Caution About Overinterpretation of Symptom Indexes in Reflux Monitoring for Refractory Gastroesophageal Reflux Disease

Slaughter, James C.; Goutte, Marion; Rymer, Jennifer A.; Oranu, Amanke; Schneider, Jonathan A.; Garrett, C. Gaelyn; Hagaman, David; Vaezi, Michael F.

doi:10.1016/j.cgh.2011.07.009

Cited by 124 publications

(120 citation statements)

References 25 publications

Supporting

Mentioning

115

Contrasting

Unclassified

Order By: Relevance

“…21 In agreement with both of these studies, we found that the majority of refluxes in PPI-refractory NERD patients were non-acid. Slaughter et al 22 concluded that SI/SAP indices could be over-interpreted unless patients with GERD refractory to PPI therapy had high rates of reflux. Others also agreed that tests like SI or SAP are preferable but sub-optimal in predicting response to high-dose PPI therapy.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic Utility of Impedance-pH Monitoring in Refractory Non-erosive Reflux Disease

Khan

Alaraj

Alsohaibani

et al. 2014

J Neurogastroenterol Motil

View full text Add to dashboard Cite

Background/Aims Approximately one-third of non-erosive reflux disease (NERD) patients are refractory to proton pump inhibitors (PPI) and face a therapeutic challenge. Therefore, it is important to differentiate between pathological and non-pathological reflux utilizing multichannel intraluminal impedance-pH (MII-pH) to analyze symptom-reflux association and diagnose true NERD versus hyper-sensitive esophagus (HE) and functional heartburn (FH). Herein, we evaluated the diagnostic yield of MII-pH in refractory NERD and sub-classified it based on quantity and quality of acid/non-acid reflux and reflux-symptom association. Methods Sixty symptomatic NERD patients on twice daily PPI for > 2 months were prospectively evaluated by MII-pH. Distal and proximal refluxes, bolus exposure time (BET), esophageal acid exposure time, symptom index (SI) and symptom association probability (SAP) were measured. Results Thirty-two (53%) patients had BET > 1.4% (MII-pH positive-true NERD), while 28 (47%) had BET < 1.4% (MII-pH negative NERD) where SI and SAP were negative in 15/60 (25%; categorized as FH) and SI or SAP were positive in 13/60 (22%; identified as HE). Thirty-eight (63%) patients reported significant SI or SAP parameters where > 80% of symptoms were associated with non-acid reflux. The number of distal refluxes in true NERD versus FH or HE were significantly different, but not between FH and HE. Conclusions Approximately 60% of refractory PPI NERD patients had positive reflux-symptom association, primarily due to non-acid reflux. Nearly half of NERD patients on PPI had normal MII-pH monitoring, sub-divided further into FH and HE equally.

show abstract

Section: Discussionmentioning

confidence: 99%

Diagnostic Utility of Impedance-pH Monitoring in Refractory Non-erosive Reflux Disease

Khan

Alaraj

Alsohaibani

et al. 2014

J Neurogastroenterol Motil

View full text Add to dashboard Cite

show abstract

“…For symptoms associated with reflux (91 % of patients), the symptom index was more likely to be positive in the obese groups (normal weight 30 %, obese groups 51-59 %). However, symptom indices (symptom index and symptom-associated probability) can be overinterpreted unless patients have high rates of reflux, which cannot be determined from this study [17].…”

mentioning

confidence: 92%

Gastroesophageal Reflux Disease and Obesity: Not as Simple as We May Think

Richter

2012

Dig Dis Sci

View full text Add to dashboard Cite

There is no doubt that, over the last 20 years, westernized countries are seeing a dramatic increase in obesity [1]. This comes at the same time that we are seeing the rates of H. pylori infection in these populations decreasing from 80 % to less than 20 % [2]. Therefore, healthy stomachs with more acid and the refluxogenic contributions of obesity are together leading to an epidemic of GERD and its complications. The epidemiologic data are conclusive that obesity increases the rates of reflux symptoms, frequency and severity of esophagitis, and the frequency of Barrett's esophagus and adenocarcinoma of the esophagus [3][4][5][6]. Recent studies are also suggesting that symptom relief from proton pump inhibitors (PPIs) is more difficult to obtain in the obese patient, with more failing ''on demand'' therapy and single dose PPIs [7,8]. Therefore, these patients may more frequently need to be on maintenance once or twice a day PPI regimens, possibly increasing the risk of long-term complications to this class of drugs.What are the physiologic mechanisms by which obesity contributes to GERD? Recent studies suggest that central or abdominal obesity, as measured by the waist-to-hip ratio, may be more important than general obesity as measured by the body mass index (BMI). For example, a large cross-sectional study of 80,111 individuals from the Kaiser Permanente health system found a significant relationship between increased abdominal diameter and reflux symptoms independent of BMI (OR 1.85, 95 % CI 1.55-2.21). Interestingly, this correlation was much more pronounced in the white population and in male subjects [9].In theory, central obesity should raise intragastric pressure, thereby predisposing to reflux. This was proven in a seminal study by Pandolfino et al.[10] where they studied 285 patients (81 overweight: BMI 25-30 kg/m 2 ; and 75 obese: BMI [ 30 kg/m 2 ) with high resolution manometry. They found that the pressure morphology within and across the esophagogastric junction is altered in obesity in a fashion that would promote the flow of gastric juices into the esophagus. Particularly, during the inspiratory phase of respiration, increased intragastric pressure and the gastroesophageal pressure gradient (GEPG) were strongly correlated with increased BMI. Both factors correlated even more strongly with waist circumference, suggesting that this is the mediator in the causal pathway of the BMI effect. There was a dose-dependent relationship such that the higher the BMI and waist circumference, the greater the intragastric pressure and GEPG. From an anatomic standpoint, obesity was also associated with increased axial separation between the LES and extrinsic crural diaphragm, an objective measure of the disruption of the esophagogastric junction (EGJ) culminating in the development of hiatal hernia. This confirms older studies where obesity was a significant independent risk factor for hiatal hernia, especially in whites [11]. Not to be forgotten in these mechanistic studies, a prospective study of 84 patients o...

show abstract

“…The Chicago Classification V3.0 approved the term "IEM", which is frequently used in conventional manometry [30] . In this recent Chicago Classification version, IEM was defined 75 February 15, 2016|Volume 7|Issue 1| WJGP|www.wjgnet.com …”

Section: High Resolution Manometrymentioning

confidence: 99%

“…The drawbacks of MIIpH are mainly due to the day-to-day variability of the test [71][72][73] . Additionally, the reflux-symptom correlation in patients with GERD who do not respond to PPI therapy is actually also calculated by the SI or SAP if its validity is still uncertain [74,75] . Recently Zerbib et al [76] reported that MII-pH findings were not always able to predict the response to PPIs in patients with typical reflux-related symptoms when the test is performed off PPI therapy.…”

Section: Multichannel Intraluminal Impedance and Phmentioning

confidence: 99%

Esophageal testing: What we have so far

Bortoli¹,

Martinucci²,

Bertani³

et al. 2016

WJGP

View full text Add to dashboard Cite

Gastroesophageal reflux disease (GERD) is a common disorder of the gastrointestinal tract. In the last few decades, new technologies have evolved and have been applied to the functional study of the esophagus, allowing for the improvement of our knowledge of the pathophysiology of GERD. High-resolution manometry (HRM) permits greater understanding of the function of the esophagogastric junction and the risks associated with hiatal hernia. Moreover, HRM has been found to be more reproducible and sensitive than conventional water-perfused manometry to detect the presence of transient lower esophageal sphincter relaxation. Esophageal 24-h pH-metry with or without combined impedance is usually performed in patients with negative endoscopy and reflux symptoms who have a poor response to anti-reflux medical therapy to assess esophageal acid exposure and symptom-reflux correlations. In particular, esophageal 24-h impedance and pH monitoring can detect acid and non-acid reflux events. EndoFLIP is a recent technique poorly applied in clinical practice, although it provides a large amount of information about the esophagogastric junction. In the coming years, laryngopharyngeal symptoms could be evaluated with up and coming non-invasive or minimally invasive techniques, such as pepsin detection in saliva or pharyngeal pH-metry.

show abstract

Caution About Overinterpretation of Symptom Indexes in Reflux Monitoring for Refractory Gastroesophageal Reflux Disease

Cited by 124 publications

References 25 publications

Diagnostic Utility of Impedance-pH Monitoring in Refractory Non-erosive Reflux Disease

Diagnostic Utility of Impedance-pH Monitoring in Refractory Non-erosive Reflux Disease

Gastroesophageal Reflux Disease and Obesity: Not as Simple as We May Think

Esophageal testing: What we have so far

Contact Info

Product

Resources

About