe coagulopathy and patient non-compliance.

The prevalence of gastroesophageal reflux disease in institutionalized intellectually disabled individuals

OBJECTIVE

The prevalence of gastroesophageal reflux disease (GERD) was randomly investigated among Dutch and Belgian intellectually disabled individuals.

METHODS

In six institutes including 1607 residents, 435 persons with IQ <50 underwent 24-h esophageal pH-metry and were scored for possible predisposing factors and characteristic reflux symptoms. In 49 (11.2%) cases the test failed because of technical reasons. A pathological pH test was defined as a pH <4 for >4.5% of the measured time. Subjects with a pathological pH test (patients) were compared with those with a normal pH test (controls).

RESULTS

Of the remaining individuals, 51.8% (200/386) showed a normal pH test, whereas 186 showed a pathological pH test (median duration pH <4: 14.2%, range: 4.5-78.4%). As possible predisposing factors scoliosis, cerebral palsy, use of anticonvulsant drugs or other benzodiazepines, and IQ <35 were found, whereas symptoms such as vomiting, hematemesis, rumination, and depressive symptoms were indicative for reflux. At endoscopy reflux esophagitis was diagnosed in 129 of the 186 patients (69.4%). In 61 (47.3%) of 129 patients, grade I, 43 (33.3%) grade II, 25 (19.4%) grade III/IV (Savary-Miller) were found. Barrett's esophagus was found in 18 (14.0%) and peptic strictures in five (3.9%) cases.

CONCLUSIONS

An abnormal 24-h pH-metry and symptoms suggestive for GERD were documented frequently in a large cohort of institutionalized intellectually disabled individuals. Further endoscopical evaluation confirmed the diagnosis of reflux esophagitis in the majority of these individuals.

Silent gastroesophageal reflux disease in patients with pharyngolaryngeal cancer: further results

BACKGROUND

Gastroesophageal reflux disease is associated with various head and neck manifestations. The aim of this retrospective study was to determine the incidence of asymptomatic, or "silent," gastroesophageal reflux disease (GERD) in patients treated for pharyngolaryngeal squamous cell carcinoma.

METHODS

Twenty-four-hour pH monitoring was performed in 72 consecutive patients without digestive manifestations (pyrosis, retrosternal heartburn) of GERD treated for pharyngolaryngeal carcinoma. Statistical analysis of the relationship between reflux scores achieved and various patient parameters (age, tobacco and alcohol consumption, gastric ulcers, medications which decrease esophageal sphincter pressure), tumor parameters (staging), and therapeutic parameters (drugs administered during neo-adjuvant chemotherapy) was performed.

RESULTS

Incidence of silent GERD varied from 36% to 37% according to the reflux scores. No relationship was found between the reflux scores and the patient or tumor parameters. Among the therapeutic parameters, a statistical relation was noted between the total dose of Cisplatin and the reflux scores (p = .005).

CONCLUSIONS

Silent GERD is a common finding in patients treated for squamous cell carcinoma of the pharyngolarynx. Additionally, chemotherapy including Cisplatin may aggravate GERD during the course of therapy.

Dental erosions and gastro-oesophageal reflux disease in institutionalized intellectually disabled individuals

OBJECTIVE

Both exogenous acids, from the diet, and endogenous acids, from stomach juice, can dissolve the enamel mineral, resulting in dental erosions. Gastric acid may reach the mouth by gastro-oesophageal reflux disease (GERD), recurrent vomiting, rumination and regurgitation. These conditions are frequently found in the intellectually disabled population. Therefore, we investigated the presence of dental erosions in combination with GERD among intellectually disabled inhabitants, with an IQ < 50, taken from three Dutch institutes.

MATERIALS AND METHODS

At random 63 individuals underwent an oesophageal pH test and dental screening and possible predisposing and attributable factors were determined. An abnormal pH level was defined as a pH < 4, > 4.5% of the measured time. Subjects with dental erosions were compared to those without dental erosions.

RESULTS

In 29 out of 63 (46.0%) cases evidence of dental erosions was found. In 19 of these 29 subjects with erosions (65.5%) GERD was diagnosed, compared to nine (26.5%) out of 34 subjects without erosions (P = 0.04). In the subjects with erosions mean duration of pH < 4 was 15.6% (range: 0.5-90.5) compared to 6.3% (range 0-40.4) in subjects without erosions (P = 0.02). An IQ < 35 was found to be predisposing (P < 0.001).

CONCLUSION

In this population of 63 institutionalised intellectually disabled persons dental erosions were diagnosed in 46%. Sixty-five per cent of them had GERD. Individuals with longer duration of pH < 4 than 6.3% of the measured time and with an IQ < 35 were at higher risk to develop dental erosions. This study shows that dental erosions in the intellectually disabled population might be an oral manifestation of GERD.

Simultaneous two-level esophageal 24-hour pH monitoring in patients with mild and severe esophagitis. Does probe position influence results of esophageal monitoring?

Simultaneous ambulatory esophageal pH monitoring was performed in 10 patients (group 1) with normal distal acid exposure and in 40 patients (group 2) with pathological distal reflux. The probes were placed 5 and 10 cm above the lower esophageal sphincter to quantify variations of pH values that can be due to a displacement of pH sensor. In group 1 the median percent time with pH < 4 for total and upright monitoring periods and composite score were significantly lower at the proximal than the distal level. In group 2 all pH data were significantly lower at the proximal than the distal level. The patients with pathological reflux were subdivided into two subgroups based on endoscopic findings (mild and severe esophagitis). The patients with severe esophagitis showed a proximal acid reduction higher than in patients with mild esophagitis. Nine patients with mild esophagitis showed normal values at 10 cm, but all patients with severe esophagitis had abnormal proximal acid exposure.

Current diagnosis and treatment of gastroesophageal reflux disease

OBJECTIVE

To review recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD).

MATERIAL AND METHODS

Original English language reports were obtained through a Medline search of the National Library of Medicine up to and including 1993. The reference lists of all original reports and review articles were searched to locate any further material. In the evaluation of therapeutic efficacy, randomized studies were preferentially considered; greatest priority was given to double-blind, placebo-controlled trials. Abstracts, nonrandomized trials, and non-English language publications were considered only when other data were unavailable.

RESULTS

Information obtained from histories and physical examinations suggests that GERD occurs in many patients. Evaluation of mucosal injury with use of either endoscopy or air contrast barium radiography is an important early step in the diagnosis of GERD. Endoscopy obtains tissue for histologic study, especially in Barrett's esophagus. Prolonged esophageal pH monitoring is the most useful determinant of the presence and amount of reflux of acid. Patients with GERD should be counseled on lifestyle modification and the use of antacids and antirefluxants. Histamine type 2 receptor antagonists provide symptomatic relief in 32 to 82% of patients with GERD and resolution of verified esophagitis in 0 to 82%. Responses with omeprazole therapy are higher; symptomatic responses were noted in 62 to 94% of patients, and healing of esophagitis occurred in 71 to 96%. Promotility agents and surgical therapy have a role in selected patients.

CONCLUSION

GERD is a chronic disorder that often necessitates individualized lifelong therapy. Many questions remain to be answered about the cost-effectiveness of both diagnostic tests and therapy for GERD.

Review article: gastro-oesophageal reflux and laryngeal symptoms

There is some evidence from clinical, experimental and multiprobe ambulatory pH studies that gastro-oesophageal reflux is more common in patients with laryngeal symptoms and could potentially play a role in the causation of these symptoms. The proportion of unselected patients with laryngeal symptoms who have gastro-oesophageal reflux as the primary aetiology may be overestimated in some series. The symptom that has been most evaluated is hoarseness, but even for this symptom the proportion of patients who have significant reflux varies widely. There is even less agreement for other symptoms, and the data on globus sensation remains confused. It is likely that these patients present to ear, nose and throat (ENT) clinics because of the relative insensitivity of the oesophageal mucosa to acid exposure. Given the lack of specificity for routine diagnostic tests for gastro-oesophageal reflux, it is necessary to perform ambulatory pH monitoring for a secure diagnosis in these patients. Treatment studies have been surprisingly few and inadequate in design. It is suspected that there is a strong placebo response for these symptoms. No clear information on efficacy can be provided until placebo-controlled randomised studies are available.

Prolonged remission of oesophagitis does not alter the magnitude of oesophageal acid exposure

In a previous study we reported lack of improvement in oesophageal motor function after complete healing of oesophagitis achieved by treatment with omeprazole for a median duration of 12 weeks. This study investigates the effect on oesophageal acid exposure of a longer period of complete remission. It was decided to approach all patients who had 24-h pH monitoring as part of the earlier project and whose second endoscopy showing complete healing of oesophagitis as done at least 24 weeks previously. Of 38 such patients, 24 underwent endoscopy, which showed relapse of oesophagitis in 5 of them. In 18 patients who were eligible and agreed to take part, omeprazole/ranitidine was withdrawn for at least 7 days, after which pH monitoring was repeated. The median duration of remission was 39.5 weeks (range, 26-81 weeks). The median percentage of total time with pH below 4 was 11.5% before and 11.0% after (NS). The corresponding figures for the upright and supine reflux, the number of reflux episodes longer than 5 min, and the duration of the longest reflux episode were 10.7% versus 7.7%, 11.4% versus 12.1%, 7.5 versus 7.5, and 35.5 versus 30.5 min, respectively (NS for all variables). These results suggest that maintenance of remission of oesophagitis for prolonged periods does not alter the degree of acid reflux on discontinuation of medication. This has important implications for the understanding of the natural history of gastro-oesophageal reflux disease.