Five-year audit of ambulatory 24-hour esophageal pH-manometry in clinical practice

[The Additional Role of Symptom-Reflux Association Analysis of Diagnosis of Gastroesophageal Reflux Disease Using Bravo Capsule pH Test]

Background/Aims

Since the development of ambulatory esophageal pH monitoring test to diagnose gastroesophageal reflux disease (GERD), several parameters have been introduced. The aim of this study was to assess whether using the symptom index (SI), symptom sensitivity index (SSI), and symptom association probability (SAP), in addition to the DeMeester score (DS), would be useful for interpreting the Bravo pH monitoring test.

Methods

A retrospective study, which included 68 patients with reflux symptoms refractory to proton pump inhibitor (PPI) therapy who underwent a Bravo capsule pH test between October 2006 and May 2015, was carried out. Acid reflux parameters and symptom reflux association parameters were analyzed.

Results

The median percent time of total pH<4 and DS were 2.90% (interquartile range [IQR] 1.13-6.03%) and 11.10 (IQR 4.90-22.80), respectively. According to the analysis of the day-to-day variation in percent time of total pH<4 (r=0.724) and DS (r=0.537), there was a significant correlation between Day 1 and Day 2. The positive rate of Bravo test according to DS was 27 (39.7%). Although thirty patients experienced symptoms during the test, there were no significant differences of reflux parameters compared with other patients. In the symptom group, 7 patients (23.3%) were identified as having negative DS and an abnormal symptom-related index. There were no significant test-related complications.

Conclusions

In addition to the analysis of traditional acid parameters of the Bravo capsule pH test, diagnosis of GERD, including reflux hypersensitivity, can be improved by performing an analysis of the symptom-reflux association and of the day-to-day variation.

Incidence of Achalasia in South Australia Based on Esophageal Manometry Findings

BACKGROUND & AIMS

Achalasia is a disorder of esophageal motility with a reported incidence of 0.5 to 1.6 per 100,000 persons per year in Europe, Asia, Canada, and America. However, estimates of incidence values have been derived predominantly from retrospective searches of databases of hospital discharge codes and personal communications with gastroenterologists, and are likely to be incorrect. We performed a cohort study based on esophageal manometry findings to determine the incidence of achalasia in South Australia.

METHODS

We collected data from the Australian Bureau of Statistics on the South Australian population. Cases of achalasia diagnosed by esophageal manometry were identified from the 3 adult manometry laboratory databases in South Australia. Endoscopy reports and case notes were reviewed for correlations with diagnoses. The annual incidence of achalasia in the South Australian population was calculated for the decade 2004 to 2013. Findings were standardized to those of the European Standard Population based on age.

RESULTS

The annual incidence of achalasia in South Australia ranged from 2.3 to 2.8 per 100,000 persons. The mean age at diagnosis was 62.1 ± 18.1 years. The incidence of achalasia increased with age (Spearman rho, 0.95; P < .01). The age-standardized incidence ranged from 2.1 (95% CI, 1.8-2.3) to 2.5 (95% CI, 2.2-2.7).

CONCLUSIONS

Based on a cohort study of esophageal manometry, we determined the incidence of achalasia in South Australia to be 2.3 to 2.8 per 100,000 persons and to increase with age. South Australia's relative geographic isolation and the population's access to manometry allowed for more accurate identification of cases than hospital code analyses, with a low probability of missed cases.

Gastroesophageal reflux symptoms in typical and atypical GERD: roles of gastroesophageal acid refluxes and esophageal motility

BACKGROUND/AIM

To determine the roles of gastroesophageal acid reflux (GER) and esophageal dysmotility on typical and atypical GERD symptoms.

METHODS

Two hundred thirty-six patients (159 females, age 47 ± 14 years) with typical and atypical GERD symptom(s) for > 3 months underwent standard water perfused esophageal manometry (EM) and 24 h esophageal pH studies during off therapy.

RESULTS

Eighty seven and 93 patients had positive lower esophageal pH tests and abnormal EM, respectively. Patients with positive lower esophageal pH test were significantly older (50 ± 13 vs 45 ± 13 years, P < 0.005) and had higher prevalence of acid regurgitation symptoms than patients with negative test (56/87 vs 72/149, P < 0.05). Patients with positive upper esophageal pH test (n = 67) also had significantly higher prevalence of acid regurgitation symptoms (43/67 vs 74/152, P < 0.05). Prevalence of other upper gastrointestinal and respiratory symptoms were similar between patients with positive and negative upper and lower pH test. Patients with abnormal EM were significantly older (49 ± 14 vs 45 ± 13 years, P < 0.05) and had higher prevalence of chronic cough than patients with normal EM(30/93 vs 26/143, P < 0.05). In patients with positive pH tests, the prevalence of dysphagia, chronic cough, and hoarseness of voice were significantly higher in patients with abnormal than those with normal EM (18/31 vs 18/56, P < 0.05; 12/31 vs 6/56, P < 0.005 and 19/31 vs 18/56, P < 0.01, respectively). Whereas in patients with negative lower pH tests, only the prevalence of heartburn was significantly lower in patients with normal than those with abnormal EM (26/87 vs 30/62, P < 0.05).

CONCLUSIONS

Acid regurgitation but not heartburn was associated with GER. Esophageal dysmotility had no significant effect on acid regurgitation symptom but associated with chronic cough, hoarseness of voice, and dysphagia only in patients with abnormal esophageal acid exposure.

Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis

BACKGROUND

Non-cardiovascular chest pain (NCCP) has a high healthcare cost, but insufficient guidelines exist for its diagnostic investigation. The objective of the present work was to identify important diagnostic indicators and their accuracy for specific and non-specific conditions underlying NCCP.

METHODS

A systematic review and meta-analysis were performed. In May 2012, six databases were searched. Hand and bibliography searches were also conducted. Studies evaluating a diagnostic test against a reference test in patients with NCCP were included. Exclusion criteria were having <30 patients per group, and evaluating diagnostic tests for acute cardiovascular disease. Diagnostic accuracy is given in likelihood ratios (LR): very good (LR+ >10, LR- <0.1); good (LR + 5 to 10, LR- 0.1 to 0.2); fair (LR + 2 to 5, LR- 0.2 to 0.5); or poor (LR + 1 to 2, LR- 0.5 to 1). Joined meta-analysis of the diagnostic test sensitivity and specificity was performed by applying a hierarchical Bayesian model.

RESULTS

Out of 6,316 records, 260 were reviewed in full text, and 28 were included: 20 investigating gastroesophageal reflux disorders (GERD), 3 musculoskeletal chest pain, and 5 psychiatric conditions. Study quality was good in 15 studies and moderate in 13. GERD diagnosis was more likely with typical GERD symptoms (LR + 2.70 and 2.75, LR- 0.42 and 0.78) than atypical GERD symptoms (LR + 0.49, LR- 2.71). GERD was also more likely with a positive response to a proton pump inhibitor (PPI) test (LR + 5.48, 7.13, and 8.56; LR- 0.24, 0.25, and 0.28); the posterior mean sensitivity and specificity of six studies were 0.89 (95% credible interval, 0.28 to 1) and 0.88 (95% credible interval, 0.26 to 1), respectively. Panic and anxiety screening scores can identify individuals requiring further testing for anxiety or panic disorders. Clinical findings in musculoskeletal pain either had a fair to moderate LR + and a poor LR- or vice versa.

CONCLUSIONS

In patients with NCCP, thorough clinical evaluation of the patient's history, symptoms, and clinical findings can indicate the most appropriate diagnostic tests. Treatment response to high-dose PPI treatment provides important information regarding GERD, and should be considered early. Panic and anxiety disorders are often undiagnosed and should be considered in the differential diagnosis of chest pain.

The pharmacological therapy of non-variceal upper gastrointestinal bleeding

The modern management of patients with upper gastrointestinal bleeding includes, in selected patients, the performance of timely multimodal endoscopic hemostasis followed by profound acid suppression. This article discusses the available data on the use of antisecretory regimens in the management of patients with bleeding peptic ulcers, which are a major cause of non-variceal upper gastrointestinal bleeding, and briefly addresses other medications used in this acute setting. The most important clinically relevant data are presented, favoring fully published articles.

The evolution of oesophageal function testing and its clinical applications in the management of patients with oesophageal disorders

The last decade has brought significant technical advances in laparoscopic surgery. In this constantly evolving technological climate, less told is the story of the evolution of diagnostic technology that improved the clinical management of patients with oesophageal disorders. The successful outcome of the laparoscopic treatment of oesophageal disorders is due to a combination of three different factors: the skills and the ability of the foregut surgeon, the high volume of referral, the expertise in the critical evaluation of the oesophageal function tests. This is an art per se, and it is rarely acknowledged in the achievement of the excellent results of surgery. Oesophageal function testing provides the clinician with information that cannot be obtained by the clinical, endoscopic, and radiological evaluation of patients. This expertise, intimately coupled with the other factors, allows the surgeon to better understand the pathophysiology of these diseases and to provide the optimal management. Therefore, it is essential to understand the evolution that this technology is currently undergoing, and how these changes are expanding the current indications for antireflux surgery by identifying additional predictors of successful outcome.

Clinical trial: intravenous pantoprazole vs. ranitidine for the prevention of peptic ulcer rebleeding: a multicentre, multinational, randomized trial

BACKGROUND

Controlled pantoprazole data in peptic ulcer bleeding are few.

AIM

To compare intravenous (IV) pantoprazole with IV ranitidine for bleeding ulcers.

METHODS

After endoscopic haemostasis, 1256 patients were randomized to pantoprazole 80 mg+8 mg/h or ranitidine 50 mg+13 mg/h, both for 72 h. Patients underwent second-look endoscopy on day 3 or earlier, if clinically indicated. The primary endpoint was an overall outcome ordinal score: no rebleeding, rebleeding without/with subsequent haemostasis, surgery and mortality. The latter three events were also assessed separately and together.

RESULTS

There were no between-group differences in overall outcome scores (pantoprazole vs. ranitidine: S0: 91.2 vs. 89.3%, S1: 1.5 vs. 2.5%, S2: 5.4 vs. 5.7%, S3: 1.7 vs. 2.1%, S4: 0.19 vs. 0.38%, P = 0.083), 72-h clinically detected rebleeding (2.9% [95% CI 1.7, 4.6] vs. 3.2% [95% CI 2.0, 4.9]), surgery (1.9% [95% CI 1.0, 3.4] vs. 2.1% [95% CI 1.1, 3.5]) or day-3 mortality (0.2% [95% CI 0, 0.09] vs. 0.3% [95% CI 0, 1.1]). Pantoprazole significantly decreased cumulative frequencies of events comprising the ordinal score in spurting lesions (13.9% [95% CI 6.6, 24.7] vs. 33.9% [95% CI 22.1, 47.4]; P = 0.01) and gastric ulcers (6.7% [95% CI 4, 10.4] vs. 14.3% [95% CI 10.3, 19.2], P = 0.006).

CONCLUSIONS

Outcomes amongst pantoprazole and ranitidine-treated patients were similar; pantoprazole provided benefits in patients with arterial spurting and gastric ulcers.

ACG practice guidelines: esophageal reflux testing

Investigations and technical advances have enhanced our understanding and management of gastroesophageal reflux disease. The recognition of the prevalence and importance of patients with endoscopy-negative reflux disease as well as those refractory to proton pump inhibitor therapy have led to an increasing need for objective tests of esophageal reflux. Guidelines for esophageal reflux testing are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. Issues regarding the utilization of conventional, catheter-based pH monitoring are discussed. Improvements in the interpretation of esophageal pH recordings through the use of symptom-reflux association analyses as well as limitations gleaned from recent studies are reviewed. The clinical utility of pH recordings in the proximal esophagus and stomach is examined. Newly introduced techniques of duodenogastroesophageal reflux, wireless pH capsule monitoring and esophageal impedance testing are assessed and put into the context of traditional methodology. Finally, recommendations on the clinical applications of esophageal reflux testing are presented.

Review article: acid-related disease--what are the unmet clinical needs?

Proton pump inhibitors have dramatically improved the management options available for patients with acid-related disorders. In patients with gastro-oesophageal reflux disease, currently available proton pump inhibitors provide an excellent outcome for the majority; however, they do not provide optimal pH control in many. Proton pump inhibitors co-therapy reduces, but does not eliminate, the risk of gastrointestinal ulcers and complications in patients taking non-steroidal anti-inflammatory drugs, while in patients with upper gastrointestinal bleeding, it may be difficult to reach and maintain the current therapeutic target of intragastric pH of 6-7. This article reviews the effectiveness of current antisecretory therapy in these three acid-related diseases and areas of unmet clinical need. The potential role of a proton pump inhibitor with an extended duration of action and enhanced acid control from a single daily dose, particularly improved control at night, is discussed. Finally, therapy that could be administered without regard to time of day and/or food intake would offer dosing flexibility and thus have a positive effect on patients' compliance.

[Predominant respiratory symptoms in indications for prolonged esophageal pH-monitoring in children]

BACKGROUND

An increasing prevalence of extraesophageal complications of gastroesophageal reflux (GER) has been seen. Evaluation of clinical profiles of patients submitted to prolonged esophageal pH monitoring could help to identify the patients who could benefit from the early diagnosis of GER.

OBJECTIVE

To evaluate the population, indications and results of esophageal pH-monitoring for the diagnosis of GER in a pediatric gastroenterology clinic.

PATIENTS AND METHODS

Data from 190 children and adolescents who had esophageal pH-monitoring were analyzed. A descriptive analysis of the population was performed and the children were categorized in five groups according to the age. The equipment used was a Digitrapper MKIII (Synetics) and all data were analyzed by using a software EsopHogram 5.7. Reflux index was established for analysis.

RESULTS

The most frequent indications for the exam were: asthma (26.8%), apnea/cyanosis (20%), recurrent pulmonary infections (18.4%), wheezing infant syndrome (15.8%) and chronic cough/horseness (11%). The most frequent groups of age for the respiratory symptoms were: asthma--above 5 years (92.2%); apnea/cyanosis--under 3 months (55.3%); recurrent pulmonary infections and wheezing infant syndrome--3 to 12 months (31.4% and 83.3%). Reflux index of patients with positive exam for GER was significantly higher in patients under 2 years than above 2 years of age.

CONCLUSION

Respiratory symptoms were predominant among the indications for esophageal pH-monitoring in children. The knowledge of the clinical profile of the patients who had esophageal pH monitoring could help to improve the technical quality of the exam.

Effects of ABT-229, a motilin agonist, on acid reflux, oesophageal motility and gastric emptying in patients with gastro-oesophageal reflux disease

AIM

The effect of ABT-229, a new macrolide with no antibacterial activity, on gastro-oesophageal reflux, oesophageal motility and gastric emptying in patients with gastro-oesophageal reflux disease was investigated.

METHODS

Twenty-one patients were treated with a placebo and ABT-229 (2.5, 5 or 10 mg b.d.) in a randomized, incomplete crossover study design. Ambulatory 24-h pH manometry was performed and gastric emptying was assessed by the 13C-octanoic acid breath test on the seventh day of treatment.

RESULTS

A significant decrease was found in the mean (+/- s.e.) percentage of reflux time (intra-oesophageal pH < 4) for ABT-229 5 mg b.d. and 10 mg b.d., but not for 2.5 mg b.d., compared with placebo. For ABT-229 5 mg, it was 8.5 +/- 0.5% vs. 10.7 +/- 0.7% (P < 0.038) and, for ABT-229 10 mg, it was 6.6 +/- 0.5% vs. 8.4 +/- 0.5% (P < 0.019). There were no significant differences in any of the analysed manometric parameters. In addition, the gastric half-emptying time for all doses of ABT-229 did not differ significantly from that after placebo.

CONCLUSIONS

ABT-229 is able to reduce slightly, but significantly, acid reflux in patients with gastro-oesophageal reflux disease. This effect does not appear to be due to a measurable improvement in oesophageal motility or gastric emptying.

Upper gastrointestinal evaluation of Chinese patients with non-cardiac chest pain

AIMS

To test the usefulness of upper gastrointestinal investigations and quality of life assessment in Chinese patients with non-cardiac chest pain.

METHODS

Seventy-eight consecutive patients with non-cardiac chest pain underwent upper endoscopy. Eight patients had upper gastrointestinal pathology (10%). The remaining 70 patients received acid perfusion test, oesophageal manometry and 24-h ambulatory oesophageal pH (n=65)/manometry (n=61), and the results were compared with those of healthy controls (n=20). Symptoms and quality of life (SF-36) were assessed by standard validated questionnaire.

RESULTS

Significant acid reflux symptoms were present in five (5/70, 7%) patients. Abnormal 24-h oesophageal pH, indicating gastro-oesophageal reflux, was found in 19 (19/65, 29%) patients. The percentage of simultaneous contractions was higher and the percentage peristalsis was lower in patients with non-cardiac chest pain when compared with normal subjects by 24-h ambulatory manometry. Patients with non-cardiac chest pain had a lower SF-36 score when compared to controls.

CONCLUSIONS

Typical acid reflux symptoms are uncommon in Chinese patients with non-cardiac chest pain, but abnormal 24-h pH results, indicating gastro-oesophageal reflux, were found in 29% of patients. Ineffective contractions were more frequently found in patients with non-cardiac chest pain by 24-h ambulatory manometry, which may have a bearing on the impaired quality of life in such patients. Upper gastrointestinal investigations are useful for the evaluation of Chinese patients with non-cardiac chest pain.

Influence of pantoprazole on oesophageal motility, and bile and acid reflux in patients with oesophagitis

BACKGROUND

Reflux of duodeno-gastric juice into the oesophagus appears to be involved in the pathogenesis of both reflux oesophagitis and oesophageal adenocarcinoma. Although proton pump inhibitors have been shown to decrease acid reflux and heal oesophagitis, their effect on biliary reflux and motility is less clear.

AIM

To investigate whether pantoprazole also reduces bile reflux and whether this is paralleled by a change in oesophageal motility.

METHODS

Combined 24-h measurements of intraoesophageal bilirubin concentration, pH and pressure were performed in 18 symptomatic patients with endoscopically proven reflux oesophagitis before and on day 28 of treatment with pantoprazole, 40 mg/day, under standardized conditions. A reflux symptom score was determined initially and every 2 weeks thereafter. After 56 days on medication, a control endoscopy was performed.

RESULTS

The symptom score and the acid and bile reflux improved significantly, whereas the motility parameters did not change during the study period. Helicobacter pylori-positive patients had a significantly higher bile reflux time (32.1 +/- 4.3%) than H. pylori-negative patients (16.3 +/- 3.1%) (P=0.009). The endoscopic healing rate was 89%. The cough symptoms disappeared in three of four patients.

CONCLUSIONS

The proton pump inhibitor pantoprazole decreases both acid and bile reflux. The decrease of bile reflux cannot be explained by increased oesophageal clearance as oesophageal motility did not improve with therapy. Interestingly, H. pylori infection of the stomach was associated with higher levels of oesophageal bile reflux.

Esophageal motor disorders

Motor dysfunction is responsible for symptomatic illnesses both in the proximal skeletal muscle region and in the distal smooth muscle esophagus. Practical methods for diagnosing and treating oropharyngeal dysphagia continue to reach consensus. Achalasia, the most significant of the distal motor disorders, is of investigative interest because of the expanded armamentarium of treatment options. Minimally invasive surgical methods have taken an important foothold as a primary treatment of this disorder. Appreciation is growing for sensory dysfunction that accompanies distal motor disorders. Such dysfunction may help explain the observed discrepancies between symptoms and measurable motility abnormality.