Comparative study of two modes of gastroesophageal reflux measuring: conventional esophageal pH monitoring and wireless pH monitoring

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.

The assessment of patients with non-erosive gastroesophageal reflux disease by using the Bravo® pH monitoring system

Background and aim: Gastroesophageal reflux disease (GERD) is a common disease in the world. GERD is always treated with drugs. The Bravo® wireless pH monitoring system is a good technique. The Bravo® may affect increasing the specificity and sensitivity in the diagnosis of GERD with its 48-hour recording feature. In this study, we aimed to assess the diagnostic performance of the Bravo® pH monitoring system in patients with non-erosive GERD. Materials and Methods: Patients with non-erosive reflux disease (normal endoscopy) whose symptoms persisted after PPI treatment (at least two months) were included in the study. All patients had upper gastrointestinal system endoscopies performed in our clinic between January 2013 and December 2019. All patients had a 48-hour Bravo® wireless pH monitoring record. Results: Twenty-three patients (M: 18 (78.3%; Age: 35.7 ± 11) were included in the study. All patients completed the 2-day recording protocol. During and after the procedure, no patient showed any adverse effects of the Bravo® procedure. We diagnosed GERD in 13 of 23 patients by Bravo® capsule. According to the Bravo® pH-meter recordings; Total time pH < 4 (minute) was 187 ± 190, the total number of refluxes was 90 ± 61, the percentage of time with pH < 4 was 7.1 ± 7.22, the number of long reflux events were 8.1 ± 8, the duration of the longest reflux episode during pH < 4 (minute) was 31 ± 49, the Demeester score was 20.8 ± 19.3 detected. Conclusion: Based on the results of the current study, the Bravo® pH monitoring system is a practical and effective diagnostic technique for non-erosive GERD. Further prospective studies would be useful for comparing the differences between 24-hour and 48-hour pH recording results.

WIRELESS PH MONITORING AND CONVENTIONAL ESOPHAGEAL PH MONITORING: COMPARATIVE STUDY OF DISCOMFORT, LIMITATIONS IN DAILY ACTIVITIES AND COMPLICATIONS

Background:

The catheter of the esophageal pH monitoring is associated with nasal and throat discomfort, and different behave in patients. The capsule of the wireless pH monitoring may cause chest pain and complications.

Aim:

To compare the wireless and conventional pH monitoring concerning the degree of discomfort and limitations in daily activities, complications, ability to diagnose pathological reflux, and costs.

Methods: Twenty-five patients with symptoms of gastroesophageal reflux were prospectively submitted, in a simultaneous initial period, to 24-hour catheter esophageal pH monitoring and 48-hour wireless system. After removing each system, patients underwent a specific clinical questionnaire.

Results:

Fifteen patients (60%) pointed a higher discomfort in the introduction of the capsule (p=0.327). Discomfort and limitations in daily activities were lower on 2^nd day (p<0.05); however, continued to be expressive (32% to 44%). Chest pain occurred in 13 (52%) patients. The diagnostic gain of pathological reflux was 12% with the wireless system (p=0.355).

Conclusions:

1) There is no significant difference between the discomfort mentioned in the introduction of the capsule and the catheter; 2) during reflux monitoring, the wireless system provides significant less discomfort and limitations in daily activities; 3) there is no significant difference between the two methods in the ability to diagnose pathological reflux; 4) wireless pH monitoring has higher cost.

PROLONGED GASTROESOPHAGEAL REFLUX MONITORING BY IMPEDANCE-PHMETRY: A REVIEW OF THE SUBJECT PONDERED WITH OUR EXPERIENCE WITH 1,200 CASES

BACKGROUND

Prolonged monitoring increased our knowledge on gastroesophageal reflux (GER), and the disease became known as gastroesophageal reflux disease (GERD). Prolonged reflux monitoring permits the diagnosis of GERD when endoscopic findings are not enough to characterize it.

OBJECTIVE

The objective of this paper is to review the current knowledge on impedance-pH monitoring, taking into account the published literature and the authors experience with 1,200 exams.

METHODS

The different types of prolonged reflux monitoring, namely: conventional pHmetry, catheter-free pHmetry and impedance-pHmetry will be briefly described. The new possibilities of evaluation with impedance-pHmetry are emphasized, namely: the study of symptomatic patients in use of proton pump inhibitors (PPIs); evaluation of patients with symptoms suggestive of GERD although with normal endoscopy and normal pHmetry, diagnostic elucidation of patients with atypical symptoms or supra-esophageal symptoms, mainly chronic cough, study of patients complaining of belch, differentiating gastric and supra-gastric belching, and the proper work-up before anti-reflux surgery.

RESULTS

When impedance was associated to pH monitoring, an impressive technological evolution became apparent, when compared to pH monitoring alone. The main advantages of impedance-pHmetry are: the ability to detect all types of reflux: acid, non-acid, liquid, gaseous. In addition, other important measurements can be made: the ability of the esophagus in transporting the bolus, the measurement of basal mucosal impedance and the evaluation of primary peristalsis post reflux.

CONCLUSION

Impedance-pHmetry is a promising method, with great advantages over conventional pHmetry. The choice between these two types of monitoring should be very judicious. The authors suggest the importance of careful evaluation of each reflux episode by the physician responsible for the examination, necessary for the correct interpretation of the tracings.

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.

Pharmacokinetics and Acid Suppressant Efficacy of Esomeprazole after Intravenous, Oral, and Subcutaneous Administration to Healthy Beagle Dogs

Background

Esomeprazole is an S‐enantiomer of omeprazole that has favorable pharmacokinetics and efficacious acid suppressant properties in humans. However, the pharmacokinetics and effects on intragastric pH of esomeprazole in dogs have not been reported.

Objective

To determine the pharmacokinetics of esomeprazole administered via various routes (PK study) and to investigate the effect of esomeprazole on intragastric pH with a Bravo pH monitoring system (PD study).

Animals

Seven adult male Beagle dogs and 5 adult male Beagle dogs were used for PK and PD study, respectively.

Methods

Both studies used an open, randomized, and crossover design. In the PK study, 7 dogs received intravenous (IV), subcutaneous (SC), and oral doses (PO) of esomeprazole (1 mg/kg). Each treatment period was separated by a washout period of at least 10 days. Esomeprazole plasma concentrations were measured by HPLC/MS/MS. In the efficacy study, intragastric pH was recorded without medication (baseline pH) and following IV, SC, and PO esomeprazole dosing regimens (1 mg/kg) in 5 dogs.

Results

The bioavailability of esomeprazole administered as PO enteric‐coated granules and as SC injections was 71.4 and 106%, respectively. The half‐life was approximately 1 hour. Mean ± SD percent time intragastric pH was ≥3 and ≥4 was 58.9 ± 21.1% and 40.9 ± 17.3% for IV group, 75.8 ± 16.4% and 62.7 ± 17.7% for SC group, 88.2 ± 8.9% and 82.5 ± 7.7% for PO group, and 12.5 ± 3.6% and 3.7 ± 1.8% for baseline. The mean percent time with intragastric pH was ≥3 or ≥4 was significantly increased regardless of the dosing route (P < .05).

Conclusion

The PK parameters for PO and SC esomeprazole administration were favorable, and esomeprazole significantly increased intragastric pH after IV, PO, and SC administration. IV and SC administration of esomeprazole might be useful when PO administration is not possible. No significant adverse effects were observed.

Diagnosis and management of gastroesophageal reflux disease

INTRODUCTION

Gastroesophageal reflux disease (GERD) is probably one of the most prevalent diseases in the world that also compromises the quality of life of the affected significantly. Its incidence in Brazil is 12%, corresponding to 20 million individuals.

OBJECTIVE

To update the GERD management and the new trends on diagnosis and treatment, reviewing the international and Brazilian experience on it.

METHOD

The literature review was based on papers published on Medline/Pubmed, SciELO, Lilacs, Embase and Cochrane crossing the following headings: gastroesophageal reflux disease, diagnosis, clinical treatment, surgery, fundoplication.

RESULTS

Various factors are involved on GERD physiopathology, the most important being the transient lower esophageal sphincter relaxation. Clinical manifestations are heartburn, regurgitation (typical symptoms), cough, chest pain, asthma, hoarseness and throat clearing (atypical symptoms), which may be followed or not by typical symptoms. GERD patients may present complications such as peptic stenosis, hemorrhage, and Barrett's esophagus, which is the most important predisposing factor to adenocarcinoma. The GERD diagnosis must be based on the anamnesis and the symptoms must be evaluated in terms of duration, intensity, frequency, triggering and relief factors, pattern of evolution and impact on the patient's quality of life. The diagnosis requires confirmation with different exams. The goal of the clinical treatment is to relieve the symptoms and surgical treatment is indicated for patients who require continued drug use, with intolerance to prolonged clinical treatment and with GERD complications.

CONCLUSION

GERD is a major digestive health problem and affect 12% of Brazilian people. The anamnesis is fundamental for the diagnosis of GERD, with special analysis of the typical and atypical symptoms (duration, intensity, frequency, triggering and relief factors, evolution and impact on the life quality). High digestive endoscopy and esophageal pHmetry are the most sensitive diagnosctic methods. The clinical treatment is useful in controlling the symptoms; however, the great problem is keeping the patients asymptomatic over time. Surgical treatment is indicated for patients who required continued drug use, intolerant to the drugs and with complicated forms of GERD.

The value of early wireless esophageal pH monitoring in diagnosing functional heartburn in refractory gastroesophageal reflux disease

BACKGROUND AND AIMS

It is difficult to differentiate functional heartburn from proton pump inhibitor (PPI) failure. The aims of this study were to assess the role of early wireless esophageal pH monitoring in patients referred with gastroesophageal reflux disease (GERD) and to identify differences in the clinical spectrum among GERD subtypes.

METHODS

We enrolled consecutive referred patients with suspected GERD. After endoscopy on the first visit, all underwent wireless esophageal pH monitoring when off the PPI.

RESULTS

Two hundred thirty patients were enrolled. These patients were classified into a reflux esophagitis group (20, 8.7 %) and a normal endoscopic findings group (210, 91.3 %). Among the 210 patients in the normal endoscopic findings group, 63 (27.4 %) were diagnosed with pathological reflux, 35 (15.2 %) with hypersensitive esophagus, 87 (37.8 %) with normal acid exposure with negative symptom association, and 25 (10.9 %) with test failure. These groups did not differ in age, body mass index, smoking habit, alcohol consumption, symptom severity, quality of life, presence of atypical symptoms, overlap with irritable bowel syndrome, and the frequency of somatization, depression, and anxiety. PPI responses were evaluated in 135 patients. Fifty patients (37.0 %) were not responsive to the 4-week treatment; 26 (19.3 %) were diagnosed with refractory non-erosive gastroesophageal disease, and 24 (17.8 %) with functional heartburn. The demographics and clinical and psychological characteristics did not differ between the two groups.

CONCLUSIONS

Demographic characteristics and symptom patterns alone cannot differentiate functional heartburn from various subtypes of GERD. Wireless esophageal pH monitoring should be considered for the initial evaluation of GERD in the tertiary referral setting.

Gastroesophageal reflux, dental erosion, and halitosis in epidemiological surveys: a systematic review

In published studies, it has been suggested that dental wear is associated with gastroesophageal reflux disease (GERD). This systematic review was carried out to evaluate the association of GERD, dental erosion, and halitosis and to compare the indices adopted in epidemiological surveys. The Medline database (until October, 2011) was searched systematically to identify studies evaluating the prevalence of oral alterations, such as dental erosion and halitosis, in patients with GERD symptoms. Two reviewers analyzed all reports and the selected studies were evaluated according to the quality of evidence, using the validated Newcastle-Ottawa Quality Assessment Scale. Full-text copies of a total of 32 publications were obtained in duplicate. Sixteen publications were identified among the citations in the Bibliographic lists of studies that fulfilled the exclusion/inclusion criteria and quality of evidence. The relationship between dental erosion and GERD patients was significant in only seven studies. According to three studies, halitosis could be one of several extraesophageal symptoms or manifestations in GERD patients. In one study, it was found that the mucosa of GERD patients was significantly more acidic in comparison with that of the control group. This systematic review showed that there is a relationship between GERD and oral diseases (dental erosion and halitosis). The epidemiological surveys used different indices to analyze GERD and dental erosion. Further research could investigate the best method for assessing the two diseases.