Majority of symptoms in esophageal reflux PPI non‐responders are not related to reflux

Abstract

Background Genesis of persistent gastro-esophageal reflux symptoms despite proton pump inhibitor (PPI) therapy is not fully understood. We aimed at determining reflux patterns on 24-h pH-impedance monitoring performed on PPI and correlating impedance patterns and symptom occurrence in PPI non-responders. Methods 78 PPI non-responder patients underwent 24-h pH-impedance monitoring on PPI. Reflux impedance characterization included gastric and supragastric belches and proximal extent of reflux. Symptoms were considered associated with reflux if occurring within 5 min after a reflux event. Patients were classified into 3 groups: persistent acid reflux (acid esophageal exposure (AET) >5% of time), reflux sensitivity (AET<5%, symptom index (SI) ≥50%), and functional symptoms (AET<5%, SI<50%). Dominant impedance pattern was determined for each patient. Key results 7 patients (9%) had persistent acid reflux, 28 (36%) reflux sensitivity and 43 (55%) functional symptoms. A total of 4,296 reflux events were identified (median per patient 45 (range 4–221)). Although liquid reflux was the most common pattern in all groups, patients with reflux sensitivity and functional symptoms had much more variability in their pattern profile with a large proportion being associated with gastric and supra-gastric belching. Only 417 reflux events (9.7%) were associated with symptoms. Reflux with a supragastric component and proximal extent were more likely to be associated with symptoms. Conclusions & Inferences The impedance reflux profile in PPI non-responders was heterogeneous and the majority of reflux events were not associated with symptoms. Thus, the treatment of PPI non-responders should focus on mechanisms beyond reflux, such as visceral hypersensitivity and hypervigilance.

The added diagnostic value of postreflux swallow‐induced peristaltic wave index and nocturnal baseline impedance in refractory reflux disease studied with on‐therapy impedance‐pH monitoring

“…The number of reflux events at on‐therapy impedance‐pH monitoring is directly related to AET at off‐therapy pH testing, but few studies have documented the clinical utility of this parameter in PPI‐refractory patients evaluated during ongoing therapy . Despite their well‐recognized limitations, symptom‐reflux association indexes are considered worthwhile for the clinical evaluation of patients with suspected reflux disease: however, their positivity is directly related to high reflux rates, only a minority of reflux events are associated with symptoms, and discordant positivity has been regarded as unreliable . In clinical practice, patients often do not perceive symptoms during a 24 hours study or admit inaccurate symptom recording, making a diagnosis based on positive symptom‐reflux association overly patient‐dependent.…”

Oropharyngeal pH Testing Does Not Predict Response to Proton Pump Inhibitor Therapy in Patients with Laryngeal Symptoms

“…Laryngeal hypersensitivity may play a role in symptom recognition in laryngeal irritation, similar to the concept of esophageal hypersensitivity in patients with persistent troublesome GERD symptoms. 42, 43 At the same time, it is possible that patients enrolled in a clinical trial may be more likely to feel better with regards to health related outcomes, translating to improvements in psychosocial questionnaire results. While this chicken and egg phenomenon is unclear, our results do support the interplay between psychosocial factors and symptom generation.…”

Role of altered esophageal intraluminal baseline impedance levels in patients with gatroesophageal reflux disease refractory to proton pump inhibitors

“…Previous studies reported that patients with refractory gastroesophageal reflux symptoms often did not have GERD, [1,3,21] and that those patients diagnosed as GERD were more related with nonacid reflux (weakly acid and alkali reflux). [22–27] Consistent with the above studies, our findings showed 45.2% patients with refractory gastroesophageal reflux symptoms were associated with nonacid reflux and 16.1% patients were considered as FH.…”