Early referral for 24-h esophageal pH monitoring may prevent unnecessary treatment with acid-reducing medications

Abstract

BACKGROUND Gastroesophageal reflux disease (GERD) affects nearly 25% of adults, however an objective diagnosis is rarely established. We hypothesized that patients’ symptoms and response to acid-reducing therapy are poor predictors of the outcome of 24-hour esophageal pH monitoring. METHODS A review of 24-hour esophageal pH monitoring studies performed at an ambulatory tertiary care center between 2004 and 2011 was performed. Demographics, type of GERD symptoms, and duration and response to acid-reducing medications prior to referral for pH monitoring were collected. DeMeester score, symptom sensitivity index (SSI), and symptom index (SI) were tabulated and compared to the patients’ symptoms and response to medical therapy. RESULTS One hundred patients were included. Of all reported symptoms, only heartburn was more common in patients with positive DeMeester scores, but there were no correlations between any symptoms and SSI or SI scores. Sixty-nine percent of patients with esophageal symptoms had a positive DeMeester score compared to only 29% of patients with extraesophageal symptoms (p<0.01). Esophageal symptoms and endoscopic evidence of GERD significantly increased the likelihood of having a positive DeMeester score, but they had no influence on SSI or SI scores. There was no correlation between response to acid-reducing medications and DeMeester, SSI or SI scores. A total of 536 person-years of acid-reducing medications were prescribed to the study population, of which 151 (28%) were prescribed to patients who had a negative pH study. CONCLUSION Extraesophageal symptoms and response to empiric trials of acid-reducing medications are poor predictors of the presence of GERD and the DeMeester score is more likely to identify GERD in patients who met other empiric diagnostic criteria than either SSI or SI. Early referral for 24-hour esophageal pH monitoring may avoid lengthy periods of unnecessary medical therapy.

Esophageal Mucosal Admittance: A New Technique to Diagnose Gastroesophageal Reflux Disease – Is It Feasible?

“… 20 The DeMeester score was automatically calculated from a six-item scoring system (percent and the total amount of time esophageal pH <4 in upright and supine positions, number of reflux episodes, number of reflux episodes more than five minutes, and the duration of the longest episode). 21 …”

Potential role of new technological innovations in non-variceal hemorrhage

“…This is to ensure enough esophageal power to break the magnetic bonds and allow the device to open, allowing for normal swallowing[23]. Potential surgical candidates for MSA are those GERD patients (14-20%[57] of U.S. population[60]) who, despite optimal medical management, continue to experience symptoms of heartburn and/or uncontrolled regurgitation [medically managed and refractory to lifestyle and pharmacological interventions (6.0%-24.0%)[22,55,61,62]], have abnormal pH off PPI (61.0%-71.0%)[63-67], and do not have esophageal dysmotility (88.0%-96.0%)[68,69]. Overall, among patients with GERD, the total eligible population for MSA is estimated to be in the 2.2%-2.4% range (Figure 2).…”

“…Ambulatory esophageal pH monitoring is critical to establish a diagnosis of GERD[75]. pH monitoring directly measures the extent and frequency with which acid refluxes into the esophagus and has been shown to be the most sensitive and specific test to objectively diagnose GERD[57,63]. pH-impedance monitoring also measures the proximal extent of reflux and can differentiate between acidic, weakly-acidic and non-acid reflux.…”