The role of impedance monitoring in patients with extraesophageal symptoms

OBJECTIVES/HYPOTHESIS

Ambulatory esophageal impedance monitoring is commonly employed to assess for nonacid reflux in patients with extraesophageal reflux. We aimed to determine if on therapy impedance data can be predicted from off therapy upper endoscopy, manometry, or pH parameters.

STUDY DESIGN

Prospective Cohort Study.

METHODS

Patients with extraesophageal reflux symptoms and either partial- or nonresponders to twice-daily PPI underwent impedance monitoring on twice-daily PPI, as well as manometry, upper endoscopy, and 48-hour wireless pH monitoring off acid-suppressive medications for 1 week. Percent time pH < 4 and number of reflux episodes were obtained. Multivariable linear regression was used to determine association between the impedance data on therapy and upper endoscopy, manometry, and pH parameters measured off therapy.

RESULTS

Seventy-five patients (77% female, median BMI 29, 38% with hiatal hernia, and 19% with esophagitis) were studied both on and off therapy. Thirty-five percent had abnormal impedance monitoring on therapy and 84% had abnormal pH testing off therapy. There was no significant (P = 0.184) overall correlation between total number of impedance events and the baseline physiologic parameters of hiatal hernia, degree of acid reflux, or manometric findings, with only weak correlation (r = 0.54, P = 0.045) with % time pH < 4 among patients with esophagitis.

CONCLUSIONS

In patients with suspected extraesophageal reflux refractory to PPI therapy, impedance measures on therapy cannot be predicted from traditional baseline esophageal physiologic parameters. We recommend caution regarding over-interpretation of impedance data.

LEVEL OF EVIDENCE

2b.

High economic burden of caring for patients with suspected extraesophageal reflux

OBJECTIVES

Extraesophageal symptoms are common manifestations of gastroesophageal reflux disease (GERD). Lack of a definitive diagnostic or treatment standards complicate management, which often leads to multiple specialty consultations, procedures, pharmaceuticals and diagnostic tests. The aim of this study was to determine the economic burden associated with extraesophageal reflux (EER).

METHODS

Direct costs of evaluation were estimated for patients referred with symptoms attributed to EER between 2007 and 2011. Medicare payment for evaluation and management and pharmaceutical prices was used to calculate first year and overall costs of evaluating and treating extraesophageal symptoms attributed to reflux.

RESULTS

Overall, 281 patients were studied (cough (50%), hoarseness (23%), globus/post-nasal drainage (15%), asthma (9%), and sore throat (3%)). Over a median (interquartile range) of 32 (16-46) months follow-up, patients had a mean (95% confidence interval) of 10.1 (9.4-10.9) consultations with specialists and underwent 6.4 (3-9) diagnostic procedures. Overall, the mean initial year direct cost was $5,438 per patient being evaluated for EER. Medical and non-medical components contributed $5,154 and $283. Of the overall cost, 52% were attributable to the use of proton pump inhibitors. During the initial year, direct costs were 5.6 times higher than those reported for typical GERD ($971). A total of 54% of patients reported improvement of symptoms. Overall cost per improved patient was $13,700.

CONCLUSIONS

EER contributes substantially to health-care expenditures. In this cohort, the cost for initial year's evaluation and treatment of EER symptoms was quintuple that of typical GERD. Prescription costs and, in particular, proton pump inhibitors were the single greatest contributor to the cost of EER management.

Nonlinear relationship between body mass index and esophageal acid exposure in the extraesophageal manifestations of reflux

BACKGROUND & AIMS

Obesity is believed to be an important etiologic factor in gastroesophageal reflux disease. However, it is not clear how obesity might affect esophageal acid exposure in patients with extraesophageal manifestations of reflux.

METHODS

We conducted a cross-sectional study of 223 patients with extraesophageal symptoms suspected of being related to reflux. Participants underwent endoscopy and 48-hour wireless pH testing. The percentage of time at a pH of less than 4 (total, upright, and supine) was measured for each patient, and data were compared with corresponding body mass index (BMI), as continuous and categoric variables (normal, 18.5 to <25; overweight, 25 to <30; and obese, >30). Multivariable linear regression was used to identify variables associated with percentage of total time at a pH less than 4. The primary predictor of interest was BMI; age, sex, esophagitis, and hiatal hernia status were considered potential confounders or precision variables.

RESULTS

Esophageal acid exposure was associated significantly (P < .001) with BMI. The percentage of time at a pH less than 4 and total symptomatic reflux events increased significantly (P = .005) with increasing BMI. The relationship between percentage of time at a pH less than 4 and BMI was nonlinear and S-shaped. With BMI ranges, the percentage of time at a pH less than 4 increased by 0.23% (normal BMI), 0.75% (overweight), and 0.07% (obese) for every 1-kg/m(2) increase in BMI (P < .001).

CONCLUSIONS

Increases in esophageal acid exposure are greatest among overweight patients and plateau in obese patients. The findings have implications for benefit of weight loss in patients with suspected extraesophageal manifestations of gastroesophageal reflux disease.

Feasibility of Dual Wireless Esophageal pH Monitoring

Objective

Wireless pH monitoring is currently employed in the distal esophagus. There are no controlled studies on the feasibility/safety of proximal esophageal wireless pH capsule placement. We tested the hypothesis that there will be no difference in patient perception of a more proximally placed pH capsule.

Study Design

Randomized single-blinded sham-controlled trial.

Setting

Tertiary care center.

Subjects and Methods

All patients had a wireless pH capsule positioned 6 cm proximal to the gastroesophageal junction. They were randomized into intervention or sham groups after distal capsule placement. The delivery introducer was positioned 10 cm proximal to the distal esophageal capsule, and a second capsule was either deployed (intervention) or not (sham) based on group allocation. Patients were blinded to group assignment. Modified Edmonton Score was used to assess for chest pain, dysphagia, and odynophagia. The primary endpoints were (1) required endoscopic removal because of discomfort and (2) change in chest pain scores, controlling for baseline pain.

Results

Patients were randomized to either the intervention, proximal esophageal capsule (n = 11), or sham (n = 11). Patients with proximal pH probes had higher odds of having their chest pain (odds ratio [OR], 8.44; 95% confidence interval [CI], 1.35-52.6; P = .02), odynophagia (OR, 49.5; 95% CI, 4.70-520; P = .001), and dysphagia (OR, 14.3; 95% CI, 2.12-96.6; P = .006) exacerbated. Two (2/11; 18%) proximally deployed probes required endoscopic removal because of patient intolerance or discomfort.

Conclusion

A proximal esophageal wireless pH monitor placement is feasible but results in increased chest pain, odynophagia, and dysphagia that can be severe enough to require endoscopic removal. These limitations preclude its potential clinical benefit.

Caution about overinterpretation of symptom indexes in reflux monitoring for refractory gastroesophageal reflux disease

BACKGROUND & AIMS

Symptom index (SI) and symptom association probability (SAP) are indexes used to analyze data collected from ambulatory pH and/or impedance monitoring and quantify the association between symptoms and reflux events. However, their characteristics are not well defined. We measured factors that affect SI and SAP values to determine their utility in assessing patients with refractory gastroesophageal reflux disease (GERD).

METHODS

We conducted a cross-sectional study of 254 patients with poor responses to proton pump inhibitor (PPI) therapy. Participants underwent esophagogastroduodenoscopy and wireless pH (n = 127) or impedance/pH monitoring when they were not receiving PPI therapy (n = 41) or impedance/pH monitoring while they received twice-daily PPI therapy (n = 86). SI and SAP values were calculated individually; ranges of values for each cell in the 2 × 2 contingency table were determined. Monte Carlo simulation was conducted to determine how varying reflux and symptom rates within the contingency table impacted the expected value and variability in SI and SAP.

RESULTS

At best, only 33% of patients who were refractory to PPI therapy had positive SI or SAP scores for acid or nonacid reflux events. Abnormal SAP (>95%) and SI (>50%) scores required high rates of reflux. At reflux rates less than 10%, observed in 70% of the studied population, SI and SAP values were largely determined by chance occurrences, rather than the relationship between symptoms and reflux. The values for each index varied significantly day-to-day.

CONCLUSIONS

SI or SAP indexes can be overinterpreted, unless patients with gastroesophageal reflux disease who are refractory to PPI therapy have high rates of reflux.

Traditional reflux parameters and not impedance monitoring predict outcome after fundoplication in extraesophageal reflux

OBJECTIVES/HYPOTHESIS

Fundoplication is considered in patients with refractory extraesophageal reflux symptoms. However, postoperative symptom resolution is inconsistent. This analysis investigates which presenting symptoms and preoperative objective parameters predict postoperative symptom improvement.

STUDY DESIGN

Retrospective cohort study.

METHODS

A total of 237 patients referred for extraesophageal reflux symptoms refractory to medical therapy underwent esophageal function testing. Fundoplication was performed in 27 patients with objective evidence of gastroesophageal reflux disease. Symptomatic improvement was assessed at postoperative intervals. Logistic regression determined which symptoms and objective parameters predicted improvement of the presenting extraesophageal reflux symptom.

RESULTS

Overall, 59% of patients reported at least partial improvement of their presenting extraesophageal symptom after fundoplication. Predictors of symptomatic improvement were the presence of heartburn with or without regurgitation concomitant to their primary presenting symptom (odds ratio [OR], 6.6; 95% confidence interval [CI], 0.97-44.9; P = .05) and pH < 4 more than 12% of a 24-hour period (OR, 10.5; 95% CI, 1.36-81.1; P = .02). Probability of postoperative extraesophageal reflux symptom improvement was 90% if both conditions were present.

CONCLUSIONS

Both heartburn with or without regurgitation and esophageal pH < 4 more than 12% of a 24-hour period predicted postfundoplication resolution of the presenting extraesophageal reflux symptom.

Impact of chronic rhinosinusitis on work productivity through one-year follow-up after balloon dilation of the ethmoid infundibulum

BACKGROUND

Although multiple clinical trials have demonstrated that balloon dilation of sinus ostia in patients diagnosed with chronic rhinosinusitis (CRS) results in sustained symptomatic improvement, less data are available to measure the effects of sinusitis on worker productivity. The objective of our research was to analyze work and activity impairment before and after transantral, endoscopically-guided balloon dilation of the maxillary sinus ostia and ethmoid infundibulum.

METHODS

Subjects diagnosed with CRS and computed tomography (CT) evidence of disease in the maxillary sinuses alone, or maxillary and anterior ethmoid sinuses, completed the Work Productivity and Activity Impairment (WPAI) questionnaire and the Work Limitation Questionnaire (WLQ) before treatment and at 3, 6, and 12 months postprocedure.

RESULTS

A total of 56 subjects were enrolled and 53 completed the 1-year follow-up. The lost productivity composite score computed from the WLQ improved by 73% (9.0 to 2.4; p < 0.0001) at 1-year follow-up whereas lost productivity at work as measured by the WPAI improved by approximately 76% (38.3 to 9.2; p < 0.0001) 12 months after treatment.

CONCLUSION

These results indicate that sinus-related health problems impose a substantial burden on work productivity and physical/mental activity levels. Treatment of CRS by dilating the maxillary sinus ostium and ethmoid infundibulum can significantly improve quality of life (QOL) and work productivity.

Dilated intercellular space in chronic laryngitis and gastro-oesophageal reflux disease: at baseline and post-lansoprazole therapy

BACKGROUND

Dilation of intercellular spaces is reported to be an early morphological marker in gastro-oesophageal reflux. It remains unknown if this marker is useful in diagnosing reflux-related chronic laryngitis.

AIM

To determine histopathology and electron microscopic changes in oesophageal and laryngeal epithelium in chronic laryngitis.

METHODS

In this prospective blinded study, we enrolled 53 participants: 15 controls, 20 patients with GERD and 18 patients with chronic laryngitis. The latter two groups were subsequently treated with lansoprazole 30 mg bid for 12-weeks. Baseline and postacid suppressive therapy biopsies were obtained from distal oesophagus and laryngeal postcricoid areas. Biopsy specimens were evaluated for histopathology and dilated intercellular space changes.

RESULTS

There was no significant increase in oesophageal or laryngeal epithelium intercellular spaces among GERD or laryngitis patients compared with controls at baseline or postacid suppressive therapy. Only patients with GERD had significantly (P = 0.03) higher proportion of moderate-to-severe oesophageal spongiosis and basal cell hyperplasia, which normalized postacid suppressive therapy.

CONCLUSIONS

There was no increase in the width of intercellular spaces in the oesophagus or larynx in GERD or chronic laryngitis at baseline or postacid suppressive therapy. Our findings question the uniform presence of dilated intercellular space in patients with GERD.

Topical pimecrolimus in the treatment of human allergic contact dermatitis

BACKGROUND

Contact dermatitis is a common clinical problem, with prevalent sensitizers being cosmetics, metals, medicines, and plants. Plants of the Toxicodendron species cause allergic contact dermatitis (ACD) in 50% to 70% of the population. Pimecrolimus is an ascomycin macrolactam developed for the treatment of inflammatory skin diseases and approved by the US Food and Drug Administration for atopic dermatitis. There are studies supporting the effectiveness of macrolactams when administered before antigen challenge, but there are no studies describing the effectiveness of these drugs in the treatment of established human ACD.

OBJECTIVE

To investigate the effect of topical pimecrolimus in the treatment of Toxicodendron-induced ACD once rash is evident.

METHODS

Poison ivy tincture was applied to the bilateral anterior forearms of 12 subjects with Finn Chambers (Allerderm Diagnostic Products, Petaluma, CA). After dermatitis was evident, volunteers treated each arm twice daily with either 1% topical pimecrolimus cream or placebo in a blinded fashion. Outcomes measured were a dermatitis grading score and time to rash and itch resolution.

RESULTS

The median +/- SEM time for rash resolution was 16.55 +/- 1.59 days in the treatment group and 16.27 +/- 1.82 days in the placebo group (P = 0.601). The median time for itch resolution was 4.73 +/- 1.56 days in the treatment group and 4.91 +/- 1.59 days in the placebo group (P = 0.167). The average dermatitis score was 2.26 +/- 0.17 in the treatment group and 2.32 +/- 0.15 in the placebo group (P = 0.62).

CONCLUSIONS

The application of topical pimecrolimus is ineffective in the treatment of ongoing Toxicodendron-induced ACD.

The prostaglandin E agonist, misoprostol, inhibits airway IL-5 production in atopic asthmatics

BACKGROUND

Prostaglandin E2 is a potent immunomodulator that inhibits the early and late bronchoconstriction to inhaled allergen, as well as inhibiting the acute allergen-induced release of mediators into the human airway. To determine if the stable prostaglandin E agonist misoprostol could alter the late allergic formation of mediators we measured the appearance of eosinophils and key cytokines in the bronchoalveolar lavage fluid 24 h after allergen instillation.

METHODS

Six atopic asthmatics underwent bronchoscopy, alveolar lavage and antigen instillation followed 24 h later by bronchoalveolar lavage. Eosinophil counts were done, together with measurements of IL-4, IL-5, eotaxin, RANTES and cysteinyl leukotrienes by immunoassay. The study was done in randomized blinded fashion while the volunteers took placebo or 600 microg of misoprostol four times a day (QID).

RESULTS

Misoprostol significantly decreased the appearance of IL-5 late after allergen challenge. Eotaxin levels were reduced, but not statistically significantly. Eosinophil number, RANTES, eosinophil cationic protein and cysteinyl leukotrienes were not altered by misoprostol.

CONCLUSIONS

Misoprostol reduces the formation of IL-5 late after allergen challenge, perhaps by inhibiting eosinophil, mast cell, and/or T lymphocyte production of IL-5. Despite decreases in IL-5 and eotaxin, eosinophils were recruited and activated by allergen.