Normal values of pharyngeal and esophageal 24-hour pH impedance in individuals on and off therapy and interobserver reproducibility

Increased reflux burden on pre-transplant reflux testing independently predicts significant pulmonary function decline after lung transplantation

BACKGROUND

Gastroesophageal reflux disease has been shown to contribute to allograft injury and rejection outcomes in lung transplantation through a proposed mechanism of aspiration, inflammation, and allograft injury. The value of pre-transplant reflux testing in predicting reduction in pulmonary function after lung transplantation is unclear. We hypothesized that increased reflux burden on pre-transplant reflux testing is associated with pulmonary function decline following lung transplant.

AIM

To assess the relationship between pre-transplant measures of reflux and pulmonary function decline in lung transplant recipients.

METHODS

This was a retrospective cohort study of lung transplant recipients who underwent pre-transplant reflux testing with 24-hour pH-impedance off acid suppression at a tertiary center in 2007-2016. Patients with pre-transplant fundoplication were excluded. Time-to-event analysis was performed using Cox proportional hazards models to assess associations between reflux measures and reduction in forced expiratory volume in 1 second (FEV1) of ≥ 20% post-transplant. Patients not meeting endpoint were censored at time of post-transplant fundoplication, last clinic visit, or death, whichever was earliest.

RESULTS

Seventy subjects (58% men, mean age: 56 years) met the inclusion criteria. Interstitial lung disease represented the predominant pulmonary diagnosis (40%). Baseline demographics were similar between groups and were not associated with pulmonary decline. The clinical endpoint (≥ 20% FEV1 decline) was reached in 18 subjects (26%). In time-to-event univariate analysis, FEV1 decline was associated with increased acid exposure time (AET) [hazard ratio (HR) = 3.49, P = 0.03] and increased proximal acid reflux (HR = 3.34, P = 0.04) with confirmation on Kaplan-Meier analysis. Multivariate analysis showed persistent association between pulmonary decline and increased AET (HR = 3.37, P = 0.04) when controlling for potential confounders including age, body mass index, and sex. Sub-group analysis including only patients with FEV1 decline showed that all subjects with abnormal AET progressed to bronchiolitis obliterans syndrome.

CONCLUSION

Increased reflux burden on pre-transplant testing was associated with significant pulmonary function decline post-transplant. Pre-transplant reflux assessment may provide clinically relevant information in the prognostication and management of transplant recipients.

Reflux Testing: Wireless pH, Impedance-pH, and Mucosal Impedance

Reflux-like symptoms are common; however, not always due to gastro-esophageal reflux disease (GERD) and thus objective testing for GERD is critical, particularly prior to long-term or invasive therapy. In the absence of Los Angeles Grades B, C, or D esophagitis on upper endoscopy, ambulatory reflux monitoring off antisecretory therapy with either a 96-h prolonged wireless reflux monitoring or 24-h pH-impedance is recommended. Mucosal impedance testing is an emerging adjunct technology to assess esophageal mucosal integrity. These testing modalities can help establish the presence or absence of proven GERD, and ultimately guide antireflux-targeted treatments.

Esophageal high-resolution manometry and 24 h pH-impedance monitoring normative values in patients with obesity candidate for bariatric and metabolic surgery

Obesity is linked to increased risk of gastroesophageal reflux disease (GERD) and esophageal motility disorders, both of which may impact outcomes in metabolic and bariatric surgery (MBS). GERD pathophysiology in obesity includes elevated intraabdominal pressure and altered esophagogastric junction (EGJ) function. High resolution manometry (HRM) and 24-h esophageal pH-impedance (MII-pH) monitoring are vital in evaluating GERD, yet normative values specific to populations with obesity are limited, risking misdiagnosis if lean data are used. This study establishes normative HRM and MII-pH values in asymptomatic individuals with obesity, compared to normal-weight controls, to guide accurate diagnosis and treatment. A retrospective analysis was conducted on asymptomatic patients with obesity (BMI ≥ 30) and normal-weight controls (BMI 20-25) who underwent HRM and MII-pH prior to MBS between 2015 and 2024. Exclusion criteria included GERD symptoms, esophagitis, and prior gastrointestinal surgery. Key HRM parameters (LES pressure, EGJ morphology) and MII-pH metrics (acid exposure time, reflux episodes) were recorded and analyzed. Of the 96 patients with obesity and 25 normal-weight participants, significant differences in HRM and MII-pH results were observed. Individuals with obesity showed increased intra-gastric pressure, gastroesophageal pressure gradient, and higher acid exposure time. While LES pressure and EGJ morphology were similar to controls, participants with obesity exhibited distinct reflux patterns, especially postprandial, suggesting obesity-specific physiological changes. This study establishes normative HRM and MII-pH values for asymptomatic individuals with obesity, highlighting critical differences from normal-weight controls. Obesity-specific diagnostic criteria are essential for accurate GERD diagnosis, particularly for MBS candidates, to improve management and predict potential postoperative complications.

Insight into global burden of gastroesophageal reflux disease: Understanding its reach and impact

The exact worldwide prevalence of gastroesophageal reflux disease (GERD) remains uncertain, despite its recognition as a common condition. This conundrum arises primarily from the lack of a standardized definition for GERD. The gold standard diagnostic tests for GERD, such as pH impedance testing and endoscopy, are cumbersome and impractical for assessing community prevalence. Consequently, most epidemiological studies rely on symptom-based screening tools. GERD symptoms can be both esophageal and extraesophageal, varying widely among individuals. This variability has led to multiple symptom-based definitions of GERD, with no consensus, resulting in prevalence estimates ranging from 5% to 25% worldwide. Most systematic reviews define GERD as experiencing heartburn and/or regurgitation at least once weekly, yielding a calculated prevalence of 13.98%. In 2017, the global age-standardized prevalence of GERD was estimated at 8819 per 100000 people (95% confidence interval: 7781-9863), a figure that has remained stable from 1990 to 2017. Prevalence increases with age, leading to more years lived with disability. GERD significantly impairs quality of life and can lead to multiple complications. Additionally, it imposes a severe economic burden, with the United States alone estimated to spend around 10 billion dollars annually on diagnosis and treatment. In summary, GERD prevalence varies greatly by region and even within different areas of the same province. Determining the exact prevalence is challenging due to inconsistent diagnostic criteria. However, it is well-documented that GERD poses a significant global burden, affecting the quality of life of individuals and creating a substantial healthcare cost.

Link between pharyngeal acid reflux episodes and the effectiveness of proton pump inhibitor therapy

BACKGROUND

Diagnosing laryngopharyngeal reflux (LPR) is challenging due to overlapping symptoms. While proton pump inhibitors (PPIs) are commonly prescribed, reliable predictors of their responsiveness are unclear. Reflux monitoring technologies like dual potential of hydrogen (pH) sensors and multichannel intraluminal impedance-pH (MII-pH) could improve diagnosis. Research suggests that a composite pH parameter, defined by ≥ 2 pharyngeal acid reflux (PAR) episodes and/or excessive esophageal acid reflux (EAR), predicts PPI efficacy. The criteria for PAR episodes, a pharyngeal pH drop of ≥ 2 units to < 5 within 30 seconds during esophageal acidification, showed strong interobserver reliability. We hypothesized that PAR episodes alone might also predict PPI responsiveness.

AIM

To investigate whether PAR episodes alone predict a positive response to PPI therapy.

METHODS

Patients suspected of having LPR were prospectively recruited from otolaryngologic clinics in three Taiwanese tertiary centers. They underwent a 24-hour esophagopharyngeal pH test using either 3-pH-sensor or hypopharyngeal MII-pH catheters while off medication, followed by a 12-week esomeprazole course (40 mg twice daily). Participants were categorized into four groups based on pH results: PAR alone, EAR alone, both pH (+), and both pH (-). The primary outcome was a ≥ 50% reduction in primary laryngeal symptoms, with observers blinded to group assignments.

RESULTS

A total of 522 patients (mean age 52.3 ± 12.8 years, 54% male) were recruited. Of these, 190 (mean age 51.5 ± 12.4 years, 61% male) completed the treatment, and 89 (47%) responded to PPI therapy. Response rates were highest in the PAR alone group (73%, n = 11), followed by EAR alone (59%, n = 68), both pH (+) (56%, n = 18), and both pH (-) (33%, n = 93). Multivariate analysis adjusting for age, sex, body mass index, and endoscopic esophagitis showed that participants with PAR alone, EAR alone, and both pH (+) were 7.4-fold (P = 0.008), 4.2-fold (P = 0.0002), and 3.4-fold (P = 0.03) more likely to respond to PPI therapy, respectively, compared to the both pH (-) group. Secondary analyses using the definition of ≥ 1 PAR episode were less robust.

CONCLUSION

In the absence of proven hypopharyngeal predictors, this post-hoc analysis found that baseline ≥ 2 PAR episodes alone are linked to PPI responsiveness, suggesting the importance of hypopharyngeal reflux monitoring.

Concurrent abnormal non-acid reflux is associated with additional chronic rejection risk in lung transplant patients with increased acid exposure

Acid reflux has been associated with allograft injury and rejection in lung transplant patients; however, the pathogenic role of non-acid reflux remains debated. We aimed to evaluate the impact of concurrent abnormal non-acid reflux with acid reflux on chronic rejection in lung transplant patients with acid reflux. This was a retrospective cohort study of lung transplant recipients who underwent pre-transplant combined impedance-pH study off acid suppression. Only subjects with acid exposure >4% were included. Non-acid reflux (pH > 4) episodes >27 was considered abnormal per prior normative studies. Chronic rejection was defined as chronic lung allograft dysfunction (CLAD) per International Society for Heart and Lung Transplantation criteria. Time-to-event analyses were performed using Cox proportional hazards and Kaplan-Maier methods, with censoring at death, anti-reflux surgery, or last follow-up. In total, 68 subjects (28 abnormal/40 normal non-acid reflux) met inclusion criteria for the study. Baseline demographic/clinical characteristics were similar between groups. Among this cohort of patients with increased acid exposure, subjects with concurrent abnormal non-acid reflux had significantly higher risk of CLAD than those without on Kaplan-Meier analysis (log-ranked P = 0.0269). On Cox multivariable regression analysis controlling for body mass index, age at transplantation, and proton pump inhibitor use, concurrent abnormal non-acid reflux remained independently predictive of increased CLAD risk (hazard ratio 2.31, confidence interval: 1.03-5.19, P = 0.04). Presence of concurrent abnormal non-acid reflux in lung transplant subjects with increased acid exposure is associated with additional risk of chronic rejection. Non-acid reflux may also contribute to pathogenicity in lung allograft injury/rejection, supporting a potential role for impedance-based testing in this population.

Anatomic and Manometric Abnormalities of the Upper and Lower Esophageal Sphincters in Patients With Reflux Disease

RESEARCH QUESTION

Laryngopharyngeal reflux (LPR) may cause inflammation of the laryngeal and pharyngeal mucosa. Gastroesophageal reflux disease (GERD) involves retrograde flow of gastric content into the esophagus below the upper esophageal sphincter (UES). The goal of this study was to investigate the esophageal anatomical and manometric variations of the esophagus in patients with LPR and/or GERD.

METHODS

Adult voice center patients who underwent diagnostic workup for reflux complaints with 24-hour multichannel intraluminal pH-impedance testing and esophageal manometry were included in this retrospective study. Subjects were classified as having LPR (>10 proximal reflux events), LPR + GERD (>10 proximal reflux events plus >73 distal reflux events) or were assigned to a control group (≤10 proximal events and ≤73 distal reflux events) based on pH study results. Anatomic and manometric parameters were evaluated between groups.

RESULTS

There were 169 cases (65 male, 104 female) included in this study. The average age was 50.50 ± 17.29. Subjects in the LPR group had significantly higher UES relaxation pressures and greater UES length compared with the control group. Lower esophageal sphincter relaxation pressure was significantly higher in the control group compared with the LPR group or the GERD + LPR group. Subjects in the GERD + LPR group had a significantly shorter intra-abdominal portion of the lower esophageal sphincter compared with the LPR only group and the control group. Intrabolus pressure was significantly lower in both the LPR group and the LPR + GERD group compared with the control group. Distal wave amplitude was significantly lower in the LPR + GERD group compared to both the LPR group and the control group. The percentage of swallows with incomplete clearance was significantly greater in the LPR + GERD group than both the control group and the LPR group. The LPR group had significantly fewer swallows with incomplete clearance than the control group.

CONCLUSIONS

Anatomic and manometric abnormalities are present in subjects with LPR with or without GERD and may contribute to the pathogenesis of reflux disease. Further research is needed to confirm or refute these findings.

Review article: Diagnosis and management of laryngopharyngeal reflux

BACKGROUND

Laryngopharyngeal reflux has classically referred to gastroesophageal reflux leading to chronic laryngeal symptoms such as throat clearing, dysphonia, cough, globus sensation, sore throat or mucus in the throat. Current lack of clear diagnostic criteria significantly impairs practitioners' ability to identify and manage laryngopharyngeal reflux.

AIMS

To discuss current evidence-based diagnostic and management strategies in patients with laryngopharyngeal reflux.

METHODS

We selected studies primarily based on current guidelines for gastroesophageal reflux disease and laryngopharyngeal reflux, and through PubMed searches.

RESULTS

We assess the current diagnostic modalities that can be used to determine if laryngopharyngeal reflux is the cause of a patient's laryngeal symptoms, as well as review some of the common treatments that have been used for these patients. In addition, we note that the lack of a clear diagnostic gold-standard, as well as specific diagnostic criteria, significantly limit clinicians' ability to determine adequate therapies for these patients. Finally, we identify areas of future research that are needed to better manage these patients.

CONCLUSIONS

Patients with chronic laryngeal symptoms are complex due to the heterogenous nature of symptom pathology, inconsistent definitions and variable response to therapies. Further outcomes data are critically needed to help elucidate ideal diagnostic workup and therapeutic management for these challenging patients.

Optimizing ambulatory reflux monitoring: current findings and future directions

INTRODUCTION

Gastroesophageal reflux disease (GERD) is the most common diagnosis seen in outpatient gastroenterology clinics. The diagnosis is made by a variable combination of symptoms, response to acid suppressive therapy, endoscopic evaluation, and pH testing. In this review, we evaluate how to utilize various reflux testing in clinical practice based on current evidence.

AREAS COVERED

Ambulatory reflux monitoring is a recognized diagnostic tool for clinical decision making in patients with/without established GERD, persistent reflux symptoms, and lack of response to proton pump inhibitor (PPI) therapy. Standard evaluation approaches include 24-hour pH or impedance monitoring via transnasal catheter, prolonged (48 to 96 hour) wireless pH monitoring, and the recently developed mucosal integrity testing. Testing using one of these methods allows for measurement of acid exposure, frequency of reflux, and to phenotype patients to personalize treatment recommendations.

EXPERT OPINION

The primary goal of future studies should be to simplify ambulatory reflux monitoring, reduce diagnostic latency, improve patient tolerance, and to obtain clinical outcomes-based studies. The current paradigm of reflux testing is vastly complex with multiple modalities and shifting cutoffs of pH abnormality that lead to high economic burden on the society.

Abnormal bolus reflux on impedance-pH testing independently predicts 3-year pulmonary outcome and mortality in pulmonary fibrosis

BACKGROUND AND AIM

Gastroesophageal reflux has been associated with idiopathic pulmonary fibrosis (IPF), although the directionality of the relationship has been debated. Data on the value of objective reflux measures in predicting IPF disease progression and mortality remain limited. We aimed to evaluate the association between multichannel intraluminal impedance and pH testing (MII-pH) and 3-year pulmonary outcomes in IPF patients.

METHODS

This was a retrospective cohort study of adults with IPF who underwent pre-lung transplant MII-pH off acid suppression at a tertiary center. Patients were followed for 3 years after MII-pH for poor pulmonary outcomes (hospitalization for respiratory exacerbation or death). A secondary analysis was performed using mortality as outcome of interest. Time-to-event analyses using Kaplan-Meier and Cox regression were performed to evaluate associations between MII-pH and poor outcomes.

RESULTS

One hundred twenty-four subjects (mean age = 61.7 ± 8 years, 62% male) were included. Increased bolus exposure time (BET) on MII-pH was associated with decreased time to poor pulmonary outcomes and death (log-ranked P-value = 0.017 and 0.031, respectively). On multivariable Cox regression analyses controlling for potential confounders including age, sex, smoking history, body mass index, proton pump inhibitor use, baseline pulmonary function, and anti-fibrotic therapy, increased BET was an independent predictor for poor pulmonary outcomes [hazard ratio 3.18 (95% confidence interval: 1.25-8.09), P = 0.015] and mortality [hazard ratio 11.3 (95% confidence interval: 1.37-63.9), P = 0.025] over 3 years.

CONCLUSIONS

Increased BET on MII-pH is an independent predictor of poor pulmonary outcomes and mortality over 3 years in IPF patients. These findings also support a role for gastroesophageal reflux in IPF disease progression and the potential impact of routine reflux testing and treatment.

A perspective on the clinical relevance of weak or nonacid reflux

BACKGROUND

Advances in ambulatory esophageal reflux monitoring that incorporated impedance electrodes to pH catheters have resulted in better characterization of retrograde bolus flow in the esophagus. With pH-impedance monitoring, in addition to acid reflux episodes identified by pH drops below 4.0, weakly acid reflux (WAR, pH 4-7) and nonacid reflux (NAR, pH >7.0) are also recognized, although both may be included under the umbrella term NAR. However, despite identification of ambulatory pH-impedance monitoring, data on clinical relevance and prognostic value of NAR are limited. The Lyon Consensus, an international expert review that defines conclusive metrics for gastroesophageal reflux disease (GERD), identifies NAR as "supportive" but not conclusive for GERD.

PURPOSE

This review provides perspectives on whether NAR fulfills three criteria for clinical relevance: whether NAR sufficiently explains pathogenesis of symptoms, whether it is associated with meaningful manifestations of GERD, and whether it can predict treatment efficacy.

[Comparison of the effectiveness of rabeprazole original and generic products in the monotherapy of gastroesophageal reflux disease]

AIM

To compare the effectiveness of rabeprazole original and generic products in the treatment of gastroesophageal reflux disease (GERD) using impedance-pH monitoring.

MATERIALS AND METHODS

Patients (n=35) diagnosed with GERD were divided into two groups. Group 1 patients (n=17, 45.2±1.7 years) received the rabeprazole original product (Pariet) 20 mg/day; Group 2 patients (n=18, 48.1±1.9 years) received 20 mg/day of a generic product. On Day 10 of therapy, all patients underwent 24-hour esophagus impedance-pH monitoring (Ohmega, Medical Measurement Systems, the Netherlands). The percentage of time with pH<4 in the esophagus, the total number and number of acidic, slightly acidic and slightly alkaline gastroesophageal refluxes (GERs), the latency period, and the duration of rabeprazole action were analyzed. The clinical efficacy of the drug was assessed using the GerdQ questionnaire. Statistical data were processed using Microsoft Office 2010 (Excel) and Biostat 2000 software packages.

RESULTS

No significant differences were noted between the two groups of patients by gender, age, body mass index, smoking frequency, and GERD type (p>0.05). The average duration of action of the rabeprazole original product was significantly higher than that of the generics (13.2±0.6 and 8.8±0.7 h, respectively, p<0.05). In the rabeprazole original product group, compared to the generics group, the following values were lower: total GERs - 47.0 [43.3; 60.0] and 71.8 [54.3; 95.0], respectively, p<0.05; percentage of time with intraesophageal pH<4 - 1.8 [0.5; 2.3] and 2.1 [0.3; 6.8], respectively, p<0.05; the number of acidic GERs - 4.7 [2.2; 12.0] and 23.3 [12.6; 32.0], respectively, p<0.05. The total GerdQ questionnaire score in Group 1 was significantly lower than in Group 2 (5.4±0.1 vs 6.9±0.4, respectively; p>0.05).

CONCLUSION

In treating GERD with the rabeprazole original product compared to generics, a significantly longer duration of acid production suppression, a more pronounced decrease in esophageal acidification, and a more statistically significant clinical improvement were observed.

Pre-Lung transplant reflux testing demonstrates high prevalence of gastroesophageal reflux in cystic fibrosis and reduces chronic rejection risk

BACKGROUND

Gastroesophageal reflux (GER) has been associated with poor outcomes after lung transplantation for chronic lung disease, including increased risk of chronic rejection. GER is common in cystic fibrosis (CF), but factors influencing the likelihood of pre-transplant pH testing, and the impact of testing on clinical management and transplant outcomes in patients with CF are unknown.

AIM

To evaluate the role of pre-transplant reflux testing in the evaluation of lung transplant candidates with CF.

METHODS

This was a retrospective study from 2007-2019 at a tertiary medical center that included all patients with CF undergoing lung transplant. Patients with pre-transplant anti-reflux surgery were excluded. Baseline characteristics (age at transplantation, gender, race, body mass index), self-reported GER symptoms prior to transplantation, and pre-transplant cardiopulmonary testing results, were recorded. Reflux testing consisted of either 24-h pH- or combined multichannel intraluminal impedance and pH monitoring. Post-transplant care included a standard immunosuppressive regimen, and regular surveillance bronchoscopy and pulmonary spirometry in accordance with institutional practice as well as in symptomatic patients. The primary outcome of chronic lung allograft dysfunction (CLAD) was defined clinically and histologically per International Society of Heart and Lung Transplantation criteria. Statistical analysis was performed with Fisher's exact test to assess differences between cohorts, and time-to-event Cox proportional hazards modeling.

RESULTS

After applying inclusion and exclusion criteria, a total of 60 patients were included in the study. Among all CF patients, 41 (68.3%) completed reflux monitoring as part of pre-lung transplant evaluation. Objective evidence of pathologic reflux, defined as acid exposure time > 4%, was found in 24 subjects, representing 58% of the tested group. CF patients with pre-transplant reflux testing were older (35.8 vs 30.1 years, P = 0.01) and more commonly reported typical esophageal reflux symptoms (53.7% vs 26.3%, P = 0.06) compared to those without reflux testing. Other patient demographics and baseline cardiopulmonary function did not significantly differ between CF subjects with and without pre-transplant reflux testing. Patients with CF were less likely to undergo pre-transplant reflux testing compared to other pulmonary diagnoses (68% vs 85%, P = 0.003). There was a decreased risk of CLAD in patients with CF who underwent reflux testing compared to those who did not, after controlling for confounders (Cox Hazard Ratio 0.26; 95%CI: 0.08-0.92).

CONCLUSION

Pre-transplant reflux testing revealed high prevalence of pathologic reflux in CF patients and was associated with decreased risk of CLAD. Systematic reflux testing may enhance outcomes in this patient population.

AGA Clinical Practice Update on the Diagnosis and Management of Extraesophageal Gastroesophageal Reflux Disease: Expert Review

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert advice regarding the clinical management of patients with suspected extraesophageal gastroesophageal reflux disease.

METHODS

This article provides practical advice based on the available published evidence including that identified from recently published reviews from leading investigators in the field, prospective and population studies, clinical trials, and recent clinical guidelines and technical reviews. This best practice document is not based on a formal systematic review. The best practice advice as presented in this document applies to patients with symptoms or conditions suspected to be related to extraesophageal reflux (EER). This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these BPA statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: Gastroenterologists should be aware of potential extraesophageal manifestations of gastroesophageal reflux disease (GERD) and should inquire about such disorders including laryngitis, chronic cough, asthma, and dental erosions in GERD patients to determine whether GERD may be a contributing factor to these conditions. BEST PRACTICE ADVICE 2: Development of a multidisciplinary approach to extraesophageal (EER) manifestations is an important consideration because the conditions are often multifactorial, requiring input from non-gastroenterology (GI) specialties. Results from diagnostic testing (ie, bronchoscopy, thoracic imaging, laryngoscopy, etc) from non-GI disciplines should be taken into consideration when gastroesophageal reflux (GER) is considered as a cause for extraesophageal symptoms. BEST PRACTICE ADVICE 3: Currently, there is no single diagnostic tool that can conclusively identify GER as the cause of EER symptoms. Determination of the contribution of GER to EER symptoms should be based on the global clinical impression derived from patients' symptoms, response to GER therapy, and results of endoscopy and reflux testing. BEST PRACTICE ADVICE 4: Consideration should be given toward diagnostic testing for reflux before initiation of proton pump inhibitor (PPI) therapy in patients with potential extraesophageal manifestations of GERD, but without typical GERD symptoms. Initial single-dose PPI trial, titrating up to twice daily in those with typical GERD symptoms, is reasonable. BEST PRACTICE ADVICE 5: Symptom improvement of EER manifestations while on PPI therapy may result from mechanisms of action other than acid suppression and should not be regarded as confirmation for GERD. BEST PRACTICE ADVICE 6: In patients with suspected extraesophageal manifestation of GERD who have failed one trial (up to 12 weeks) of PPI therapy, one should consider objective testing for pathologic GER, because additional trials of different PPIs are low yield. BEST PRACTICE ADVICE 7: Initial testing to evaluate for reflux should be tailored to patients' clinical presentation and can include upper endoscopy and ambulatory reflux monitoring studies of acid suppressive therapy. BEST PRACTICE ADVICE 8: Testing can be considered for those with an established objective diagnosis of GERD who do not respond to high doses of acid suppression. Testing can include pH-impedance monitoring while on acid suppression to evaluate the role of ongoing acid or non-acid reflux. BEST PRACTICE ADVICE 9: Alternative treatment methods to acid suppressive therapy (eg, lifestyle modifications, alginate-containing antacids, external upper esophageal sphincter compression device, cognitive-behavioral therapy, neuromodulators) may serve a role in management of EER symptoms. BEST PRACTICE ADVICE 10: Shared decision-making should be performed before referral for anti-reflux surgery for EER when the patient has clear, objectively defined evidence of GERD. However, a lack of response to PPI therapy predicts lack of response to anti-reflux surgery and should be incorporated into the decision process.

Diagnosis of Laryngopharyngeal Reflux: Past, Present, and Future-A Mini-Review

Laryngopharyngeal reflux (LPR) is a variant of gastroesophageal reflux disease (GERD) in which gastric refluxate irritates the lining of the aerodigestive tract and causes troublesome airway symptoms or complications. LPR is a prevalent disease that creates a significant socioeconomic burden due to its negative impact on quality of life, tremendous medical expense, and possible cancer risk. Although treatment modalities are similar between LPR and GERD, the diagnosis of LPR is more challenging than GERD due to its non-specific symptoms/signs. Due to the lack of pathognomonic features of endoscopy, mounting evidence focused on physiological diagnostic testing. Two decades ago, a dual pH probe was considered the gold standard for detecting pharyngeal acidic reflux episodes. Despite an association with LPR, the dual pH was unable to predict the treatment response in clinical practice, presumably due to frequently encountered artifacts. Currently, hypopharygneal multichannel intraluminal impedance-pH catheters incorporating two trans-upper esophageal sphincter impedance sensors enable to differentiate pharyngeal refluxes from swallows. The validation of pharyngeal acid reflux episodes that are relevant to anti-reflux treatment is, therefore, crucial. Given no diagnostic gold standard of LPR, this review article aimed to discuss the evolution of objective diagnostic testing and its predictive role of treatment response.

Artificial intelligence facilitates measuring reflux episodes and postreflux swallow-induced peristaltic wave index from impedance-pH studies in patients with reflux disease

BACKGROUND/AIM

Reflux episodes and postreflux swallow-induced peristaltic wave (PSPW) index are useful impedance parameters that can augment the diagnosis of gastroesophageal reflux disease (GERD). However, manual analysis of pH-impedance tracings is time consuming, resulting in limited use of these novel impedance metrics. This study aims to evaluate whether a supervised learning artificial intelligence (AI) model is useful to identify reflux episodes and PSPW index.

METHODS

Consecutive patients underwent 24-h impedance-pH monitoring were enrolled for analysis. Multiple AI and machine learning with a deep residual net model for image recognition were explored based on manual interpretation of reflux episodes and PSPW according to criteria from the Wingate Consensus. Intraclass correlation coefficients (ICCs) were used to measure the strength of inter-rater agreement of data between manual and AI interpretations.

RESULTS

We analyzed 106 eligible patients with 7939 impedance events, of whom 38 patients with pathological acid exposure time (AET) and 68 patients with physiological AET. On the manual interpretation, patients with pathological AET had more reflux episodes and lower PSPW index than those with physiological AET. Overall accuracy of AI identification for reflux episodes and PSPW achieved 87% and 82%, respectively. Inter-rater agreements between AI and manual interpretations achieved excellent for individual numbers of reflux episodes and PSPW index (ICC = 0.965 and ICC = 0.921).

CONCLUSIONS

AI has the potential to accurately and efficiently measure impedance metrics including reflux episodes and PSPW index. AI can be a reliable adjunct for measuring novel impedance metrics for GERD in the near future.

On-therapy impedance-pH monitoring can efficiently characterize PPI-refractory GERD and support treatment escalation

BACKGROUND

On-therapy impedance-pH monitoring is recommended in patients with documented GERD and PPI-refractory heartburn in order to establish whether the unremitting symptom is reflux-related or not.

AIMS

To define on-PPI cut-offs of impedance-pH metrics allowing proper interpretation of on-therapy impedance-pH monitoring.

METHODS

Blinded expert review of impedance-pH tracings performed during double-dosage PPI, prospectively collected from 150 GERD patients with PPI-refractory heartburn and 45 GERD patients with PPI-responsive heartburn but persisting extra-esophageal symptoms. Acid exposure time (AET), number of total refluxes (TRs), post-reflux swallow-induced peristaltic wave (PSPW) index, and mean nocturnal baseline impedance (MNBI) were assessed. On-PPI cut-offs were defined and evaluated with ROC analysis and the area under curve (AUC).

RESULTS

All the four impedance-pH metrics significantly differed between PPI-refractory and PPI-responsive heartburn cases. At ROC analysis, AUC was 0.73 for AET, 0.75 for TRs, 0.81 for PSPW index, and 0.71 for MNBI; best cut-offs were ≥1.7% for AET, ≥45 for TRs, ≤36% for PSPW index, and ≤ 1847 Ω for MNBI; AUC of such cut-offs was 0.66, 0.71, 0.73, and 0.68, respectively. Analysis of PSPW index and MNBI added to assessment of AET and TRs significantly increased the yield of on-therapy impedance-pH monitoring in the PPI-refractory cohort (97% vs. 83%, p < 0.0001). Notably, suboptimal acid suppression as shown by AET ≥1.7% was detected in 43% of 150 PPI-refractory cases.

CONCLUSIONS

We have defined on-PPI cut-offs of impedance-pH metrics by which comprehensive assessment of impedance-pH tracings, including analysis of PSPW index and MNBI can efficiently characterize PPI-refractory GERD and support treatment escalation.

Validation of Pharyngeal Acid Reflux Episodes Using Hypopharyngeal Multichannel Intraluminal Impedance-pH

Background/Aims

Hypopharyngeal multichannel intraluminal impedance-pH (HMII-pH) technology incorporating 2 trans-upper esophageal sphincter impedance channels has been developed to detect pharyngeal reflux. We used the HMII-pH technique to validate the candidate pharyngeal acid reflux (PAR) episodes based on the dual-pH tracings and determined the interobserver reproducibility.

Methods

We conducted a cross-sectional study in tertiary centers in Taiwan. Ninety patients with suspected laryngopharyngeal reflux and 28 healthy volunteers underwent HMII-pH test when off acid suppressants. Candidate PAR episodes were characterized by pharyngeal pH drops of at least 2 units and reaching a nadir pH of 5 within 30 seconds during esophageal acidification. Two experts manually independently identified candidate PAR episodes based on the dual-pH tracings. By reviewing the HMII-pH tracings, HMII-pH-proven PAR episodes were subsequently confirmed. The consensus reviews of HMII-pH-proven PAR episodes were considered to be the reference standard diagnosis. The interobserver reproducibility was assessed.

Results

A total of 105 candidate PAR episodes were identified. Among them 84 (80.0%; 95% CI, 71.0-87.0%) were HMII-pH-proven PAR episodes (82 in 16 patients and 2 in 1 healthy subject). Patients tended to have more HMII-pH-proven PAR episodes than healthy controls (median and percentile values [25th, 75th, and 95th percentiles]: 0 [0, 0, 3] vs 0 [0, 0, 0], P = 0.067). The concordance rate in diagnosing HMII-pH-proven PAR episodes between 2 independent observers was 92.2%.

Conclusion

Our preliminary data showed that 80.0% (71.0-87.0%) of the proposed candidate PAR episodes were HMII-pH-proven PAR episodes, among which the interobserver reproducibility was good.

Symptoms classically attributed to laryngopharyngeal reflux correlate poorly with pharyngeal reflux events on multichannel intraluminal impedance testing

Laryngopharyngeal reflux (LPR) is thought to be a common etiology of throat and airway symptoms. Diagnosis of LPR is challenging, given the variable symptomatology and response to therapy. Identifying symptoms that better correlate with LPR may inform management strategies. We aimed to examine the association between patient-reported symptoms and objectively identified LPR on ambulatory reflux monitoring. This was a retrospective cohort study of consecutive adults with suspected LPR undergoing combined hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing (HEMII-pH) at a tertiary center. All patients completed standardized symptom surveys for presenting symptoms, reflux symptom index (RSI), and voice handicap index (VHI). LPR was defined as >1 full-column pharyngeal reflux event on HEMII-pH over 24 hours. Univariate and multivariable analyses were performed. A total of 133 patients were included (mean age = 55.9 years, 69.9% female). Of this 83 (62.4%) reported concomitant esophageal symptoms. RSI and VHI did not correlate with proximal esophageal or pharyngeal reflux events (Kendall's tau correlations P > 0.05), although the mean RSI was higher in the LPR group (21.1 ± 18.9 vs. 17.1 ± 8.3, P = 0.044). Cough, but not other laryngeal symptoms, was more common among patients with esophageal symptoms (58% vs. 36%, P = 0.014). Neither laryngeal symptoms nor esophageal symptoms of reflux predicted LPR on univariate or multivariable analyses (all P > 0.05). Neither laryngeal symptoms classically attributed to LPR nor typical esophageal symptoms correlated with pharyngeal reflux events on HEMII-pH. Clinical symptoms alone are not sufficient to make an LPR diagnosis. Broad evaluation for competing differential diagnoses and objective reflux monitoring should be considered in patients with suspected LPR symptoms.

Assessment of Post-traumatic Stress Disorder Among Objective Esophageal Motility and Reflux Phenotypes in Symptomatic Veterans

Prior research suggests post-traumatic stress disorder (PTSD) is associated with the development of esophageal symptoms. We aimed to evaluate the prevalence of PTSD in veterans with esophageal symptoms, and assess for differences in objective esophageal motility and reflux classifications. Consecutive veterans reporting esophageal symptoms (e.g., dysphagia and reflux) underwent clinical evaluation with standard reflux and motility testing. Relevant demographic, mental health, and clinical esophageal information was gathered. Patients were classified into "PTSD" and "Non-PTSD" groups based on the documentation of a clinician-confirmed diagnosis of PTSD in the medical chart. Of the 273 consecutive veterans (89% men, mean age: 62 years) that met inclusion criteria for the study, 34% had a clinician-confirmed diagnosis of PTSD. Differences existed between PTSD and non-PTSD groups on smoking, bipolar disorder, depression, ADHD, and opiate use. However, no differences existed in objectively determined motility or reflux phenotypes. While PTSD was highly prevalent among our sample of symptomatic veterans, the presence of PTSD was not associated with differences in motility classifications and reflux phenotypes. These findings are consistent with recent research in psychogastroenterology, which suggests psychological processes are important to consider across esophageal classifications.

Routine Reflux Testing Guides Timely Antireflux Treatment to Reduce Acute and Chronic Rejection After Lung Transplantation

INTRODUCTION

Gastroesophageal reflux has been associated with poorer lung transplantation outcomes, although no standard approach to evaluation/management has been adopted. We aimed to evaluate the effect of timely antireflux treatment as guided by routine reflux testing on postlung transplant rejection outcomes.

METHODS

This was a retrospective cohort study of lung transplant recipients at a tertiary center. All patients underwent pretransplant ambulatory pH monitoring. Timely antireflux treatment was defined as proton pump inhibitor initiation or antireflux surgery within 6 months of transplantation. Patients were separated into 3 groups: normal pH monitoring (-pH), increased reflux (+pH) with timely treatment, and +pH with delayed treatment. Rejection outcomes included acute rejection, bronchiolitis obliterans syndrome, and chronic lung allograft dysfunction per International Society for Heart and Lung Transplantation criteria. Time-to-event analyses using Cox proportional hazard models were applied. Patients not meeting outcomes were censored at death or last clinic visit.

RESULTS

One hundred seventy-five patients (59% men/mean 56.3 yr/follow-up: 496 person-years) were included. On multivariable analyses, +pH/delayed treatment patients had higher risks of acute rejection (adjust hazard ratio [aHR]:3.81 [95% confidence interval [CI]: 1.90-7.64], P = 0.0002), bronchiolitis obliterans syndrome (aHR: 2.22 [95% CI: 1.07-4.58], P = 0.03), and chronic lung allograft dysfunction (aHR: 2.97 [95% CI: 1.40-6.32], P = 0.005) than +pH/timely treatment patients. Similarly, rejection risks were increased among +pH/delayed treatment patients vs -pH patients (all P < 0.05). No significant differences in rejection risks were noted between +pH/timely treatment patients and -pH patients. Failure/complications of antireflux treatment were rare and similar among groups.

DISCUSSION

Timely antireflux treatment, as directed by pretransplant reflux testing, was associated with reduced allograft rejection risks and demonstrated noninferiority to patients without reflux. A standardized peri-transplant test-and-treat algorithm may guide timely reflux management to improve lung transplant outcomes.

Investigating the diagnostic utility of high-resolution oesophageal manometry in patients with refractory respiratory symptoms

BACKGROUND

The interaction between the respiratory and gastrointestinal systems, and the role of the latter in the development of respiratory pathology, has been examined with a focus on gastro-oesophageal reflux disease (GORD). However, little data exists examining the link between oesophageal motility and respiratory disease.

AIMS AND OBJECTIVES

In this study, we examined patterns in oesophageal motility using high-resolution oesophageal manometry (HROM) in patients with refractory respiratory symptoms.

METHODS

Data were collected retrospectively for all patients that were investigated using HROM at a single centre for refractory respiratory symptoms between January 1st, 2011-December 1st, 2021. Patients were selected for investigation based on airway reflux symptoms, measured by the Hull Airways Reflux Questionnaire (HARQ).

RESULTS

441 patients were investigated with HROM (64% female, mean age = 56.5 [SD = 13.9]). The commonest diagnoses of these patients were Chronic Cough (77%, n = 339), Asthma (10%, n = 44), and Interstitial Lung Disease (7%, n = 29). The prevalence of oesophageal dysmotility was 66% in our cohort. Those with oesophageal dysmotility had significantly higher HARQ scores than those with normal motility (40.6 vs 35.3, p < 0.001) and there was a significant inverse correlation between HARQ scores and distal contractile integral (DCI), a measure of oesophageal contractility.

CONCLUSIONS

Two-thirds of patients with refractory respiratory symptoms were found to have oesophageal dysmotility on HROM. These findings suggest motility disorders of the oesophagus may contribute to the development and progression of respiratory disease. This study highlights the need for further prospective study of the relationship between oesophageal dysmotility and respiratory disease.

The burden of gastroesophageal reflux disease on the cost of managing chronic diseases in Australia. The need for a new diagnostic and management paradigm

INTRODUCTION

Chronic disease poses a major problem for the Australian healthcare system as the leading cost-burden and cause of death. Gastroesophageal reflux disease (GORD) typifies the problems with a growing prevalence and cost. We hypothesise that a scintigraphic test could optimise the diagnosis, especially in problematic extraoesophageal disease.

MATERIALS AND METHODS

Data was collected from 2 groups of patients. Patients undergoing fundoplication for severe GORD (n = 30) and those with atypical symptoms (n = 30) were studied by scintigraphy and 24-hour oesophageal pH, impedance and manometry.

RESULTS

Mean age of cohort was 55.8 years with 40 females and 20 males. Body mass index was a mean of 28.3. DeMeester score was normal in 12/60 with atypical symptoms and abnormal in the rest. Good correlation was shown between scintigraphy and impedance, manometry and distal pH readings. Pulmonary aspiration was shown in 25/60 (15 with atypical symptoms) and LPR in 20/30. Several impedance, manometric and scintigraphic finding were good predictors of lung aspiration of refluxate.

CONCLUSION

Scintigraphy provides a good tool for screening patients with typical and atypical symptoms of GORD. It is well correlated with the standard methods for the diagnosis and provides visual evidence of LPR and lung aspiration.

Reflux scintigraphy in gastro-esophageal reflux disease: a comparison study with 24 hour pH-impedance monitoring

OBJECTIVE

Reflux scintigraphy is often used to diagnose gastro-esophageal reflux disease (GERD). However, the efficacy of this study remains controversial. Our aim was to determine the role of reflux scintigraphy in diagnosing GERD by comparing it to 24 h combined pH-impedance study as the gold standard.

MATERIALS AND METHODS

Adult patients who presented for investigations of reflux symptoms were prospectively recruited into the study. All patients underwent high resolution esophageal manometry and those with major motor disorders of the esophagus were excluded. Eligible patients immediately underwent reflux scintigraphy following insertion of the pH-impedance catheter.

RESULTS

Thirty patients were included in the study. Using a total acid exposure time (AET) of >4.2% as the reference for abnormal acid reflux, reflux scintigraphy had a sensitivity and specificity of 62.5 and 68.2%, respectively, in detecting acid reflux. When compared to AET >6%, reflux scintigraphy had a sensitivity and specificity of 66.7 and 62.5%, respectively, and a positive predictive value of 30.8% and a negative predictive value of 88.2%. There were no associations between outcomes of reflux scintigraphy and total AET (p = .46), total (acid or non-acid) reflux events (p = 0.11), proximal AET (p = .33) or the number of proximal reflux episodes (p = .75) on 24 h pH-impedance study.

CONCLUSIONS

Reflux scintigraphy has limited role in diagnosing GERD when compared to 24 h combined pH-impedance monitoring.

Anatomical and physiological characteristics in patients with Laryngopharyngeal Reflux Symptoms: A case-control study utilizing high-resolution impedance manometry

BACKGROUND/PURPOSE

This study aimed to explore the anatomical and physiological characteristics of patients with laryngopharyngeal reflux (LPR) symptoms, such as hoarseness, throat clearing, throat pain, globus, and chronic cough, with the novel high-resolution impedance manometry (HRIM).

METHODS

Consecutive patients exhibited at least one LPR symptom for ≥4 weeks after 2-month proton-pump inhibitor treatment were enrolled during November 2014 and March 2018 from single tertiary medical center. All patients completed validated symptom questionnaires, esophagogastroduodenoscopy, and HRIM. Healthy volunteers were also recruited for comparison of esophageal parameters on HRIM.

RESULTS

Eighty-nine LPR patients and 63 healthy volunteers were analyzed. Compared with healthy volunteers, LPR patients had significantly shorter upper and lower esophageal sphincters (UES and LES), a shorter intraabdominal esophagus (all P < 0.01), higher 4-s integrated relaxation pressures (IRP-4s) (P = 0.011) of the LES. After adjusted for age, sex, body weight, body height and alcohol consumption, multiple regression analysis showed that age, LES IRP-4s and the UES length were independent risk factors for LPR symptoms (OR 1.056, 95% CI 1.019-1.094; OR 1.107, 95% CI 1.004-1.222; OR 0.432, 95% CI 0.254-0.736, respectively). In subgroup analysis, patients with moderate LPR symptoms had lower IRP-4s (6.64 ± 4.55 vs. 8.69 ± 5.10, P = 0.049) and more failed peristalsis (27.33 ± 29.26 vs. 11.36 ± 21.20, P = 0.004) than those with mild LPR symptoms.

CONCLUSION

Our study suggests that esophageal structural factors and LES IRP-4s may contribute to the occurrence of LPR symptoms. Patients with moderate LPR symptoms were more likely to present with failed peristalsis.

Clinical practice guidelines for esophageal ambulatory reflux monitoring in Chinese adults

Esophageal ambulatory reflux monitoring is the current gold standard for the diagnosis of gastroesophageal reflux disease (GERD). In order to facilitate standardized procedure and improve diagnostic accuracy, clinical guidelines for ambulatory esophageal reflux monitoring were developed based on thorough literature search and working group conference by experts in gastrointestinal motility. Indications, contraindications, methodology, and reporting of ambulatory esophageal reflux monitoring were discussed in these clinical guidelines.

Phenotyping patients with borderline elevated esophageal acid exposure

Acid exposure time (AET) <4% on ambulatory reflux monitoring definitively rules out pathologic gastroesophageal acid reflux, while AET >6% indicates pathologic reflux per the Lyon Consensus, leaving AET of 4-6% as borderline. We aimed to elucidate the borderline AET population and identify metrics that could help differentiate this group. A total of 50 subjects in each group, AET <4, 4-6, and >6% on pH-impedance monitoring between 2015 and 2019, were retrospectively reviewed. In addition to demographic and clinical information, the extracted data included mean nocturnal baseline impedance (MNBI) on reflux study and high-resolution manometry (HRM) parameters and diagnosis. After excluding patients with prior foregut surgery, major esophageal motility disorder, or unreliable impedance testing, a total of 89 subjects were included in the analysis (25 with normal AET < 4%, 38 with borderline 4-6%, 26 with abnormal >6%). MNBI in borderline AET patients was significantly lower compared to normal AET (1607.7 vs. 2524.0 ohms, P < 0.01), and higher than abnormal AET (951.5 ohms, P < 0.01). Borderline subjects had a greater frequency of ineffective esophageal motility (IEM) diagnosis per Chicago classification v3.0 (42.1 vs. 8.0%, P = 0.01), but did not demonstrate any differences compared to abnormal subjects (34.6%, P = 0.56). Patients with borderline AET had an average MNBI that was in between normal AET and abnormal AET. Borderline AET patients also commonly demonstrate IEM on HRM, similar to those with abnormal AET. Our findings can be potentially useful in assigning higher clinical significance for patients found to have borderline AET with concomitant low MNBI and IEM on manometry.

Novel Advanced Impedance Metrics on Impedance-pH Testing Predict Lung Function Decline in Idiopathic Pulmonary Fibrosis

INTRODUCTION

Gastroesophageal reflux has been associated with idiopathic pulmonary fibrosis (IPF). Mean nocturnal baseline impedance (MNBI) is a marker of esophageal mucosal integrity, whereas postreflux swallow-induced peristaltic wave (PSPW) index reflects esophageal chemical clearance. Both metrics offer novel ways to assess reflux burden on multichannel intraluminal impedance-pH testing (MII-pH), but their role in extraesophageal reflux remains unclear. We aimed to evaluate the relationship between these novel metrics and lung function decline in patients with IPF.

METHODS

Adults with IPF undergoing prelung transplant MII-pH were enrolled. All patients completed pulmonary function testing (PFT) at the time of MII-pH and at the 1-year follow-up. MNBI was calculated by averaging baseline impedance at three 10-minute intervals (1 AM/2 AM/3 AM). PSPW index was the proportion of all reflux episodes, followed by a peristaltic swallow within 30 seconds. Univariate (Student t-test/Pearson correlation) and multivariable (general linear regression) analyses were performed.

RESULTS

One hundred twenty-five subjects (mean age = 61.7 years, 62% men) were included. Forced expiratory volume in one second and forced vital capacity declined more significantly over 12 months in subjects with lower distal MNBI, proximal MNBI, and PSPW index (all P < 0.05). On multivariable analyses adjusting for age, sex, proton pump inhibitor use, and baseline lung function, distal MNBI (β = -10.86, P = 0.024; β = -8.03, P = 0.045), proximal MNBI (β = -13.5, P = 0.0068; β = -9.80, P = 0.025), and PSPW index (β = -18.1, P = 0.010; β = -12.55, P = 0.050) remained predictive of greater forced expiratory volume in one second and forced vital capacity decline.

DISCUSSION

Low distal MNBI, proximal MNBI, and PSPW index independently predicted more severe lung function decline over 1 year in patients with IPF. These impedance metrics may have prognostic value and support a role for reflux in IPF pathogenesis.

NORMAL VALUES OF ESOPHAGEAL 24-HOUR IMPEDANCE-PH AMBULATORY IN AN ARGENTINE COHORT OF HEALTHY VOLUNTEERS

ABSTRACT Background There are no data of reference values on 24-hour multichannel intraluminal impedance and pH (pH-MII) monitoring in Argentinian populations. Objective Our aim was to obtain the normal values of pH-MII variables among healthy asymptomatic volunteers in a metropolitan Health Care Center of Argentina, and to compare them with data already published from other regions around the world. Methods A cross-sectional study was undertaken in a tertiary referral center in Buenos Aires. We enrolled healthy subjects and asked them to undergo esophageal pH-MII 24hours monitoring. pH-MII variables were recorded and described. Results Median reflux events was 20.5 (25-75%, 95%) interquartile range: (14-46, 50) and proximal reflux episodes was 2.5 (0-10, 11). Sixty percent were acid reflux episodes: 12 (5-29, 38), representing a relatively low value when compared to those reported in European, American and Chinese populations. Conclusion Our study shows the first reference of normal values of gastroesophageal reflux in an Argentinian population. We found a total number of reflux events and a total number of proximal reflux events lower than what was reported until this date by other authors.

Episode-level reflux characteristics: How experienced reviewers differentiate true reflux from artifact on pH-impedance studies

BACKGROUND

Accurate reflux episode identification is crucial for pH-impedance interpretation. Individual reflux episode characteristics associated with inter-reviewer concordance are incompletely understood.

METHODS

Ambulatory pH-impedance studies from 19 GERD patients (median age 52 years, 78.9% F) were analyzed by 5 reviewers. Metadata from pH-impedance studies were exported to a dedicated software tool designed to compare episode-by-episode identification between reviewers within a ±7.5 s window. Patient position, acidic vs. nonacidic episodes, acid clearance time (ACT), bolus clearance time (BCT), and proximal extent of reflux episodes were compared between episodes identified by all reviewers against those identified by automated analysis, and one to four reviewers, respectively.

RESULTS

Automated analysis identified 1644 episodes (median 78 episodes per patient, IQR 64-108), of which 84.9% were identified by ≥3 reviewers and 57.1% by all reviewers; 339 unique episodes were added by at least 1 reviewer. Characteristics defining 5 reviewer concordance included acid reflux episodes (88.9%), upright episodes (88.4%), high proximal extent (median 17 cm, IQR 15-17 cm), and longer acid clearance times (67.0 s, IQR 29.0-146.0 s) (P < 0.001 compared to 1-4 reviewer concordance for each). In contrast, 1 reviewer-identified episodes were 69.8% acidic, 76.9% upright, and limited to the distal esophagus. Using 5-reviewer concordance, designation of GERD evidence changed from automated analysis in 16%-19% of patients.

CONCLUSIONS

Acidic episodes with high proximal extent in the upright position and longer acid clearance times on pH-impedance studies have the highest concordance for identification by expert reviewers. Reflux episode identification may be influenced by reviewer opinion despite availability of established criteria.

Evaluating the impact of an enhanced triage process on the performance and diagnostic yield of oesophageal physiology studies post COVID-19

OBJECTIVES

The COVID-19 pandemic significantly impacted on the provision of oesophageal physiology investigations. During the recovery phase, triaging tools were empirically recommended by national bodies for prioritisation of referrals amidst rising waiting lists and reduced capacity. We evaluated the performance of an enhanced triage process (ETP) consisting of telephone triage combined with the hierarchical 'traffic light system' recommended in the UK for prioritising oesophageal physiology referrals.

DESIGN

In a cross-sectional study of patients referred for oesophageal physiology studies at a tertiary centre, data were compared between patients who underwent oesophageal physiology studies 6 months prior to the COVID-19 pandemic and those who were investigated within 6 months after service resumption with implementation of the ETP.

OUTCOME MEASURES

Adjusted time from referral to investigation; non-attendance rates; the detection of Chicago Classification (CC) oesophageal motility disorders on oesophageal manometry and severity of acid reflux on 24 hours pH/impedance monitoring.

RESULTS

Following service resumption, the ETP reduced non-attendance rates from 9.1% to 2.8% (p=0.021). Use of the 'traffic light system' identified a higher proportion of patients with CC oesophageal motility disorders in the 'amber' and 'red' triage categories, compared with the 'green' category (p=0.011). ETP also reduced the time to test for those who were subsequently found to have a major CC oesophageal motility diagnosis compared with those with minor CC disorders and normal motility (p=0.004). The ETP did not affect the yield or timing of acid reflux studies.

CONCLUSION

ETPs can effectively prioritise patients with oesophageal motility disorders and may therefore have a role beyond the current pandemic.

Post-reflux swallow-induced peristaltic wave is impaired in laryngopharyngeal and gastro-oesophageal reflux disease

INTRODUCTION

Laryngopharyngeal reflux (LPR) and gastro-oesophageal reflux disease (GORD) result from the reflux of gastric contents. The post-reflux swallow-induced peristaltic wave (PSPW) is an oesophageal reflex that facilitates chemical clearance of gastric contents following reflux events. PSPW index is a novel parameter that has been validated in assessing the effectiveness of chemical clearance in GORD, but not in LPR. This study aimed to assess chemical clearance in LPR and GORD by measuring PSPW indices in a consecutive series of patients.

METHODS

Reviewers blindly analysed off-therapy impedance-pH tracings from 187 patients clinically categorized as LPR (n = 105) or GORD (n = 82) by predominant symptom profile. Conventional impedance-pH measures and PSPW indices were analysed.

RESULTS

Mean PSPW index in the LPR group was higher than in the GORD group (39.7% (±17.7%) vs. 20.6% (±13.4%); p < 0.001). Abnormally low PSPW index (<61%) was seen in 85 (81%) of the LPR group, and 80 (97.6%) of the GORD group (p < 0.001). Area under the ROC curve for PSPW index to diagnose LPR was 0.83 (95% CI: 0.767-0.889; p < 0.001).

CONCLUSION

Post-reflux swallow-induced peristaltic wave was impaired in patients with LPR as well as oesophageal GORD, indicating an abnormality of chemical clearance following a reflux episode in both groups. PSPW index was more severely impaired in gastro-oesophageal reflux disease (GORD). The present study shows PSPW index is useful in the diagnosis of both LPR and GORD and exposes an abnormality of clearance of the oesophagus.

Is belching increasing after bariatric bypass surgery in the long term period?

BACKGROUND AND AIMS

Gastric bypass surgery effectively treats obesity; however, its association with belching, which occurs in other bariatric surgeries, remains unclear. Hence, we aimed to evaluate belching occurrence after gastric bypass surgery.

METHODS

We enrolled 12 healthy volunteers and 17 patients (12 and 5 underwent Roux-en-Y gastric bypass and mini-gastric bypass surgeries 24 (18-54) months prior, respectively). Gastrointestinal symptoms were assessed. Gastroscopy was performed, followed by the 24-hour pH-impedance analysis.

RESULTS

Age and sex were not statistically different between the two groups (P > 0.05). Patients had a significantly higher mean DeMeester score than the healthy controls (9.11 ± 19.40 vs. 6.04 ± 5.60, P = 0.048), but the pathologic acid reflux (DeMeester score > 14) rate was similar in both groups (11.8% vs. 8.3%). Regarding the impedance, symptom-association probability was positive in 11.8% of patients. The patients also had higher alkaline reflux rates (6% vs. 0%); additionally, 50% of them experienced belching based on the questionnaire, and 25% had esophagitis based on gastroscopy. Furthermore, patients had a significantly higher number of gas reflux (123.24 ± 80 vs. 37.2 ± 21.5, P = 0.001) and supragastric/ gastric belches (182 ± 64/228 ± 66.69 vs. 25.08 ± 15.20/12.17 ± 17.65, P = 0.001). Supragastric belching was more frequent than gastric belching in the controls, whereas gastric belching was more frequent in the patients.

CONCLUSION

Belching increases after gastric bypass surgery in a long-term period. Gastric belching was more frequent than supragastric belching in these patients.

Inter-reviewer Variability in Interpretation of pH-Impedance Studies: The Wingate Consensus

Ambulatory pH-impedance monitoring evaluates gastroesophageal reflux disease (GERD) symptoms that persist despite empiric treatment trials.¹ Although automated analysis of pH-impedance monitoring is known to overestimate non-acid reflux episodes,² even experts may disagree on individual reflux episodes,^3,4 and accurate identification of postreflux swallow-induced peristaltic wave (PSPW). We hypothesized that a formal consensus meeting between expert pH-impedance reviewers would establish definitive criteria for identification of reflux episodes and PSPW, and improve inter-reviewer variability.

Pharyngeal reflux episodes in patients with suspected laryngopharyngeal reflux versus healthy subjects: a prospective cohort study

PURPOSE

This study aimed to analyze pharyngeal reflux episodes in patients with suspected LPR versus healthy subjects using 24-h MII-pH monitoring.

METHODS

One hundred twenty-one patients who visited our clinic with a chief complaint of LPR-related symptoms and underwent 24-h MII-pH monitoring were enrolled prospectively. Also, 27 healthy subjects were enrolled and underwent 24-h MII-pH monitoring during the same period. We analyzed sensitivity, specificity, and accuracy comprehensively to determine appropriate cut-off values of pharyngeal reflux episodes in 24-h MII-pH monitoring to diagnose patients with LPR.

RESULTS

Twenty-nine of 121 patients with suspected LPR showed no pharyngeal reflux episodes, while 92 showed more than one pharyngeal reflux event. In contrast, the 22 healthy subjects showed no pharyngeal reflux episodes, three showed one reflux event, and two showed two reflux events. A cut-off value of ≥ 1 showed best accuracy reflected by combined sensitivity and specificity values, while ≥ 2 demonstrated better specificity with slight loss of sensitivity and slightly lower overall accuracy, suggesting cut-off value of ≥ 1 pharyngeal reflux episodes is a good clinical indicator.

CONCLUSION

A cut-off value of ≥ 1 in pharyngeal reflux episodes on 24-h MII-pH monitoring in patients with suspected LPR might be an acceptable diagnostic tool for LPR.

Low FODMAPs diet or usual dietary advice for the treatment of refractory gastroesophageal reflux disease: An open-labeled randomized trial

BACKGROUND

The low FODMAPs (fermentable oligo-, di-, monosaccharides, and polyols) diet improves lower gastrointestinal symptoms. Patients suffering from proton pump inhibitor (PPI) refractory gastroesophageal reflux disease (GERD) have limited treatment options. We investigated the efficacy of a low FODMAPs diet in patients with PPI refractory GERD.

METHODS

This multicenter, randomized, open-label study compared the efficacy of a 4-week low FODMAPs diet and usual dietary advice (ie, low-fat diet and head of bed elevation) in patients with symptomatic PPI refractory GERD, defined by a Reflux Disease Questionnaire (RDQ) score >3 and abnormal pH-impedance monitoring on PPIs. The primary endpoint was the percentage of responders (RDQ ≤3) at the end of the diet.

RESULTS

Thirty-one patients (55% women, median age 45 years) were included, 16 randomized in the low FODMAPs diet group and 15 in the usual dietary advice group. Adherence to the assigned diet was good, with a significant difference in the FODMAPs intake per day between the low FODMAPs diet (2.5 g) and the usual dietary advice group (13 g) (p < 0.001). There was no difference in response rates (RDQ score ≤3) between the low FODMAPs diet (6/16, 37.5%) and usual dietary advice (3/15, 20%) groups (p = 0.43). Total RDQ score and dyspepsia subscore decreased significantly over time in both groups (p = 0.002), with no difference according to the assigned diet group (p = 0.85).

CONCLUSION

Low FODMAPs diet and usual dietary advice have similar but limited beneficial effects on symptoms in patients with PPI refractory GERD.

Prevalence and clinical significance of esophageal motility disorders in patients with laryngopharyngeal reflux symptoms

BACKGROUND AND AIM

Esophageal motor dysfunction may underlie impaired bolus/refluxate clearance in laryngopharyngeal reflux (LPR). However, the prevalence of esophageal dysmotility and its correlation with reflux parameters and symptoms in LPR is not well established. The aim of this study was to evaluate the prevalence of coexisting esophageal dysmotility among patients with suspected LPR.

METHODS

This was a retrospective cohort study of 194 consecutive patients with LPR symptoms referred for high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance and pH testing at a tertiary center in March 2018 to August 2019. Validated symptom surveys were prospectively collected at time of testing, including Reflux Symptom Index, Gastroesophageal Reflux Disease Questionnaire, dominant symptom intensity, and 12-Item Short-Form Health Survey. HRM findings were categorized using Chicago Classification v3.0.

RESULTS

Abnormal findings on HRM were identified in 84 (43.3%) patients, with ineffective esophageal motility (n = 60, 30.9%) as the most common diagnosis. A disorder of esophagogastric junction outflow or a major disorder of peristalsis was identified in 26 (13.4%) patients, including 2 (1%) with achalasia and 7 (3.6%) with jackhammer esophagus. Reflux burden (distal, proximal, or pharyngeal) on combined hypopharyngeal-esophageal multichannel intraluminal impedance and pH testing did not differ across HRM findings. Patients reporting esophageal symptoms were more likely to have a primary motility disorder (odds ratio 2.34, P = 0.04). However, no significant differences in Reflux Symptom Index, Gastroesophageal Reflux Disease Questionnaire, or 12-Item Short-Form Health Survey were noted across HRM diagnoses.

CONCLUSION

Esophageal motility disorders are prevalent among patients with LPR symptoms, including up to one in seven with esophagogastric junction outflow or major peristaltic disorder. Patients with abnormal motility more likely report esophageal symptoms. Clinicians should be aware of these coexisting conditions, particularly in those with refractory symptoms.

Normative Ambulatory Reflux Monitoring Metrics for Laryngopharyngeal Reflux: A Systematic Review of 720 Healthy Individuals

OBJECTIVES

To review the normative data for acid, weakly acid, and nonacid proximal esophageal (PRE) and hypopharyngeal reflux (HRE) events in diagnosing laryngopharyngeal reflux (LPR) using ambulatory reflux monitoring.

DATA SOURCES

PubMed, Cochrane Library, and Scopus.

REVIEW METHODS

A literature search was conducted about the normative data for PRE and HRE on multichannel intraluminal impedance-pH monitoring (MII-pH), hypopharyngeal-esophageal MII-pH (HEMII-pH), or oropharyngeal pH monitoring using PICOTS (population, intervention, comparison, outcome, timing, and setting) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statements. Outcomes reviewed included device characteristics, impedance/pH sensor placements, study duration, number/average and percentiles of PRE or HRE occurrence, and the event characteristics (pH, composition, and position).

RESULTS

Of 154 identified studies, 18 met criteria for analysis, including 720 healthy individuals. HEMII-pH, MII-pH, and oropharyngeal pH monitoring were used in 7, 6, and 5 studies, respectively. The definition and inclusion/exclusion criteria of healthy individuals varied substantially across studies, with 6 studies considering only digestive symptoms to exclude potential LPR patients. Substantial heterogeneity across studies was noted, including impedance/pH sensor placements/configurations and definitions of composition (liquid, gas, mixed) and type (acid, weakly acid, nonacid) of PRE/HRE. The 95th percentile thresholds were 10 to 73 events for PRE, 0 to 10 events for HRE on HEMII-pH, and 40 to 128 for events with pH <6.0 on oropharyngeal pH monitoring. Most HREs were nonacid and occurred upright. The mean HRE among healthy individuals was 1.

CONCLUSION

The low number of studies and the heterogeneity in inclusion criteria, definitions, and characterization of PRE and HRE limit the establishment of consensual normative criteria for LPR on ambulatory reflux monitoring. Future large multicenter studies are needed.

Diagnostic Value of the PeptestTM in Detecting Laryngopharyngeal Reflux

BACKGROUND

The Peptest^TM is a non-invasive diagnostic test for measuring the pepsin concentration in saliva, which is thought to correlate with laryngopharyngeal reflux (LPR). The aim of this study was to investigate the diagnostic value of the Peptest in detecting LPR based on 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring using several hypopharyngeal reflux episodes as criterion for LPR.

METHODS

Patients with suspected LPR were examined with the Reflux Symptom Index (RSI), Reflux Finding Score (RFS), fasting Peptest, and MII-pH monitoring. We calculated the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the Peptest, RSI, and RFS based on the threshold of one and six hypopharyngeal reflux episodes.

RESULTS

Altogether, the data from 46 patients were analyzed. When one hypopharyngeal reflux episode was used as a diagnostic threshold for LPR, the accuracy, sensitivity, specificity, PPV, and NPV were, respectively, as follows: 35%, 33%, 100%, 100%, and 3%, for the Peptest; 39%, 40%, 0%, 95%, and 0%, for the RSI; and 57%, 58%, 0%, 96%, and 0%, for the RFS. The accuracy, sensitivity, specificity, PPV, and NPV of the Peptest for diagnosing gastroesophageal reflux disease (GERD) were 46%, 27%, 63%, 40.0%, and 48%, respectively.

CONCLUSIONS

A positive Peptest is highly supportive of a pathological LPR diagnosis. However, a negative test could not exclude LPR.

Normal acid exposure time in esophageal pH monitoring in Asian and Western populations: A systematic review and meta-analysis

BACKGROUND

Esophageal acid exposure time (AET) during 24 h pH monitoring is reproducible and predictive outcomes of treatment for gastroesophageal reflux disease. Several small Asian studies have investigated the normal range of the AET; the range may be different from that in Western populations. We evaluated its normal range in healthy Asian compared to Western subjects.

METHODS

We searched PubMed, Embase, Cochrane Library, and KoreaMed for studies that reported pH monitoring parameters in healthy subjects. Studies that reported the AET values of healthy subjects were eligible for the analyses. The upper limit of normal of the AET was obtained from the 95th percentile of the available raw data or calculated as the mean value +2 standard deviations.

KEY RESULTS

Nineteen Asian and 49 Western studies were assessed. The estimated AET values were analyzed using a bootstrapping technique, weighted according to the sample size. The mean AET was 1.1% and 2.9% in the Asian and Western populations, respectively. The upper limit of the reference range was 3.2% (95% confidence interval [CI], 2.7-3.9%) and 8.2 (95% CI, 6.7-9.9) in the Asian and Western populations, respectively. The normal AET differed between the Asian and Western populations because the CI of the two groups did not overlap.

CONCLUSIONS & INFERENCES

The upper limit of normal of the AET in healthy Asian subjects was 3.2% (95% CI, 2.7-3.9%), which was lower than that of healthy Western subjects.

Modified Reflux Scintigraphy Detects Pulmonary Microaspiration in Severe Gastro-Esophageal and Laryngopharyngeal Reflux Disease

INTRODUCTION

Previously described methodologies for detecting laryngopharyngeal reflux (LPR) have limitations. Symptoms alone are non-diagnostic, and pH-impedance studies have poor sensitivity. Pulmonary micro-aspiration is under-recognised in LPR and gastro-esophageal reflux disease (GERD). The present study aimed to describe the results of a modified technique for scintigraphic reflux studies in two groups with severe reflux: those with typical reflux symptoms and those with laryngopharyngeal manifestations of reflux.

METHODS

A prospective database of severely symptomatic, treatment-resistant reflux patients was grouped based upon predominant symptom profile of typical GERD or LPR. All patients underwent reflux scintigraphy. Results were obtained for early scintigraphic reflux contamination of the pharynx and proximal esophagus, and delayed contamination of the pharynx and lungs after 2 h.

RESULTS

187 patients were studied (82 GERD, 105 LPR). The LPR patients were predominantly female (70.5% vs. 56.1%; p = 0.042) and older than the GERD group (median age 60 years vs. 55.5 years; p = 0.002). Early scintigraphic reflux was seen at the pharynx in 89.2% (GERD 87.7%, LPR 90.4%; p = 0.133), and at the proximal esophagus in 89.7% (GERD 88.9%, LPR 90.4%; p = 0.147). Delayed contamination of the pharynx was seen in 95.2% (GERD 93.9%, LPR 96.2%; p = 0.468). Delayed pulmonary aspiration was seen in 46% (GERD 36.6%, LPR 53.3%; p = 0.023).

CONCLUSION

Reflux scintigraphy demonstrated a high rate of reflux-related pulmonary aspiration. Contamination of the proximal esophagus and pharynx was observed frequently in both groups of severe disease. The likelihood of pulmonary aspiration and potential pulmonary disease needs to be entertained in severe GERD and LPR.

Number of reflux episodes on pH-impedance monitoring associates with improved symptom outcome and treatment satisfaction in gastro-oesophageal reflux disease (GERD) patients with regurgitation

OBJECTIVE

Number of reflux episodes, an adjunctive metric on pH-impedance monitoring, is incompletely studied. We aimed to determine if number of reflux episodes associates with therapeutic outcome in regurgitation predominant gastro-oesophageal reflux disease (GERD).

DESIGN

We performed post hoc analysis of postintervention pH-impedance data from adult patients with moderate/severe regurgitation despite QD proton pump inhibitor (PPI), randomised to either two times a day PPI or magnetic sphincter augmentation (MSA) in 2:1 allocation. After 6 and 12 months, symptom response was defined by improvement in Foregut Symptom Questionnaire (FSQ) regurgitation score to none or minimal, ≥50% reduction in GERD health-related quality of life (HRQL) score and satisfaction with therapy. Univariate and multivariate analyses were performed to determine predictors of symptom improvement.

RESULTS

Of 152 randomised patients, 123 (age 46.9±1.2 year, 43% female) had complete data. Symptom and satisfaction scores significantly improved after MSA compared with two times a day PPI. Both acid exposure time (13.4%±0.7% to 1.3±0.2%, p<0.001) and reflux episodes (86±4 to 48±4, p<0.001) declined with therapy. Reduction to <40 reflux episodes was significantly more frequent in those with symptom response by FSQ regurgitation score, GERD HRQL score and satisfaction with therapy (p≤0.03 for each); <35 episodes performed better on receiver operating characteristic analysis. On multivariate analysis, improvement in regurgitation score remained independently predictive of satisfaction with therapy (p<0.001 for each). In patients crossing over to MSA, >80 episodes pretreatment predicted improvement.

CONCLUSIONS

Reduction of reflux episodes on pH-impedance to physiological levels associates with improved outcomes, while pathological levels predict improvement with MSA in regurgitation predominant GERD.

TRAIL REGISTRATION NUMBER

ClinicalTrials.gov: NCT02505945.

A new diagnostic paradigm for laryngopharyngeal reflux disease: correlation of impedance-pH monitoring and digital reflux scintigraphy results

PURPOSE

No gold-standard investigation exists for laryngopharyngeal reflux (LPR). Multichannel intraluminal impedance (MII)-pH testing has uncertain utility in LPR. Meanwhile, reflux scintigraphy allows immediate and delayed visualisation of tracer reflux in the esophagus, pharynx, and lungs. The present study aimed to correlate MII-pH and scintigraphic reflux results in patients with primary LPR.

METHODS

Consecutive patients with LPR underwent MII-pH and scintigraphic reflux studies. Abnormal values for MII-pH results were defined from existing literature. MII-pH and scintigraphic data were correlated.

RESULTS

105 patients with LPR [31 males (29.5%), median age 60 years (range 20-87)] were studied. Immediate scintigraphic reflux was seen in the pharynx in 94 (90.4%), and in the proximal esophagus in 94 (90.4%). Delayed scintigraphic contamination of the pharynx was seen in 101 patients (96.2%) and in the lungs of 56 patients (53.3%). For MII-pH, abnormally frequent reflux was seen in the distal esophagus in 12.4%, proximal esophagus in 25.7%, and in the pharynx in 82.9%. Patients with poor scintigraphic clearance had higher Demeester scores (p = 0.043), more proximal reflux episodes (p = 0.046), more distal acid reflux episodes (p = 0.023), and more prolonged bolus clearance times (p = 0.002).

CONCLUSION

Reflux scintigraphy has a high yield in LPR patients. Scintigraphic time-activity curves correlated with validated MII-pH results. A high rate of pulmonary microaspiration was found in LPR patients. This study demonstrated a high level of pharyngeal contamination by scintigraphy and MII-pH, which supports the use of digital reflux scintigraphy in diagnosing LPR.

The Role of the Transdiaphragmatic Pressure Gradient (TGP) in the Pathophysiology of Proximal Reflux

INTRODUCTION

An increased transdiaphragmatic pressure gradient (TGP) is a main element for distal gastroesophageal reflux disease (GERD). The role of TGP for proximal reflux is still unclear. This study aims to evaluate the presence, severity, and importance of proximal reflux in relationship to the TGP, comparing healthy volunteers, obese individuals, and patients with chronic obstructive pulmonary disease (COPD).

METHODS

We studied 114 individuals comprising 19 healthy lean volunteers, 47 obese individuals (mean body mass index 45 ± 7 kg/m²), and 48 patients with COPD. All patients underwent high-resolution manometry and dual-channel esophageal pH monitoring. Esophageal motility, thoracic pressure (TP), abdominal pressure (AP), TGP, DeMeester score, and % of proximal acid exposure time (pAET) were recorded.

RESULTS

Pathologic distal GERD was found in 0, 44, and 57% of the volunteers, obese, and COPD groups, respectively. pAET was similar among groups, only higher for obese individuals GERD + as compared to obese individuals GERD - and COPD GERD -. pAET did not correlate with any parameter in healthy individuals, but it correlated with AP in the obese, TP in the COPD individuals, and TGP and DeMeester score in both groups. When all individuals were analyzed as a total, pAET correlated with AP, TGP, and DeMeester score. DeMeester score was the only independent variable that correlated with pAET.

CONCLUSIONS

Our results show that (a) TGP is an important mechanism associated with distal esophageal acid exposure and this fact is linked with proximal acid exposure and (b) obesity and COPD both seem to be primary causes for GERD but not directly for proximal reflux.

A transformational change in scintigraphic gastroesophageal reflux studies: A comparison with historic techniques

BACKGROUND

The inclusion of scintigraphy in the diagnostic algorithm for gastroesophageal reflux is controversial due to variability in methodology and reporting. A novel scintigraphic reflux study has been developed and validated against the current standards for the diagnosis of gastroesophageal reflux disease (GORD).

OBJECTIVE

To compare a new scintigraphic reflux test against historic techniques and standardised diagnostic reference tests for gastroesophageal reflux disease.

METHODS

Paired scintigraphic studies were conducted in seventeen patients. All patients underwent at least one other standardised diagnostic reflux test such as 24- hour oesophageal impedance/ pH, and oesophageal manometry, barium swallow, gastroscopy or the Peptest. Patients inadvertently presented at sites B for scintigraphic reflux testing rather than at Site A which was part of an approved study. The findings from sites B did not correlate with clinical symptoms and other diagnostic reference tests from GORD. These studies were then repeated at Site A with approval from the patients. A second reflux study was performed at site A, utilising a novel technique with the capability of assessing oesophageal and extra-oesophageal disease.

RESULTS

The Site A technique shows good concordance with the reference diagnostic tests with an accuracy of 82.4% and kappa of 0.64 (SE: 0.16, p = 0.00). Site B had an overall accuracy of 47.1% and kappa of 0.066 (SE: 0.068, p = 0.45).

CONCLUSION

The Site A technique shows higher accuracy than either site B or the historic reflux techniques. It has characteristics that make it an effective screening tool for assessment of local oesophageal disease and its extraoesophageal manifestations.

Advances in the diagnosis and management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a multifaceted disorder encompassing a family of syndromes attributable to, or exacerbated by, gastroesophageal reflux that impart morbidity, mainly through troublesome symptoms. Major GERD phenotypes are non-erosive reflux disease, GERD hypersensitivity, low or high grade esophagitis, Barrett's esophagus, reflux chest pain, laryngopharyngeal reflux, and regurgitation dominant reflux. GERD is common throughout the world, and its epidemiology is linked to the Western lifestyle, obesity, and the demise of Helicobacter pylori. Because of its prevalence and chronicity, GERD is a substantial economic burden measured in physician visits, diagnostics, cancer surveillance protocols, and therapeutics. An individual with typical symptoms has a fivefold risk of developing esophageal adenocarcinoma, but mortality from GERD is otherwise rare. The principles of management are to provide symptomatic relief and to minimize potential health risks through some combination of lifestyle modifications, diagnostic testing, pharmaceuticals (mainly to suppress or counteract gastric acid secretion), and surgery. However, it is usually a chronic recurring condition and management needs to be personalized to each case. While escalating proton pump inhibitor therapy may be pertinent to healing high grade esophagitis, its applicability to other GERD phenotypes wherein the modulating effects of anxiety, motility, hypersensitivity, and non-esophageal factors may dominate is highly questionable.

Gastroesophageal Reflux Disease and Barrett Esophagus in the Elderly

As our population continues to age, the early diagnosis and optimal management of patients with gastroesophageal reflux disease becomes paramount. Maintaining a low threshold for evaluating atypical symptoms in this population is key to improving outcomes. Should patients develop complications including severe esophagitis, peptic stricture, or Barrett esophagus, then a discussion of medical, endoscopic, and surgical treatments that accounts for patient's comorbidities and survival is important. Advances in screening, surveillance, and endoscopic treatment of Barrett esophagus have allowed us to dispel concerns of futility and treat a larger subset of the at-risk population.

Normal values and regional differences in oesophageal impedance-pH metrics: a consensus analysis of impedance-pH studies from around the world

OBJECTIVE

Limitations of existing impedance-pH thresholds include small sample size of normative studies, inclusion of artefactual pH drops and incorrect identification of impedance reflux events. We aimed to obtain new impedance-pH thresholds from expert consensus analysis of tracings from a large number of healthy subjects.

DESIGN

Of 541 studies performed worldwide using two different systems (Diversatek, USA, and Laborie, Netherlands), 150 tracings with oesophageal diagnoses, behavioural disorders and study-related artefacts were excluded. The remainder studies were subject to two reviewer consensus analysis, in-person or through video conference, consisting of editing meals and pH drops, identification of impedance reflux and postreflux swallow-induced peristaltic wave (PSPW) using strict pre-established criteria and measurement of distal mean nocturnal baseline impedance (MNBI).

RESULTS

Consensus analysis was performed in 391 tracings (age 32.7 years, range 18-71, 54.2% female). Normative thresholds were significantly different between Diversatek and Laborie (total acid exposure time: 2.8% and 5%; reflux episodes: 55 and 78; MNBI at 3 cm: 1400 and 1500 ohms, at 5 cm: 1400 and 1800 ohms). Males had higher acid exposure, more reflux episodes and lower MNBI. Significant regional differences were identified, including higher PSPW scores in Western countries, and higher MNBI in Asia using Diversatek, and higher acid exposure in the Netherlands, higher MNBI in Asia and South Africa, and lower MNBI in Turkey using Laborie.

CONCLUSION

Normal impedance-pH monitoring thresholds have regional and system-related differences. Clinical interpretation needs to use normal thresholds valid for the system used and world region, following careful editing of the tracings.