Comparison of the impact of wireless versus catheter-based pH-metry on daily activities and study-related symptoms

Prolonged wireless pH monitoring increases diagnostic yield in patients with reflux symptoms and borderline 24-hour impedance pH

The Lyon Consensus defines pathological gastroesophageal reflux disease (GERD) as an acid exposure time (AET) greater than 6%, while AET less than 4% rules it out. AET between 4% and 6% is borderline. Prolonged wireless capsule pH monitoring may enhance GERD diagnosis, though it is not widely used in Latin America. This study aimed to categorize patients with borderline AET as GERD or non-GERD using prolonged wireless capsule pH monitoring, assess treatment response, and compare tolerance and interference with 24-hour impedance testing. Thirty-three patients with persistent reflux symptoms and borderline AET (4%-6%) from a 24-hour impedance study were included. Exclusions were prior esophageal surgery, major motility disorders, or unreliable impedance tests. A 96-hour off-proton pump inhibitor (PPI) wireless capsule pH monitoring was performed. Patients were categorized as GERD (AET >6% for 2+ days) or non-GERD (AET <4% for 4 days). Treatment was based on these categories, and GerdQ scores were assessed at baseline and 8 weeks. Three patients were excluded due to incomplete data. Of the 30 patients, 16 (53%) were classified as GERD, 6 (20%) as non-GERD, and 8 (27%) remained borderline. Wireless capsule monitoring provided a diagnosis in 73% of borderline cases. GERD patients responded well to PPI optimization, while non-GERD patients benefited from neuromodulation. Tolerance and daily activity interference were better with wireless capsule monitoring. Prolonged wireless capsule pH monitoring effectively categorized over 70% of borderline AET patients, leading to improved treatment outcomes with good patient tolerance.

KEY POINTS

Capsules for the Diagnosis and Treatment of Gastrointestinal Motility Disorders- A Game Changer

PURPOSE OF REVIEW

Over the last few decades, there have been remarkable strides in endoscopy and radiological imaging that have advanced gastroenterology. However, the management of neurogastroenterological disorders has lagged behind, in part handicapped by the use of catheter-based manometry that is both non-physiological and uncomfortable. The advent of capsule technology has been a game changer for both diagnostic and therapeutic applications.

RECENT FINDINGS

Here, we discuss several capsule devices that are available or under investigation. There are three technologies that are FDA approved. Wireless motility capsule measures pH and pressure and provides clinically impactful information regarding gastric, small intestine and colonic transit, without radiation that has been demonstrated to guide management of gastroparesis, dyspepsia and constipation. Wireless ambulatory pH monitoring capsule is currently the gold standard for assessing gastroesophageal acid reflux. In the therapeutics arena, an orally ingested vibrating capsule has been recently FDA approved for the treatment of chronic constipation, supported by a robust phase 3 clinical trial which showed significant improvement in constipation symptoms and quality of life. There are several capsules currently under investigation. Smart capsule bacterial detection system and Capscan® are capsules that can sample fluid in the small or large bowel and provide microbiome analysis for detection of small intestinal bacterial (SIBO) or fungal overgrowth (SIFO). Another investigational gas sensing capsule analyzing hydrogen, CO2, volatile fatty acids and capsule orientation, can measure regional gut transit time and luminal gas concentrations and assess gastroparesis, constipation or SIBO. Therapeutically, other vibrating capsules are in development. Innovations in capsule technology are poised to transform our ability to investigate gut function physiologically, and non-invasively deliver targeted treatment(s), thereby providing both accurate diagnostic information and luminally-directed, safe therapy.

Latin American consensus on diagnosis of gastroesophageal reflux disease

BACKGROUND

Diagnosing gastroesophageal reflux disease (GERD) can be challenging given varying symptom presentations, and complex multifactorial pathophysiology. The gold standard for GERD diagnosis is esophageal acid exposure time (AET) measured by pH-metry. A variety of additional diagnostic tools are available. The goal of this consensus was to assess the individual merits of GERD diagnostic tools based on current evidence, and provide consensus recommendations following discussion and voting by experts.

METHODS

This consensus was developed by 15 experts from nine countries, based on a systematic search of the literature, using GRADE (grading of recommendations, assessment, development and evaluation) methodology to assess the quality and strength of the evidence, and provide recommendations regarding the diagnostic utility of different GERD diagnosis tools, using AET as the reference standard.

KEY RESULTS

A proton pump inhibitor (PPI) trial is appropriate for patients with heartburn and no alarm symptoms, but nor for patients with regurgitation, chest pain, or extraesophageal presentations. Severe erosive esophagitis and abnormal reflux monitoring off PPI are clearly indicative of GERD. Esophagram, esophageal biopsies, laryngoscopy, and pharyngeal pH monitoring are not recommended to diagnose GERD. Patients with PPI-refractory symptoms and normal endoscopy require reflux monitoring by pH or pH-impedance to confirm or exclude GERD, and identify treatment failure mechanisms. GERD confounders need to be considered in some patients, pH-impedance can identify supragrastric belching, impedance-manometry can diagnose rumination.

CONCLUSIONS

Erosive esophagitis on endoscopy and abnormal pH or pH-impedance monitoring are the most appropriate methods to establish a diagnosis of GERD. Other tools may add useful complementary information.

Safety and Efficacy of Wireless pH Monitoring in Patients Suspected of Gastroesophageal Reflux Disease: A Systematic Review

INTRODUCTION

The primary aim of this systematic review was to determine the safety, technical efficacy, and effectiveness of 48-hour wireless pH monitoring (WM) for gastroesophageal reflux disease (GERD), compared with no pH monitoring in patients who failed to tolerate a catheter. In the absence of eligible studies, the secondary aim was to determine these performance characteristics for WM relative to catheter-based pH monitoring (CBM) in patients suspected of GERD, who are able to tolerate a catheter.

METHODS

A protocol was registered on the PROSPERO database (CRD42013005852) before conducting the systematic review, which included the study selection criteria, and critical appraisal methods. Several key databases were searched to identify eligible comparative studies.

RESULTS

Chest pain occurred more often with WM compared with CBM; however, other adverse events were reported less frequently with WM. Technical failures, mostly due to attachment failures and early capsule detachments, were 3 times higher with WM, compared with CBM, [pooled relative risk (from meta-analysis)=3.3; 95% confidence interval, 1.63-6.81; I=0%; P=0.012; k=8). The sensitivity and specificity of WM varied widely, depending on type of analysis, monitoring time, capsule placement, reference standard, and diagnostic threshold.

DISCUSSION

WM is usually better tolerated than CBM but has more technical problems. Test accuracy was highly variable between studies; therefore, conclusions could not be drawn regarding the performance of the 2 tests. To make meaningful comparisons between WM and CBM a consensus is needed on the diagnostic threshold for GERD, monitoring time, appropriate capsule positioning, and the reference standard.

Interference with daily activities and major adverse events during esophageal pH monitoring with bravo wireless capsule versus conventional intranasal catheter: a systematic review of randomized controlled trials

For three decades, ambulatory 24-hour intranasal pH monitoring has been the established gold standard for detecting acid reflux in patients with refractory gastroesophageal reflux disease. However, device-associated adverse events and unpleasant experiences, reported by patients during pH monitoring have led to the invention of more convenient pH monitors such as Bravo wireless capsule. To compare the interference with daily activities and major adverse events during pH monitoring with Bravo wireless capsule (Bravo) versus conventional intranasal catheter (catheter), PubMed, Cochrane Library, Clinical Trials.gov, and Google Scholar were searched up to March 20, 2015. Only randomized controlled trials in adult patients that compared the interference with routine daily activities and adverse events between Bravo and catheter pH monitors were included. After screening 574 articles, three unique studies with 167 patients met our inclusion criteria. The average age of patients enrolled in these studies was 51 years. Interference with normal daily activities was more in the catheter than Bravo group: 75 ± 5 versus 92 ± 2, P < 0.001 (Andrews et al, findings were reported as100 mm, mean visual analogue scale (VAS) ± standard error of the mean, 100 = completely normal); Wong et al. (mean ± standard error of the mean): 1.3 ± 0.2 versus 0.32 ± 0.1, P = 0.001 and Wenner et al. using 10 cm median VAS (Interquartile range),10 been the worst is 5.7 (2.3-8.0) compared to 0.7 (0.2-3.4), P < 0.0001, respectively. Overall adverse events were more in the catheter group than Bravo (39 ± 4 vs. 26 ± 4, P = 0.012 for Andrews et al. (100 been the worst) and 5.1 (2.0-6.6) vs. 2.1 (0.5-4.6), P < 0.001 for Wenner et al.). No overall adverse events recorded for Wong et al. Most patients in catheter group complained of nasal and throat symptoms. Significantly, runny nose in 24 out of 25 patients (96%) catheter versus 13 out of 25 (52%) Bravo, P = 0.001 and nose pain 15 out 25 (60%) versus 8 out of 25 patients (32%), P = 0.047, respectively for Wong et al. Andrews and Wenner et al also showed profound nasal discomforts in catheter group compared to Bravo (39 ± 3 vs. 10 ± 3, P < 0.001 and 6.5 (1.5-8.0) versus 0.2 (0.0-1.9), P < 0.0001, respectively. Throat symptoms reported in Wong et al. were mainly throat discomfort in catheter group 23 out of 25 patients (92%) versus Bravo 12 out of 25 (48%), P = 0.001 and throat pain catheter (12 out of 25 patients (48%) vs. Bravo 4 out of 25 (16%)), P = 0.032. This trend was also observed in Andrews et al. with profound throat discomfort in the catheter group 43 ± 4 compared to Bravo 19 ± 4, P < 0.001. Majority of the patients randomized to Bravo group reportedly perceived chest pain higher than those in catheter group; 9 out of 25 patients (36%) versus 2 out of 25 (8%), P = 0.037 in Wong et al. 29 ± 4 versus 14 ± 3, P = 0.001 for Andrews et al., 2.4 (0.3-5.9) versus 1.1 (0.3-2.9), P = 0.084 in Wenner et al. respectively (though not statistically significant). Bravo wireless capsule pH monitor interfered less with daily activities and adverse events were minimal compared to conventional intranasal catheter.

Wireless esophageal pH capsule for patients with gastroesophageal reflux disease: A multicenter clinical study

AIM: To investigate the feasibility and safety of pH capsule to monitor pH in patients with gastroesophageal reflux disease (GERD).

METHODS: Ninety-one patients with symptoms suggestive of GERD were enrolled in this study, 46 of whom were randomized to the pH capsule group; the remaining 45 patients used the conventional catheter and pH capsule simultaneously. The pH data and traces were recorded via automatic analysis, and capsule detachment was assessed using X-ray images. All of the patients were required to complete a questionnaire regarding tolerance with the capsule.

RESULTS: The capsules were successfully attached on the first attempt, and no early detachment of the capsules was observed. Compared to the 24-h pH data recorded with the conventional catheter, the data collected with the pH capsule showed no significant differences in 24-h esophageal acid exposure. The measurements of esophageal acid exposure over 24 h collected with the two devices showed a significant correlation (r² = 0.996, P < 0.001). Capsule detachment occurred spontaneously in 89 patients, and 2 capsules required endoscopic removal due to chest pain. The capsule was associated with less interference with daily activity.

CONCLUSION: The wireless pH capsule provides a feasible and safe method for monitoring gastroesophageal reflux and therefore may serve as an important tool for diagnosing GERD.

Comparative analysis of primary repair vs resection and anastomosis, with laparostomy, in management of typhoid intestinal perforation: results of a rural hospital in northwestern Benin

Background

Wireless esophageal pH monitoring system is an important approach for diagnosis of gastroesophageal reflux disease (GERD), the aim of this study is to test the tolerability and utility of the first wireless esophageal pH monitoring system made in China, and evaluate whether it is feasible for clinical application to diagnose GERD.

Methods

Thirty patients from Department of Gastroenterology of The First Affiliated Hospital of Chongqing Medical University who were suspected GERD underwent JSPH-1 pH capsule. The capsule was placed 5 cm proximal to the squamocolumnar junction (SCJ) by endoscopic determination, the data was recorded consecutively for 48 hours. Then all pH data was downloaded to a computer for analysis. The discomforts reported by patients were recorded.

Results

30 patients were placed JSPH-1 pH capsule successfully and completed 24-hour data recording, 29 patients completed 48-hour data recording. One patient complained of chest pain and required endoscopic removal. No complications and interference of daily activities were reported during data monitoring or follow-up period. 48-hour pH monitoring detected 15 patients of abnormal acid exposure, on day1 detected 9 patients, the difference had statistical significance (P<0.01). Positive symptom index (SI) was identified in 3 patients with normal pH data in both 24-hours. In total, 48-hour monitoring increased diagnosis of GERD in 9 patients.

Conclusion

48-hour esophageal pH monitoring with JSPH-1 wireless pH monitoring system is safe, well tolerated and effective. It can be feasible for clinical application to diagnose GERD.

Unsedated peroral wireless pH capsule placement vs. standard pH testing: a randomized study and cost analysis

BACKGROUND

Wireless capsule pH-metry (WC) is better tolerated than standard nasal pH catheter (SC), but endoscopic placement is expensive.

AIMS

to confirm that non-endoscopic peroral manometric placement of WC is as effective and better tolerated than SC and to perform a cost analysis of the available esophageal pH-metry methods.

METHODS

Randomized trial at 2 centers. Patients referred for esophageal pH testing were randomly assigned to WC with unsedated peroral placement or SC after esophageal manometry (ESM). Primary outcome was overall discomfort with pH-metry. Costs of 3 different pH-metry strategies were analyzed: 1) ESM + SC, 2) ESM + WC and 3) endoscopically placed WC (EGD + WC) using publicly funded health care system perspective.

RESULTS

86 patients (mean age 51 ± 2 years, 71% female) were enrolled. Overall discomfort score was less in WC than in SC patients (26 ± 4 mm vs 39 ± 4 mm VAS, respectively, p = 0.012) but there were no significant group differences in throat, chest, or overall discomfort during placement. Overall failure rate was 7% in the SC group vs 12% in the WC group (p = 0.71). Per patient costs ($Canadian) were $1475 for EGD + WC, $1014 for ESM + WC, and $906 for ESM + SC. Decreasing the failure rate of ESM + WC from 12% to 5% decreased the cost of ESM + WC to $991. The ESM + SC and ESM + WC strategies became equivalent when the cost of the WC device was dropped from $292 to $193.

CONCLUSIONS

Unsedated peroral WC insertion is better tolerated than SC pH-metry both overall and during placement. Although WC is more costly, the extra expense is partially offset when the higher patient and caregiver time costs of SC are considered.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT01364610.