Wireless pH monitoring: better tolerability and lower impact on daily habits

Diagnostic Yield of Ambulatory Reflux Monitoring Systems for Evaluation of Chronic Laryngeal Symptoms

INTRODUCTION

Among patients with chronic laryngeal symptoms, ambulatory reflux monitoring off acid suppression is recommended to evaluate for laryngopharyngeal reflux (LPR). However, reflux monitoring systems are diverse in configuration and monitoring capabilities, which present a challenge in creating a diagnostic reference standard in these patients. This study aimed to compare diagnostic yield and performance between reflux monitoring systems in patients with chronic laryngeal symptoms.

METHODS

This multicenter, international study of adult patients referred for evaluation of LPR over a 5-year period (March 2018-May 2023) assessed and compared diagnostic yield of pathologic gastroesophageal reflux (GER+) on ambulatory reflux monitoring off acid suppression.

RESULTS

Of 813 patients, 296 (36%) underwent prolonged wireless pH, 532 (65%) underwent 24-hour pH-impedance monitoring, and 15 (2%) underwent both tests. Overall diagnostic yield for GER+ was 36% and greater for prolonged wireless pH compared with that for 24-hour pH-impedance monitoring (50% vs 27%; P < 0.01). Among 15 patients who underwent both prolonged wireless pH and 24-h pH-impedance monitoring, concordance between systems for GER+ was 40%. The most common source of discordance was strong evidence of GER+ across multiple days on prolonged wireless pH compared with no evidence of GER+ on pH-impedance.

DISCUSSION

In this multicenter international study of patients with chronic laryngeal symptoms referred for LPR evaluation, diagnostic yield of ambulatory reflux monitoring off acid suppression was 36% and rose to 50% when using wireless pH monitoring. In patients referred for chronic laryngeal symptoms, 24-hour pH-impedance monitoring may risk a low negative predictive value in patients with unproven GER+ disease.

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.

Latin American consensus on diagnosis of gastroesophageal reflux disease

BACKGROUND

Diagnosing gastroesophageal reflux disease (GERD) can be challenging given varying symptom presentations, and complex multifactorial pathophysiology. The gold standard for GERD diagnosis is esophageal acid exposure time (AET) measured by pH-metry. A variety of additional diagnostic tools are available. The goal of this consensus was to assess the individual merits of GERD diagnostic tools based on current evidence, and provide consensus recommendations following discussion and voting by experts.

METHODS

This consensus was developed by 15 experts from nine countries, based on a systematic search of the literature, using GRADE (grading of recommendations, assessment, development and evaluation) methodology to assess the quality and strength of the evidence, and provide recommendations regarding the diagnostic utility of different GERD diagnosis tools, using AET as the reference standard.

KEY RESULTS

A proton pump inhibitor (PPI) trial is appropriate for patients with heartburn and no alarm symptoms, but nor for patients with regurgitation, chest pain, or extraesophageal presentations. Severe erosive esophagitis and abnormal reflux monitoring off PPI are clearly indicative of GERD. Esophagram, esophageal biopsies, laryngoscopy, and pharyngeal pH monitoring are not recommended to diagnose GERD. Patients with PPI-refractory symptoms and normal endoscopy require reflux monitoring by pH or pH-impedance to confirm or exclude GERD, and identify treatment failure mechanisms. GERD confounders need to be considered in some patients, pH-impedance can identify supragrastric belching, impedance-manometry can diagnose rumination.

CONCLUSIONS

Erosive esophagitis on endoscopy and abnormal pH or pH-impedance monitoring are the most appropriate methods to establish a diagnosis of GERD. Other tools may add useful complementary information.

The assessment of patients with non-erosive gastroesophageal reflux disease by using the Bravo® pH monitoring system

Background and aim: Gastroesophageal reflux disease (GERD) is a common disease in the world. GERD is always treated with drugs. The Bravo® wireless pH monitoring system is a good technique. The Bravo® may affect increasing the specificity and sensitivity in the diagnosis of GERD with its 48-hour recording feature. In this study, we aimed to assess the diagnostic performance of the Bravo® pH monitoring system in patients with non-erosive GERD. Materials and Methods: Patients with non-erosive reflux disease (normal endoscopy) whose symptoms persisted after PPI treatment (at least two months) were included in the study. All patients had upper gastrointestinal system endoscopies performed in our clinic between January 2013 and December 2019. All patients had a 48-hour Bravo® wireless pH monitoring record. Results: Twenty-three patients (M: 18 (78.3%; Age: 35.7 ± 11) were included in the study. All patients completed the 2-day recording protocol. During and after the procedure, no patient showed any adverse effects of the Bravo® procedure. We diagnosed GERD in 13 of 23 patients by Bravo® capsule. According to the Bravo® pH-meter recordings; Total time pH < 4 (minute) was 187 ± 190, the total number of refluxes was 90 ± 61, the percentage of time with pH < 4 was 7.1 ± 7.22, the number of long reflux events were 8.1 ± 8, the duration of the longest reflux episode during pH < 4 (minute) was 31 ± 49, the Demeester score was 20.8 ± 19.3 detected. Conclusion: Based on the results of the current study, the Bravo® pH monitoring system is a practical and effective diagnostic technique for non-erosive GERD. Further prospective studies would be useful for comparing the differences between 24-hour and 48-hour pH recording results.

A SIGE-SINGEM-AIGO technical review on the clinical use of esophageal reflux monitoring

Patients with esophageal symptoms potentially associated with gastroesophageal reflux disease such as heartburn, regurgitation, chest pain, or cough represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal reflux monitoring in clinical practice is: (1) to accurately define reflux burden, (2) to segregate patients according to reflux monitoring results as true GERD, reflux hypersensitivity and functional heartburn, and (3) to establish a treatment plan. With this in mind, in the last decade, investigations and technical advances, with the introduction of impedance-pH monitoring and wireless pH capsule, have enhanced our understanding and management of GERD. The following recommendations were discussed and approved after a comprehensive review of the medical literature pertaining to reflux testing techniques and their recent application. This review created under the auspices of the Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE), Società Italiana di Neuro-Gastro-Enterologia e Motilità (SINGEM) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying reflux studies in the most fruitful manner within the context of their patients with esophageal symptoms.

[The Additional Role of Symptom-Reflux Association Analysis of Diagnosis of Gastroesophageal Reflux Disease Using Bravo Capsule pH Test]

Background/Aims

Since the development of ambulatory esophageal pH monitoring test to diagnose gastroesophageal reflux disease (GERD), several parameters have been introduced. The aim of this study was to assess whether using the symptom index (SI), symptom sensitivity index (SSI), and symptom association probability (SAP), in addition to the DeMeester score (DS), would be useful for interpreting the Bravo pH monitoring test.

Methods

A retrospective study, which included 68 patients with reflux symptoms refractory to proton pump inhibitor (PPI) therapy who underwent a Bravo capsule pH test between October 2006 and May 2015, was carried out. Acid reflux parameters and symptom reflux association parameters were analyzed.

Results

The median percent time of total pH<4 and DS were 2.90% (interquartile range [IQR] 1.13-6.03%) and 11.10 (IQR 4.90-22.80), respectively. According to the analysis of the day-to-day variation in percent time of total pH<4 (r=0.724) and DS (r=0.537), there was a significant correlation between Day 1 and Day 2. The positive rate of Bravo test according to DS was 27 (39.7%). Although thirty patients experienced symptoms during the test, there were no significant differences of reflux parameters compared with other patients. In the symptom group, 7 patients (23.3%) were identified as having negative DS and an abnormal symptom-related index. There were no significant test-related complications.

Conclusions

In addition to the analysis of traditional acid parameters of the Bravo capsule pH test, diagnosis of GERD, including reflux hypersensitivity, can be improved by performing an analysis of the symptom-reflux association and of the day-to-day variation.

Safety and Efficacy of Wireless pH Monitoring in Patients Suspected of Gastroesophageal Reflux Disease: A Systematic Review

INTRODUCTION

The primary aim of this systematic review was to determine the safety, technical efficacy, and effectiveness of 48-hour wireless pH monitoring (WM) for gastroesophageal reflux disease (GERD), compared with no pH monitoring in patients who failed to tolerate a catheter. In the absence of eligible studies, the secondary aim was to determine these performance characteristics for WM relative to catheter-based pH monitoring (CBM) in patients suspected of GERD, who are able to tolerate a catheter.

METHODS

A protocol was registered on the PROSPERO database (CRD42013005852) before conducting the systematic review, which included the study selection criteria, and critical appraisal methods. Several key databases were searched to identify eligible comparative studies.

RESULTS

Chest pain occurred more often with WM compared with CBM; however, other adverse events were reported less frequently with WM. Technical failures, mostly due to attachment failures and early capsule detachments, were 3 times higher with WM, compared with CBM, [pooled relative risk (from meta-analysis)=3.3; 95% confidence interval, 1.63-6.81; I=0%; P=0.012; k=8). The sensitivity and specificity of WM varied widely, depending on type of analysis, monitoring time, capsule placement, reference standard, and diagnostic threshold.

DISCUSSION

WM is usually better tolerated than CBM but has more technical problems. Test accuracy was highly variable between studies; therefore, conclusions could not be drawn regarding the performance of the 2 tests. To make meaningful comparisons between WM and CBM a consensus is needed on the diagnostic threshold for GERD, monitoring time, appropriate capsule positioning, and the reference standard.

Long-term wireless pH monitoring of the distal esophagus: prolonging the test beyond 48 hours is unnecessary and may be misleading

Wireless pH monitoring of the esophagus has been widely used to detect GERD for more than a decade. It is generally well tolerated and accepted by patients, but it is still unclear whether prolonging a recording beyond the usual 48 hours can improve the test's diagnostic value. The aim of this study is to examine the diagnostic yield of 96-hour pH monitoring vis-à-vis 24- and 48-hour tests, and to ascertain whether any gain in diagnostic terms was of genuine clinical utility. Patients with suspected GERD underwent 4-day PPI-off wireless pH monitoring of the distal esophagus. The capsule was inserted under endoscopic control, 6 cm above the squamocolumnar junction. Average acid exposure time was calculated after 24, 48, and 96 hours of recording. Ninety-nine patients completed the 96 hour test, and formed the study sample. The wireless test method was used in 42 patients (42.4%) unable to tolerate the traditional pH-monitoring catheter, and in 57 (57.6%) with a previous negative pH study despite symptoms suggestive of GERD. On complete analysis, 47 patients (47.5%) had a pathological test result: 19 patients within the first 24 hours (19.2%, 24 hour group); another 16 after 48 hours (+16.2%, 48 hour group), and a further 12 (+12.1%, 96 hour group) only after 96 hours of monitoring. All 47 patients with an abnormal acid exposure were offered and accepted surgery (10 patients) or medical therapy (37 patients). Clinical follow-up was obtained in all patients with a positive Bravo test result after a median 67 months (IQR: 38-98) using a validated symptom questionnaire. A good outcome after fundoplication or medical therapy was achieved in 73.7% of patients in the 24 hour group, in 62.5% of those in the 48 hour group, and in only 25% of those in the 96 hour group, P = 0.02. Long-term wireless pH monitoring enables an increase in the diagnostic yield over traditional 24- and 48-hour pH studies, but prolonging the test may constitute an unwanted bias and prompt the recruitment of more complex patients, in whom the outcome of surgical or medical therapy may prove less than satisfactory. These findings should be taken into account when establishing the guidelines for assessing GERD with such long-term pH monitoring methods.

Sedation and Afternoon Placement of the 48-Hour Wireless Ambulatory pH Capsule Results in More Reflux on the First Day

BACKGROUND

A 48-hour wireless capsule results often vary from the first to second day. Previous investigations comparing discrepant acid reflux readings have yielded variable results. In this study we investigated differences in data obtained on day 1 versus day 2, and the effect of time of capsule placement on discrepancies.

METHODS

We performed a retrospective cohort study. Patients undergoing a 48-hour wireless capsule study between January 2012 through November 2013 were eligible for inclusion. We collected reflux data for each patient and calculated the proportion of patients in four groups based on abnormal DeMeester score groups (+/+, -/+, +/-, -/-). We placed patients into morning placement or afternoon placement categories and calculated the proportions of patients with various DeMeester score discrepancies.

KEY RESULTS

This study evaluated 229 patients. The mean day 1 DeMeester score was 28.38 and the mean day 2 DeMeester score was 23.24 (P<0.0001). The mean day 1 DeMeester score in the morning group was 24.9 and 31.7 in the afternoon group (P<0.05). The mean total DeMeester score in the morning placement group was 23.1 and 30.6 in the afternoon group (P<0.05). Twenty-five percent of afternoon patients had a +day 1/-day 2 DeMeester discordance, whereas only 12% of morning placement patients had this discordance (P=0.26).

CONCLUSIONS

Afternoon capsule placement is associated with a significantly increased amount of acid reflux on day 1. Approximately 10% of 48-hour esophageal wireless monitoring studies may falsely overestimate reflux when the capsule is placed in the afternoon. Capsule placement should ideally be performed in the morning.

Interference with daily activities and major adverse events during esophageal pH monitoring with bravo wireless capsule versus conventional intranasal catheter: a systematic review of randomized controlled trials

For three decades, ambulatory 24-hour intranasal pH monitoring has been the established gold standard for detecting acid reflux in patients with refractory gastroesophageal reflux disease. However, device-associated adverse events and unpleasant experiences, reported by patients during pH monitoring have led to the invention of more convenient pH monitors such as Bravo wireless capsule. To compare the interference with daily activities and major adverse events during pH monitoring with Bravo wireless capsule (Bravo) versus conventional intranasal catheter (catheter), PubMed, Cochrane Library, Clinical Trials.gov, and Google Scholar were searched up to March 20, 2015. Only randomized controlled trials in adult patients that compared the interference with routine daily activities and adverse events between Bravo and catheter pH monitors were included. After screening 574 articles, three unique studies with 167 patients met our inclusion criteria. The average age of patients enrolled in these studies was 51 years. Interference with normal daily activities was more in the catheter than Bravo group: 75 ± 5 versus 92 ± 2, P < 0.001 (Andrews et al, findings were reported as100 mm, mean visual analogue scale (VAS) ± standard error of the mean, 100 = completely normal); Wong et al. (mean ± standard error of the mean): 1.3 ± 0.2 versus 0.32 ± 0.1, P = 0.001 and Wenner et al. using 10 cm median VAS (Interquartile range),10 been the worst is 5.7 (2.3-8.0) compared to 0.7 (0.2-3.4), P < 0.0001, respectively. Overall adverse events were more in the catheter group than Bravo (39 ± 4 vs. 26 ± 4, P = 0.012 for Andrews et al. (100 been the worst) and 5.1 (2.0-6.6) vs. 2.1 (0.5-4.6), P < 0.001 for Wenner et al.). No overall adverse events recorded for Wong et al. Most patients in catheter group complained of nasal and throat symptoms. Significantly, runny nose in 24 out of 25 patients (96%) catheter versus 13 out of 25 (52%) Bravo, P = 0.001 and nose pain 15 out 25 (60%) versus 8 out of 25 patients (32%), P = 0.047, respectively for Wong et al. Andrews and Wenner et al also showed profound nasal discomforts in catheter group compared to Bravo (39 ± 3 vs. 10 ± 3, P < 0.001 and 6.5 (1.5-8.0) versus 0.2 (0.0-1.9), P < 0.0001, respectively. Throat symptoms reported in Wong et al. were mainly throat discomfort in catheter group 23 out of 25 patients (92%) versus Bravo 12 out of 25 (48%), P = 0.001 and throat pain catheter (12 out of 25 patients (48%) vs. Bravo 4 out of 25 (16%)), P = 0.032. This trend was also observed in Andrews et al. with profound throat discomfort in the catheter group 43 ± 4 compared to Bravo 19 ± 4, P < 0.001. Majority of the patients randomized to Bravo group reportedly perceived chest pain higher than those in catheter group; 9 out of 25 patients (36%) versus 2 out of 25 (8%), P = 0.037 in Wong et al. 29 ± 4 versus 14 ± 3, P = 0.001 for Andrews et al., 2.4 (0.3-5.9) versus 1.1 (0.3-2.9), P = 0.084 in Wenner et al. respectively (though not statistically significant). Bravo wireless capsule pH monitor interfered less with daily activities and adverse events were minimal compared to conventional intranasal catheter.

Yield of prolonged wireless pH monitoring in achalasia patients successfully treated with pneumatic dilation

BACKGROUND

Gastro-oesophageal reflux disease (GORD) is a long-term complication of achalasia treatments. The aim of our study was to evaluate the yield of prolonged wireless pH monitoring in patients with successfully treated achalasia and its influence on proton pump inhibitor (PPI) use.

METHODS

Twenty-five patients with achalasia who underwent prolonged wireless pH monitoring after a successful treatment with pneumatic dilation were enrolled. pH variables were analysed in the first 24 hours of monitoring to determine if tracings were indicative of GORD; the same variables were analysed in the following 24-hour period in order to obtain a worst-day diagnosis of GORD. PPI therapy before and after the test was recorded.

RESULTS

Five out of 25 patients had GORD diagnosis during the first day of monitoring and four of them had oesophagitis at endoscopy. During the following days of monitoring four more patients had a diagnosis of GORD. Out of the 25 patients, PPIs were started after the test in six asymptomatic GORD-positive ones, whereas prescription of PPIs was stopped without detrimental effect on symptoms in three GORD-negative patients.

CONCLUSIONS

Prolonged wireless pH monitoring is a useful test to be added to endoscopy in order to evaluate GORD and to optimise antisecretory treatment in successfully treated achalasia patients.

Evaluation of Gastroesophageal Reflux Disease Using the Bravo Capsule pH System

Gastroesophageal reflux disease (GERD) is a disease predominantly seen in the West but there is a rising trend in Asia. Ambulatory 24-hour catheter-based pH monitoring has been the de facto gold standard test for GERD that correlates symptoms with acid reflux episodes. However, drawbacks such as patients’ discomfort, and catheter displacement render the test as cumbersome and error-prone. The Bravo pH wireless system is designed to be user-friendly and has an added advantage of prolonged pH monitoring. The system is comparable to the catheter-based pH monitoring system in terms of diagnostic yield and symptom-reflux association. Indications include evaluation of patients with refractory GERD symptoms and prior to anti-reflux surgery. Bravo utilizes a wireless pH-sensing capsule with a complete prepackaged system, and a data processing software. The capsule may be positioned indirectly using endoscopic or manometric landmarks or under direct endoscopic guidance. Optimal threshold cut-off values are yet to be standardized but based on available studies, for the Asian population, it may be recommended for total % time pH < 4 of 5.8 over 48 hours. Cost is a limitation but capsule placement is relatively safe although technical failures may be seen in small percentage of cases.

Inconsistency in the Diagnosis of Functional Heartburn: Usefulness of Prolonged Wireless pH Monitoring in Patients With Proton Pump Inhibitor Refractory Gastroesophageal Reflux Disease

Background/Aims

The diagnosis of functional heartburn is important for management, however it stands on fragile pH monitoring variables, ie, acid exposure time varies from day to day and symptoms are often few or absent. Aim of this study was to investigate consistency of the diagnosis of functional heartburn in subsequent days using prolonged wireless pH monitoring and its impact on patients’ outcome.

Methods

Fifty proton pump inhibitotor refractory patients (11 male, 48 years [range, 38–57 years]) with a diagnosis of functional heart-burn according to Rome III in the first 24 hours of wireless pH monitoring were reviewed. pH variables were analysed in the following 24-hour periods to determine if tracings were indicative of diagnosis of non-erosive reflux disease (either acid exposure time > 5% or normal acid exposure time and symptom index ≥ 50%). Outcome was assessed by review of hospital files and/or telephone interview.

Results

Fifteen out of 50 patients had a pathological acid exposure time after the first day of monitoring (10 in the second day and 5 in subsequent days), which changed their diagnosis from functional heartburn to non-erosive reflux disease. Fifty-four percent of non-erosive reflux disease vs 11% of functional heartburn patients (P < 0.003) increased the dose of proton pump inhibitors or underwent fundoplication after the pH test. Outcome was positive in 77% of non-erosive reflux disease vs 43% of functional heartburn patients (P < 0.05).

Conclusions

One-third of patients classified as functional heartburn at 24-hour pH-monitoring can be re-classified as non-erosive reflux disease after a more prolonged pH recording period. This observation has a positive impact on patients’ management.

Wireless esophageal pH capsule for patients with gastroesophageal reflux disease: A multicenter clinical study

AIM: To investigate the feasibility and safety of pH capsule to monitor pH in patients with gastroesophageal reflux disease (GERD).

METHODS: Ninety-one patients with symptoms suggestive of GERD were enrolled in this study, 46 of whom were randomized to the pH capsule group; the remaining 45 patients used the conventional catheter and pH capsule simultaneously. The pH data and traces were recorded via automatic analysis, and capsule detachment was assessed using X-ray images. All of the patients were required to complete a questionnaire regarding tolerance with the capsule.

RESULTS: The capsules were successfully attached on the first attempt, and no early detachment of the capsules was observed. Compared to the 24-h pH data recorded with the conventional catheter, the data collected with the pH capsule showed no significant differences in 24-h esophageal acid exposure. The measurements of esophageal acid exposure over 24 h collected with the two devices showed a significant correlation (r² = 0.996, P < 0.001). Capsule detachment occurred spontaneously in 89 patients, and 2 capsules required endoscopic removal due to chest pain. The capsule was associated with less interference with daily activity.

CONCLUSION: The wireless pH capsule provides a feasible and safe method for monitoring gastroesophageal reflux and therefore may serve as an important tool for diagnosing GERD.

Comparative analysis of primary repair vs resection and anastomosis, with laparostomy, in management of typhoid intestinal perforation: results of a rural hospital in northwestern Benin

Background

Wireless esophageal pH monitoring system is an important approach for diagnosis of gastroesophageal reflux disease (GERD), the aim of this study is to test the tolerability and utility of the first wireless esophageal pH monitoring system made in China, and evaluate whether it is feasible for clinical application to diagnose GERD.

Methods

Thirty patients from Department of Gastroenterology of The First Affiliated Hospital of Chongqing Medical University who were suspected GERD underwent JSPH-1 pH capsule. The capsule was placed 5 cm proximal to the squamocolumnar junction (SCJ) by endoscopic determination, the data was recorded consecutively for 48 hours. Then all pH data was downloaded to a computer for analysis. The discomforts reported by patients were recorded.

Results

30 patients were placed JSPH-1 pH capsule successfully and completed 24-hour data recording, 29 patients completed 48-hour data recording. One patient complained of chest pain and required endoscopic removal. No complications and interference of daily activities were reported during data monitoring or follow-up period. 48-hour pH monitoring detected 15 patients of abnormal acid exposure, on day1 detected 9 patients, the difference had statistical significance (P<0.01). Positive symptom index (SI) was identified in 3 patients with normal pH data in both 24-hours. In total, 48-hour monitoring increased diagnosis of GERD in 9 patients.

Conclusion

48-hour esophageal pH monitoring with JSPH-1 wireless pH monitoring system is safe, well tolerated and effective. It can be feasible for clinical application to diagnose GERD.

Wireless oesophageal pH monitoring: establishing values in a multiracial cohort of asymptomatic Asian subjects

BACKGROUND

Wireless oesophageal (Bravo) readings in healthy European and American subjects show varied results. Values in Asians remain unstudied.

AIMS

We performed Bravo studies in healthy Asians to determine if values differed from previously published and identified reflux parameters to differentiate healthy volunteers from patients.

METHODS

Fifty healthy volunteers were recruited between August 2009 and August 2011 to undergo 48 h wireless pH monitoring. Bravo capsule was introduced transorally and placed 6 cm above the squamocolumnar junction. Acid reflux parameters were compared against 41 patients previously evaluated for non-erosive reflux disease.

RESULTS

Five volunteers were excluded. Capsule dislodgement occurred in four and three volunteers on study days 1 and 2 respectively. Forty and 37 volunteers (73% male, mean age 33.0 ± 7.6 years) had interpretable readings at 24 and 48 h, respectively. Percentage of time oesophageal pH<4 in 37 volunteers who completed 48 h recordings was 1.6% (7.5%), 1.5% (6.3%) and 1.9% (5.8%) on days 1, 2 and overall study duration, respectively.

CONCLUSION

Bravo readings in Asians differed from previously published. Percentage of time oesophageal pH<4 on day 2 and DeMeester score on day 2 (95th percentile 22.9) best discriminated healthy volunteers from patients.

Diagnostic yield of 96-h wireless pH monitoring and usefulness in patients' management

OBJECTIVE

To get insight into usefulness of 96-h wireless monitoring in diagnosis of gastro-esophageal reflux disease (GERD) and in patients' management.

MATERIAL AND METHODS

51 patients who underwent 96-h wireless and 51 matched patients who underwent 24-h traditional pH monitoring were enrolled and retrospectively contacted with a structured telephone interview.

RESULTS

In the wireless group, the 96-h recording improved (p < 0.05) the diagnostic yield compared with the first 48-h recording by allowing Symptom Association Probability to be measured in eight more patients and by decreasing indeterminate tests from 11 to 5. After pH monitoring, concordance between results of the test and treatment for GERD was higher in the wireless compared with the traditional group, 78% versus 58% of the patients (p < 0.05). Both improvement/disappearance of the clinically relevant symptom and satisfaction (score of 1-10) at time of the telephone interview were however similar in the two groups, 73% versus 65% and 7.0 versus 6.5.

CONCLUSIONS

Wireless pH monitoring prolonged to 96 h increased the likelihood to exclude/confirm GERD as the cause of the clinically relevant symptoms in those patients with an indeterminate result for GERD after the first 48 h. Outcome was however similar to the one of traditional pH monitoring.

To Bravo or not? A comparison of wireless esophageal pH monitoring and conventional pH catheter to evaluate non-erosive gastroesophageal reflux disease in a multiracial Asian cohort

OBJECTIVE

Non-erosive reflux disease (NERD) constitutes the majority of patients with gastroesophageal reflux disease (GERD). Esophageal pH monitoring is useful in distinguishing patients with NERD from functional heartburn. The gastroenterologist often faces the dilemma of choosing the most appropriate investigative modality. The wireless Bravo capsule allows prolonged 48 hour monitoring with improved patient tolerance, but concerns regarding its reduced sensitivity compared to conventional pH catheter have been raised. We compared the prevalence of high esophageal acid exposure and positive symptom correlation profiles (using the symptom index [SI] and symptom association probability [SAP]) in patients who underwent Bravo compared to patients who underwent conventional pH catheter, and evaluated the efficacy of Bravo monitoring in a multiracial Asian cohort.

METHODS

Retrospective analysis of all pH studies performed between January 2004 and February 2009 for patients with persistent reflux symptoms and a normal gastroscopy.

RESULTS

66 (27 Male, 42.4 +/- 13.4 years) and 55 (24 Male, 47.1 +/- 13.3 years) patients underwent wireless and pH catheter evaluation respectively. "True NERD" (abnormal acid exposure) was diagnosed in 26 (39.4%) and 20 (36.4%) patients (pNS) while "acid-sensitive esophagus" (SI > or = 50% and/or SAP > or = 95%) occurred in 14 (21.2%) and 12 (21.8%) patients (pNS) using the wireless and pH catheter respectively. Extended recording time with Bravo led to an incremental diagnostic yield of 30%.

CONCLUSION

The wireless capsule was well tolerated. The diagnostic yield was similar using both modalities. With the increasing availability of impedance-pH technology, it is uncertain if devices that detect only acid-reflux events will be surpassed.

Subcardial 24-h wireless pH monitoring in gastroesophageal reflux disease patients with and without hiatal hernia compared with healthy subjects

OBJECTIVES

After meals, highly acidic gastric juice is present in the subcardial region, the so-called acid pocket. Patients with gastroesophageal reflux disease (GERD) have a higher frequency of acidic reflux. Our aim was to investigate the possible differences in subcardial pH in GERD over 24 h and the role of hiatal hernia (HH), using a wireless capsule.

METHODS

A total of 14 healthy volunteers (4 men, 24-60 years), 10 GERD patients without HH (4 men, 25-68 years), and 11 GERD patients with HH >or=3 cm (2 men, 46-74 years) underwent 24-h wireless pH monitoring 2 cm below the squamocolumnar junction. All patients had increased 24-h acid reflux. A standardized lunch was given to all study subjects.

RESULTS

No capsule detached during the 24-h recording. Median 24-h pH was similar in healthy subjects, and in patients without and with HH, median: 1.4 (interquartile range: 1.2 -1.9), 1.5 (1.3 -1.7), and 1.4 (1.3 -1.7), respectively. Similar results were seen in the supine period. Median pH after the standardized meal was often highly acidic, 2.7 (1.5 - 3.2), 1.9 (1.6 - 2.3), and 2.5 (1.6 - 3.2), respectively. The first minute with a median pH <2 occurred 14 min (4 - 49), 14 min (6 - 25), and 20 min (4 - 43), respectively, P=NS, after the end of the meal. Similar data were observed on pooling all meals together.

CONCLUSIONS

Subcardial pH is confirmed to be highly acidic early after meals, but it is similar over 24 h in healthy subjects and GERD patients independent of the presence of HH.