Inclusion of supine period in short-duration pH monitoring is essential in diagnosis of gastroesophageal reflux disease

Twenty-four-hour pH metry alone is inferior to additional impedance monitoring in the diagnosis of gastroesophageal reflux disease, particularly in presence of reduced gastric acid secretion

BACKGROUND

Current gold standard for the diagnosis of gastroesophageal reflux disease (GERD) is 24-hour pH metry though it fails to detect non-acidic reflux. The sensitivity of 24-hour pH metry alone (both catheter-based and Bravo capsule) is questionable, especially if gastric acid secretion is low due to reduced parietal cell mass, Helicobacter pylori-induced gastric atrophy and antisecretory therapy. Accordingly, we analyzed the diagnostic ability of 24-hour pH metry as compared to impedance monitoring in relation to the gastric pH without antisecretory therapy.

METHODS

A retrospective analysis of prospectively collected data from 150 patients with suspected GERD undergoing a 24-hour pH impedance study was done.

RESULTS

Among 150 patients with symptoms suggestive of GERD, 106 (70.6%) had confirmed GERD diagnosed either by 24-hour pH metry alone (10 [9.4%]), impedance monitoring alone (49 [46.2%]) or both (47 [44.3%]). Abnormal reflux of acidic and non-acidic gastric contents was detected by 24-hour pH metry and 24-hour impedance monitoring in 57/106 (53.7%) and 96/106 (90.5%) of patients, respectively (p < .00001). Patients with GERD diagnosed by 24-hour impedance monitoring had a higher mean gastric pH (2.9 [median 1.3, IQR 5.3]) than those diagnosed by 24-hour pH metry (2.1 [median 1.4, IQR 2.6]) or both (1.6 [median 1.2, IQR 2.1]) (p = 0.001).

CONCLUSION

Twenty-four-hour impedance monitoring detects GERD more often than 24-hour pH metry. Patients with higher mean gastric pH leading to non-acidic reflux were more often diagnosed by 24-hour impedance monitoring than 24-hour pH metry. Thus, 24-hour pH metry alone is inferior to additional impedance monitoring in the diagnosis of GERD, particularly in presence of reduced gastric acid secretion.

Nocturnal Gastroesophageal Reflux Disease (GERD) and Sleep: An Important Relationship That Is Commonly Overlooked

Gastroesophageal reflux disease (GERD) is a prevalent, chronic medical condition that affects 13% of the adult population globally at least once a week. Sleep disturbances are frequently encountered in up to 25% of the GERD patients, likely due to nocturnal gastroesophageal reflux (GER). With advance in diagnostic techniques allowing for an improved understanding of involved physiological mechanisms of nocturnal reflux, there is growing evidence of a bidirectional relationship between GERD and sleep disturbances. Furthermore, nocturnal GER is associated with more complicated GERD. Obstructive sleep apnea (OSA) and GERD also have been linked, but to what degree remains controversial. Treatment of nocturnal GER has been shown to improve both subjective and objective sleep measures. The therapeutic approach includes lifestyle modifications and medication individualization and optimization with proton-pump inhibitors serving as the mainstay of treatment. Antireflux surgery and newer endoscopic procedures have been demonstrated to control nocturnal GER.

Acid and nonacid reflux monitoring

Detection of acid and nonacid reflux using esophageal reflux monitoring, which includes conventional and wireless pH monitoring and pH impedance, can be a valuable diagnostic tool when used appropriately in the assessment of patients with gastroesophageal reflux disease. Reflux monitoring may be especially helpful if a management change is desired, such as when initial or empirical treatment is ineffective. However, each of these methods has its limitations, which need to be accounted for in their clinical use. Indications, test performance, interpretation, and clinical applications of esophageal reflux monitoring, as well as their limitations, are discussed in this review.

Can multichannel intraluminal pH-impedance monitoring be limited to 3 hours? Comparison between ambulatory 24-hour and post-prandial 3-hour recording

Esophageal multichannel intraluminal pH-impedance recording (MII) is now a valid technique for determining the acidic, liquid, gas or mixed nature of gastroesophageal reflux episodes. However, some recordings may stop prematurely due to technical reasons or poor patient tolerance of the probe. Therefore, we questioned whether analysis of post-prandial 3-hour recording could predict the results obtained in ambulatory 24-hour recording. Fifty patients with symptoms of gastroesophageal reflux disease were investigated. For each patient, post-prandial 3-hour MII was recorded after a test meal, then followed by ambulatory 21-hour MII. Correlation between the total number of liquid reflux events in the 3-hour and 24-hour recordings was elevated (R=0.71; P<0.001), with better correlation for acid (R=0.80; P<0.001) and weak acid reflux (R=0.56; P<0.001) than non-acid reflux (R=0.44; P<0.01). Sensitivity and specificity of 3-hour recording in detecting elevated liquid reflux over 24 hours (id>75reflux/24 h) were 49% and 100%, respectively, for 8 or less liquid/mixed reflux events per 3 hours, and 78% and 88%, respectively for 15 or more liquid/mixed reflux events per 3 hours. The sensitivity and specificity of symptom association probability (SAP) calculated over 3 hours were 56% and 91%, respectively. In conclusion, we identified relevant indicators on the 3-hour post-prandial recording likely to give accurate prediction of absence or presence of gastroesophageal reflux disease from 24-hour MII recording.

The relationship between complaints of night-time heartburn and sleep-related gastroesophageal reflux

This study investigated whether the complaint of night-time heartburn (NHB) as opposed to daytime heartburn (DHB) is a reliable reflection of actual sleep-related reflux events. Three groups of individuals were studied: individuals with complaints of NHB at least twice per week (n = 24), individuals with complaints of DHB (n = 23), and normal participants without any complaints of regular heartburn during the day or night (n = 25). All three groups were studied on one occasion with combined pH monitoring and polysomnography, and subjective questionnaires about sleep disturbance and sleep quality were given to all participants. The NHB group had significantly more sleep-related reflux events compared with both DHB and control groups (P < 0.01). DHB subjects had significantly (P < 0.05) more sleep-related reflux events than normal controls. Total acid contact time (ACT) was significantly (P < 0.05) elevated in the NHB group compared with both the DHB and control group. Sleep-related ACT was also significantly (P < 0.05) elevated in the NHB group compared with the other two groups, while upright (daytime) ACT was not significantly different. The NHB group was significantly (P < 0.05) worse regarding measures of both objective and subjective sleep quality. Subjects with exclusively DHB do have sleep-related reflux that is greater than normal controls. Subjects with NHB have significantly more sleep-related reflux, and both objective and subjective sleep abnormalities compared with normal controls. Complaints of NHB reflect sleep-related reflux events and may be indicative of a more clinically significant condition.

Review article: sleep-related gastro-oesophageal reflux as a distinct clinical entity

BACKGROUND

Many patients with chronic gastro-oesophageal reflux disease (GERD) have frequent nighttime heartburn as well as sleep-related gastro-oesophageal reflux (GOR). Sleep-related GOR has been shown to play an important role in the development of oesophagitis and other complications of GOR.

AIM

To present a conceptual argument that nighttime heartburn and associated sleep-related GOR should be recognized as a distinct clinical entity deserving special attention with regard to the diagnosis and treatment of GERD.

METHODS

The data presented come from surveys of GERD patients as well as from physiological studies to include studies monitoring oesophageal pH and spontaneous reflux events during polysomnographically (PSG) monitored sleep.

RESULTS

Evidence is presented to show that nighttime heartburn is prevalent and its occurrence separates patients from those who have heartburn most exclusively in the daytime. The evidence presented also supports the notion that nighttime heartburn sufferers have a more complicated disease and they have a greater risk of developing oesophagitis and other respiratory complications. The data also show that responses to acid mucosal contact are quite different during sleep compared to responses measured during the waking state.

CONCLUSIONS

Nighttime heartburn and GOR represent a distinct clinical entity which deserves specific attention in the diagnosis and optimal treatment of GERD.

Review article: sleep and its relationship to gastro-oesophageal reflux

Gastro-oesophageal reflux disease (GERD) is among the most common gastrointestinal conditions in the USA. For most symptomatic patients, reflux events occur during both daytime and night-time hours. Whereas daytime reflux events tend to be frequent but brief, reflux events that occur during sleep are comparatively less frequent but significantly longer. Longer oesophageal acid-clearance and acid-mucosal contact times during sleep are at least partly due to several physiological changes associated with sleep, including dramatic declines in saliva production and frequency of swallowing, decreased conscious perception of heartburn and consequent arousal and clearance behaviours, and slower gastric emptying. Obstructive sleep apnea syndrome and obesity seem to predispose some patients to nocturnal GERD, and the presence of either of these conditions may help to identify patients with symptoms consistent with GERD. Recognition and treatment of night-time GERD are important because it can be associated with decreased quality of life (including sleep disruption) and increased risk of serious oesophageal and respiratory complications.

Postprandial Acid Reflux is Reduced by Delayed Gastric Emptying

The aim of this study was to investigate influence of delayed gastric emptying on postprandial reflux in esophageal pH. Sixty-nine consecutive patients underwent 24 hour (h) esophageal pH monitoring and gastric emptying. In 24 h esophageal pH monitoring, % postprandial reflux pH<4 for 2 h after each meal (% PRT) was extracted from the 24 h pH profile. After solid test meal (1 mCi, Tc99m) was given, gastric emptying was measured with a gamma detector placed transnasally 5 cm below lower esophageal sphincter. % PRT was similar among the 34 normal, 26 delayed and 9 rapid gastric emptying rate patients. Thirty-five with a positive pH study and 34 with a negative had a similar prevalence of gastric emptying disorder. In the positive pH study group, patients with normal gastric emptying had significantly higher % PRT than those with delayed gastric emptying (22.0 vs 12.1%, P<0.05). In the same population, patients with a normal %PRT had a significantly higher prevalence of delayed gastric emptying compared with those with a positive % PRT (6/8 vs 9/27, P<0.05). In patient with abnormal acid exposure but normal % PRT on 24 h esophageal pH monitoring, gastric emptying may be delayed.

Gastrointestinal functioning during sleep: a new horizon in sleep medicine

A body of clinical and research literature is accumulating suggesting that there are significant alterations in gastrointestinal functioning during sleep, as well as sleep complaints and disorders in patients suffering from gastrointestinal disease. This review addresses the clinical applications of some basic alterations in gastrointestinal functioning during sleep, with a particular focus on gastroesophageal reflux disease and functional bowel disorders. Recent studies have shown that gastroesophageal reflux during sleep results in a marked prolongation of esophageal acid clearance time, and consequent mucosal damage. Data are reviewed which suggest that the more serious complications of gastroesophageal reflux, e.g. esophagitis and the extra-esophageal complications of reflux such as the exacerbation of bronchial asthma, laryngopharyngitis, and pulmonary aspiration are the result of sleep-related gastroesophageal reflux. Recent studies have also shown that patients with functional bowel disorder (e.g. irritable bowel syndrome and dyspepsia) have a high incidence of sleep complaints as well as abnormalities of autonomic functioning. Recent studies have shown that the measurement of autonomic functioning during sleep can differentiate the patients with functional bowel disorders from normal controls. The continued study of gastrointestinal functioning during sleep clearly establishes a new horizon of investigation in both sleep medicine and gastroenterology. 2001 Harcourt Publishers Ltd

Ascites and spontaneous bacterial peritonitis in fulminant hepatic failure

OBJECTIVE

Although presence of ascites has been reported in patients with fulminant hepatic failure (FHF), spontaneous bacterial peritonitis (SBP) has not been studied in a large group of such patients. Hence, the present study was conducted to evaluate the prevalence and prognostic significance of ascites and SBP in FHF patients.

METHODS

Two hundred ninety-eight consecutive patients (mean age 32.9+/-14.8 yr) with FHF were studied. There were 133 (44.6%) men and 165 (55.4%) women. Acute viral hepatitis accounted for 91.6% of the patients and were analyzed in the present study.

RESULTS

Ascites was clinically detected in 79 (28.9%) patients. The patients with ascites were older (p = 0.005), had longer jaundice-encephalopathy interval (p<0.0000001), lesser grade of encephalopathy on admission (p = 0.0000043), and a lower incidence of raised intracranial pressure on admission (p = 0.0007). Patients with ascites had significantly lower serum albumin (p = 0.021), ALT (p = 0.0005), AST (p = 0.00017), and PT (p = 0.002) on admission than in patients without ascites. Multivariate logistic regression analysis showed that jaundice-encephalopathy interval (> or =14 days) and serum albumin (< or =2.5 g/dl) were the only independent predictors of ascites. SBP was detected in 14 (17.7%) patients (neutrocytic culture positive, 4; neutrocytic culture negative, 9; and monomicrobial bacterascites, 1). Escherichia coli was identified in three patients. Survival was no different between patients with and those without ascites and also between patients with and those without SBP.

CONCLUSIONS

Ascites is a frequent accompaniment of FHF and is complicated by SBP. Jaundice-encephalopathy interval of 14 days or more and serum albumin (< or =2.5 g/dl) on admission predicts the development of ascites in these patients.