Twelve hour overnight oesophageal pH monitoring in patients with reflux symptoms

Oesophageal function testing and antireflux surgery

Despite the increasing emphasis that is placed on both pH measurement and oesophageal manometry, there is little consensus about their usefulness in the clinical setting. These tests are far from infallible and it is difficult to support their universal application in patients with gastrooesophageal reflux disease. Nevertheless, these imperfect tests are useful in certain situations and clinicians must strive to use them intelligently for those most likely to benefit.

Esophageal motility and reflux testing. State-of-the-art and clinical role in the twenty-first century

Esophageal function testing has an important place in the investigation of a significant proportion of patients with esophageal disorders. Appropriate application of these tests requires a proper understanding of their capabilities and limitations and careful primary assessment by other modalities. Esophageal manometry is most useful for assessing significant troublesome dysphagia in the absence of organic obstruction. Esophageal pH monitoring is an important adjunct to clinical assessment and endoscopy in the diagnosis of reflux disease. Although it is the gold standard for the measurement of esophageal acid exposure and assessment of the relationship of symptoms to reflux, there are weakness in both of these functions that should be understood when applying the test to the diagnosis of reflux disease.

Symptoms and disease severity in gastro-oesophageal reflux disease

The definition of criteria relevant to disease severity assessments should be considered in parallel with the long-term aims of treatment in gastro-oesophageal reflux disease (GORD). There is no doubt that the resolution of symptoms is the major management aim. Heartburn and regurgitation are specific for GORD when they are the predominant symptoms, but prove to be insensitive when the diagnosis of GORD is based on the measurement of oesophageal acid exposure. A relationship between the frequency of heartburn and the degree of acid exposure has been reported in GORD patients both with and without oesophagitis. GORD may also, however, cause a wide spectrum of atypical symptoms (e.g. non-cardiac chest pain or respiratory symptoms). To the extent that a causal relationship between these symptoms and reflux episodes has been established, evaluation of symptom severity should also encompass these atypical presentations. The role of symptoms in the prediction of relapse of oesophagitis is controversial, but in several studies the presence of residual symptoms of GORD at the time of healing has indicated a greater probability of relapse. Endoscopy is a useful technique for the evaluation of disease severity. Indeed, even typical symptoms may not predict the presence and severity of oesophagitis in an individual patient. Despite the fact that the interpretation of therapeutic trials is often impeded by differences in the grading systems used, healing rates of oesophageal lesions are inversely proportional to the initial severity of oesophagitis when drugs such as H2-receptor antagonists are used. Differences are less evident with highly effective drugs such as omeprazole.(ABSTRACT TRUNCATED AT 250 WORDS)

Prolonged intraesophageal pH monitoring with 16-hr overnight recording. Comparison with "24-hr" analysis

From studies in 43 patients (17 male, 26 female, mean age 51 years), we compared the analysis of the routine complete "24-hr" ambulatory esophageal pH monitoring study to that of the 16-hr overnight interval (4:00 PM to 8:00 AM). The latter included a major meal with an upright postprandial period and a recumbent period. All patients were monitored for at least 20 hr (median = 22.6 hr). The percent distal esophageal pH less than 4.0 and number of reflux episodes were measured for the total, upright, and recumbent periods of both the 16-hr and "24-hr" monitoring times. Significant (P less than 0.001) positive correlations were found for all comparisons between the two monitoring periods including percent time of pH less than 4.0 (total: r = 0.98; upright: r = 0.96) and number of episodes (totals r = 0.97; upright: r = 0.93). Patients were separated into normal and abnormal refluxers based on results of "24-hr" monitoring (pH below 4.0 greater than 4.2% total time; greater than 6.0% upright; greater than 1.2% recumbent). Based on this, sensitivity and specificity for 16-hr monitoring were as follows: total study: 86% and 95%; upright: 80% and 91%; recumbent: 100% for both.

CONCLUSIONS

(1) a 16-hr overnight pH monitoring period can provide a reliable representation of "24-hr" distal esophageal acid exposure, (2) this shorter monitoring may improve patient acceptability and compliance, and (3) the symptom index was changed in 26.3% of patients using the 16-hr evaluation.