Ninety-six-hour wireless oesophageal pH monitoring following proton pump inhibitor administration in NERD patients

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.

Current advances in the diagnosis and treatment of nonerosive reflux disease

Nonerosive reflux disease (NERD) is a distinct pattern of gastroesophageal reflux disease (GERD). It is defined as a subcategory of GERD characterized by troublesome reflux-related symptoms in the absence of esophageal mucosal erosions/breaks at conventional endoscopy. In clinical practice, patients with reflux symptoms and negative endoscopic findings are markedly heterogeneous. The potential explanations for the symptom generation in NERD include microscopic inflammation, visceral hypersensitivity (stress and sleep), and sustained esophageal contractions. The use of 24-hour esophageal impedance and pH monitoring gives further insight into reflux characteristics and symptom association relevant to NERD. The treatment choice of NERD still relies on acid-suppression therapy. Initially, patients can be treated by a proton pump inhibitor (PPI; standard dose, once daily) for 2–4 weeks. If initial treatment fails to elicit adequate symptom control, increasing the PPI dose (standard dose PPI twice daily) is recommended. In patients with poor response to appropriate PPI treatment, 24-hour esophageal impedance and pH monitoring is indicated to differentiate acid-reflux-related NERD, weakly acid-reflux-related NERD (hypersensitive esophagus), nonacid-reflux-related NERD, and functional heartburn. The response is less effective in NERD as compared with erosive esophagitis.

Prolonged 2-day esophageal pH-metry with impedance monitoring improves symptom-reflux association analysis

BACKGROUND

The day-to-day variability in the number of reflux episodes and symptoms of gastro-esophageal reflux disease is high; therefore, the assessment of reflux disease based on 24-h monitoring may be inaccurate.

AIMS

The aim of the study was to compare prolonged (48 h) and standard (24 h) pH-impedance monitoring (pH-MII).

METHODS

Fifty-four consecutive patients with typical and atypical reflux symptoms underwent 48-h pH-MII. Acid exposure time (AET), total number of reflux episodes (TR), number of symptoms, and symptom association probability (SAP) were analyzed after the first 24 h and compared with the results obtained during 48 h of monitoring.

RESULTS

The differences between the fractions of patients with normal and abnormal total AET and TR on both days were not significant. The percentage of patients with positive SAP was 57.9% at 24 h and 71.9% at 48 h (difference: 14.81%, 95% CI 0.7-21.29, P<0.05). There were ten patients (10/54, 18.5%) with positive SAP after 48 h that had been negative in the first 24 h. In comparison to 24 h monitoring, patients reported a significantly increased number of various symptoms correlated with reflux after 48 h.

CONCLUSIONS

Extending pH-MII monitoring to 48 h does not improve the detection of abnormal acid exposure. However, it does increase the fraction of patients with positive symptom-reflux association by as much as 18.5%.

Reflux and sex: what drives testing, what drives treatment?

Gastroesophageal reflux (GER) affects ∼10-20% of American adults. Although symptoms are equally common in men and women, we hypothesized that sex influences diagnostic and therapeutic approaches in patients with GER. PubMed database between 1997 and October 2011 was searched for English language studies describing symptoms, consultative visits, endoscopic findings, use and results of ambulatory pH study, and surgical therapy for GER. Using data from Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, we determined the sex distribution for admissions and reflux surgery between 1997 and 2008. Studies on symptoms or consultative visits did not show sex-specific differences. Even though women are less likely to have esophagitis or Barrett's esophagus, endoscopic studies enrolled as many women as men, and women were more likely to undergo ambulatory pH studies with a female predominance in studies from the US. Surgical GER treatment is more commonly performed in men. However, studies from the US showed an equal sex distribution, with Nationwide Inpatient Sample data demonstrating an increase in women who accounted for 63% of the annual fundoplications in 2008. Despite less common or severe mucosal disease, women are more likely to undergo invasive diagnostic testing. In the US, women are also more likely to undergo antireflux surgery. These results suggest that healthcare-seeking behavior and socioeconomic factors rather than the biology of disease influence the clinical approaches to reflux disease.

Barrett's esophagus: proton pump inhibitors and chemoprevention II

The following on proton pump inhibitors (PPIs) and chemoprevention in relation to Barrett's esophagus includes commentaries on 48-h pH monitoring, pH-impedence, bile acid testing, dyspepsia, long/short segment Barrett's esophagus, nonerosive reflux disease (NERD), functional heartburn, dual-release delivery PPIs, immediate-release PPIs, long-term PPI use, prokinetic agents, obesity, baclofen, nocturnal acid breakthrough, nonsteroidal anti-inflammatory drugs (NSAIDs), and new PPIs.

Diagnostic yield of 96-h wireless pH monitoring and usefulness in patients' management

OBJECTIVE

To get insight into usefulness of 96-h wireless monitoring in diagnosis of gastro-esophageal reflux disease (GERD) and in patients' management.

MATERIAL AND METHODS

51 patients who underwent 96-h wireless and 51 matched patients who underwent 24-h traditional pH monitoring were enrolled and retrospectively contacted with a structured telephone interview.

RESULTS

In the wireless group, the 96-h recording improved (p < 0.05) the diagnostic yield compared with the first 48-h recording by allowing Symptom Association Probability to be measured in eight more patients and by decreasing indeterminate tests from 11 to 5. After pH monitoring, concordance between results of the test and treatment for GERD was higher in the wireless compared with the traditional group, 78% versus 58% of the patients (p < 0.05). Both improvement/disappearance of the clinically relevant symptom and satisfaction (score of 1-10) at time of the telephone interview were however similar in the two groups, 73% versus 65% and 7.0 versus 6.5.

CONCLUSIONS

Wireless pH monitoring prolonged to 96 h increased the likelihood to exclude/confirm GERD as the cause of the clinically relevant symptoms in those patients with an indeterminate result for GERD after the first 48 h. Outcome was however similar to the one of traditional pH monitoring.

Guidance on the use of over-the-counter proton pump inhibitors for the treatment of GERD

OBJECTIVE

The aim of this paper was to develop a guideline on the over-the-counter management of gastroesophageal reflux disease with proton pump inhibitors (i.e. omeprazole).

SETTING

A meeting of internationally renowned gastroenterologists in January 2009, in Berlin, Germany.

METHODS

An expert panel group of gastroenterologists convened to develop a consensus-based algorithm for pharmacists for over-the-counter (OTC) treatment with proton pump inhibitors (PPIs). Key considerations were the short-term safety and efficacy of PPIs, and the extent of the risk to the sufferer, owing to the treatment not being controlled by a physician. Main outcome measures A consensus-based treatment algorithm for the OTC management of gastroesophageal reflux disease and evidence-based guidance on the use of OTC PPIs.

RESULTS

As defined by the treatment algorithm, the pharmacist should first confirm the diagnosis based on the presence of typical symptoms and secondly, as a result, rule out general practitioner referral. The third step focuses on the nature, severity and frequency of the symptoms--the patients who might have the highest benefit from a short course (14 days) of OTC PPIs are those with less than three episodes of heartburn and/or acid regurgitation per week. Patients who have three or more episodes per week can use the OTC PPIs but should also be encouraged to visit a physician, and those who already have a diagnostic work-up can use proton pump inhibitors as rescue treatment if they are known responders. Guidance for pharmacists, in the form of questions and answers, summarises the current published clinical experience with PPIs in terms of their efficacy and safety, and optimal treatment schedule. Conclusions Gastroesophageal reflux disease imposes a considerable burden on sufferers. Owing to their accepted efficacy and safety, PPIs are becoming popular as OTC options for the treatment of gastroesophageal reflux disease symptoms such as heartburn and acid regurgitation. Effective self-management of gastroesophageal reflux disease with OTC PPIs, e.g. omeprazole, could lead to lasting freedom from symptoms and improved quality of life for sufferers.

Efficacy of three different dosages of esomeprazole in the long-term management of reflux disease: a prospective, randomized study, using the wireless Bravo pH system

OBJECTIVES

Gastroesophageal reflux disease (GERD) is a chronic condition that usually requires long-term maintenance therapy with proton-pump inhibitors (PPIs). In clinical practice, patients receive PPIs at the lowest dose to control symptoms. However, it is not known whether this approach adequately controls acidic esophageal reflux. We sought to investigate the efficacy of three different dosages of esomeprazole in patients receiving maintenance therapy for GERD, using the Bravo pH system.

METHODS

Patients with a previous history of erosive esophagitis A or B (LA classification) that was healed at the time of enrollment or endoscopy-negative reflux disease (ENRD), documented with an abnormal pH study, were randomized to receive maintenance therapy with esomeprazole 40 mg twice daily (group A), once daily (group B), or every other day (group C). Intraesophageal pH was monitored for two consecutive days using the Bravo wireless system, 30 days after randomization. The parameters subjected to analysis were percent of total time pH<4 and the De Meester score.

RESULTS

The pH results from 73 patients (group A=24, group B=24, group C=25 patients) were subjected to final analysis. On the first day of the study, the mean (+/-s.d.) percent of total time pH <4 and the De Meester score were group A: 0.9(1.2) and 4.1(4.0); group B: 1.5(1.6) and 7.0(6.9); group C: 1.3(1.0) and 6.0(3.3), respectively (P=0.262 and 0.134, respectively). On the second day of the study, the corresponding values were group A: 0.7(1.0) and 3.9(5.9); group B: 1.5(1.8) and 6.4(6.6); group C: 7.0(4.4) and 29.4(19.4), respectively. The difference was statistically significant (P<0.0001 and <0.0001, respectively). Further analysis showed that patients not receiving PPI had a significantly higher mean percent of total time pH<4 and De Meester score as compared with patients on PPI once or twice daily (P<0.001 and <0.001 respectively).

CONCLUSIONS

The administration of esomeprazole 40 mg every other day does not control acidic esophageal reflux on the day off PPI. Esomeprazole 40 mg once daily effectively controls reflux of acid in patients with history of mild esophagitis or ENRD, whereas doubling the dose does not seem to confer any further advantage.

Nonerosive Reflux Disease (NERD) - An Update

Recognizing nonerosive reflux disease (NERD) as a distinct presentation of gastroesophageal reflux disease (GERD) was one of the most important developments in the field of GERD in the last decade. Whilst the definition of NERD has not changed significantly over the years, the disorder accounts for the majority of the GERD patients and those who failed proton pump inhibitor (PPI) treatment. Recent developments in NERD focused primarily on understanding the pathophysiology and natural history. The introduction of esophageal impedance + pH has led to the assessment of other forms of gastroesophageal reflux in causing NERD. Therapeutic modalities still focus on acid suppression, but there is growing recognition that other therapeutic strategies should be considered in NERD.