Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring

Abstract

Background and aims: Empiric proton pump inhibitor (PPI) trials have become increasingly popular leading to gastroenterologists frequently evaluating gastro-oesophageal reflux disease (GORD) patients only after they have ''failed'' PPI therapy. Combined multichannel intraluminal impedance and pH (MIIpH) monitoring has the ability to detect gastro-oesophageal reflux (GOR) episodes independent of their pH and evaluate the relationship between symptoms and all types of GOR. Using this technique, we aimed to characterise the frequency of acid and non-acid reflux (NAR) and their relationship to typical and atypical GOR symptoms in patients on PPI therapy. Methods: Patients with persistent GORD symptoms referred to three centres underwent 24 hour combined MII-pH monitoring while taking PPIs at least twice daily. Reflux episodes were detected by impedance channels located 3, 5, 7, 9, 15, and 17 cm above the lower oesophageal sphincter (LOS) and classified into acid or non-acid based on pH data from 5 cm above the LOS. A positive symptom index (SI) was declared if at least half of each specific symptom events were preceded by reflux episodes within five minutes. Results: A total of 168 patients (103 (61%) females and 65 (39%) males; mean age 53 (range 18-85) years) underwent combined MII-pH monitoring while taking PPIs at least twice daily. One hundred and forty four (86%) patients recorded symptoms during the study day and 24 (15%) patients had no symptoms during testing. Sixty nine (48%) symptomatic patients had a positive SI for at least one symptom (16 (11%) with acid reflux and 53 (37%) with NAR) and 75 (52%) had a negative SI. A total of 171 (57%) typical GORD symptoms were recorded, 19 (11%) had a positive SI for acid reflux, 52 (31%) for NAR, and 100 (58%) had a negative SI. One hundred and thirty one (43%) atypical symptoms were recorded, four (3%) had a positive SI for acid reflux, 25 (19%) had a positive SI for NAR, and 102 (78%) had a negative SI. Conclusion: Combined MII-pH identifies the relation of reflux of all types to persistent symptoms and the importance of NAR in patients taking PPIs.

MULTICHANNEL INTRALUMINAL IMPEDANCE AND pH

“…This technology shed new light in investigation of patients with persistent symptoms despite adequate esophageal acid exposure control by proton pump inhibitors (PPI) (5) . In this regard, MII-pH monitoring has improved the diagnostic yield of GERD patients as it provides better identification of patients with functional heartburn.…”

Esophageal Acidification During Nocturnal Acid-breakthrough with Ilaprazole Versus Omeprazole in Gastroesophageal Reflux Disease

“…While 40% of symptoms were related to non-acid reflux, only 10% of symptoms were related to acid reflux. 12 Vela et al 11 suggested that, on omeprazole, the percentage of acid reflux decreased from 45% to 3% but that of non-acid reflux increased from 55% to 97%. 11 Though PPIs are highly effective in neutralizing gastric acid and preventing esophageal acidification, non-acidic liquid reflux remains to be a significant problem in a large proportion of patients.…”

“…This is consistent with other studies that investigated non-acidic reflux in patients who were non-responsive to PPI therapy. [23][24][25] Mainie et al 12 performed impedance pH monitoring in 168 PPI non-responsive GERD patients while on twice daily PPI. While 40% of symptoms were related to non-acid reflux, only 10% of symptoms were related to acid reflux.…”

“…10 Though PPIs prevent abnormal esophageal acidification, studies using impedance monitoring suggested that frequency of non-acidic reflux increases on PPI therapy resulting in persistent symptoms. 11,12 However, the association between degree of gastric acid suppression, occurrence of non-acidic volume reflux and symptoms while on PPI therapy has not been studied, especially in the Asian population.…”

Reflux inhibitors – new therapy of gastroesophageal reflux disease

“…Większość Grażyna Jurkowska, Agnieszka Świdnicka-Siergiejko, Andrzej Dąbrowski chorych nieodpowiadających na leczenie stanowią pacjenci z nienadżerkową postacią choroby refluksowej (non-erosive reflux disease -NERD) i zgagą czynnościo-wą. Dzięki zastosowaniu 24-godzinnego pomiaru pH i impedancji wewnątrzprzełykowej wykazano, że w grupie chorych z objawami refluksowymi, utrzymującymi się pomimo leczenia PPI w dawce standardowej stosowanej 2 razy dziennie, 50-60% osób ma objawy niezwiązane z refluksem, 10% ma objawy związane z refluksem kwaśnym, a 30-40% z refluksem niekwaś -nym [4]. Choć PPI są podstawą leczenia GERD, wyniki tych badań sugerują, że potrzebne są nowe metody.…”