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Physiological Characteristics of Isolated Laryngopharyngeal Reflux Symptoms
This figure shows the equal and additive contributions of asthma, hiatal hernia, and heartburn at various BMIs.
597 MEAN NOCTURNAL BASELINE IMPEDANCE ON MULTICHANNEL INTRALUMINAL IMPEDANCE MONITORING PREDICTS ONE-YEAR PULMONARY FUNCTION DECLINE IN PATIENTS WITH IDIOPATHIC PULMONARY FIBROSIS Lawrence F. Borges, Kelly Hathorn, Sravanya Gavini, Wai-Kit Lo, Robert Burakoff, Natan Feldman, Walter W. Chan
Table 1. Variations in HRV in patients with GERD
Background: Gastro-esophageal reflux (GER) has been associated with poor outcomes in patients with idiopathic pulmonary fibrosis (IPF). Mean nocturnal baseline impedance (MNBI) is a novel measure of esophageal mucosal integrity that has been shown to correlate with GER, and may represent a marker for reflux burden among patients with typical esophageal symptoms. However, the value of MNBI in predicting outcomes in extra-esophageal manifestations of GER such as IPF remains unknown. Aim: To assess the association between MNBI as measured on multichannel intraluminal impedance and pH testing (MIIpH) and change in pulmonary function testing (PFT) parameters over 1 year in IPF patients. Methods: This was a retrospective cohort study of adults with IPF who underwent prelung transplant evaluation with MII-pH off acid suppression at a tertiary care center in 6/ 2008-11/2015. Patients with fundoplication prior to MII-pH were excluded. PFT data was collected for all patients at the time of MII-pH and at 12-month follow-up. Three stable 10-minute periods (around 1 am, 2 am, and 3 am) on MII-pH were selected for calculation of baseline impedance, which were averaged to determine the MNBI for each impedance channel. Distal MNBI was defined by averaging values at channels 3, 5, 7, and 9 cm, while proximal MNBI was calculated as the mean of channels at 15 and 17 cm. Pearson correlation coefficient was used to assess the relationship between MNBI and PFT decline in 1 year. The association between dichotomized MNBI and change in PFT parameters over 1 year was evaluated using Student's t-test. Results: 44 subjects (mean age= 60.1 yrs, 61.4% male) met criteria for inclusion. Distal MNBI was positively correlated with 1-year decline in forced expiratory volume in 1 second (FEV1) (r=0.50, p=0.03) and forced vital capacity (FVC) (r= 0.47, p=0.05). Proximal MNBI was also significantly correlated with 1-year decrease in FEV1 (r=0.47, p=0.05), with a similar trend for positive correlation with FVC change at 12 months (r=0.44, p=0.07). When MNBI was dichotomized into low vs high at 2750 ohms (optimal cutoff identified on sensitivity analyses), both low distal and low proximal MNBI were associated with more severe decline in PFT parameters at 12 months (see table 1). Conclusion: Low distal and proximal MNBI on MII-pH predict more severe decline in lung function over 1 year on PFT among pre-lung transplant IPF patients. MNBI may be a useful metric in addition to traditional parameters on MII-pH in evaluating these patients. The correlation between lower MNBI and decline in lung function also supports a role for reflux in IPF pathogenesis. Table 1. Association between MNBI and change in pulmonary function over 1 year in patients with IPF.
Table 2. Variations in HRV for reflux duration > 3 minutes
599 PHYSIOLOGICAL CHARACTERISTICS OF ISOLATED LARYNGOPHARYNGEAL REFLUX SYMPTOMS Han-Chung Lien Background: Patients with Isolated laryngopharyngeal reflux (LPR) symptoms are frequently encountered in otolaryngologic clinics. Aim: We compared their endoscopic and physiological features with those of LPR patients with concomitant typical reflux symptoms (CTRS). Methods: Patients with predominant LPR symptoms were recruited for upper endoscopy, esophageal manometry, 24h esophagopharyngeal pH monitoring off proton pump inhibitors (PPI), and Bernstein test. Subjects with abnormal esophagopharyngeal pH were divided into two groups: LPR symptoms with and without CTRS. CTRS was defined by the presence of heartburn and/or regurgitation with mild severity for at least twice a week or moderate severity for at least once a week. The endoscopic esophagitis, manometric findings, acid reflux parameters, esophageal acid sensitivity, and response to PPI therapy were compared between 2 groups. Results: We performed 24h esophagopharyngeal pH test in 253 subjects with suspected LPR. Of them, 108 had abnormal pH results and were divided into two groups on the basis of presence (n= 66) or absence (n= 42) of CTRS. The median (IQR) percent time of distal esophageal acid exposure (5.6% (3.3%, 10.7%) vs. 5.1% (4.1%, 8.4%), p= 0.7) and rate of reflux esophagitis (26% vs. 24%, p= 0.9) were comparable between two groups. However, the median (IQR) number of pharyngeal acid reflux events (predominantly in upright position, 1(0, 5) vs. 0(0, 1), p= 0.0001) and the median (IQR) percent time of proximal esophageal acid exposure (0.5% (0.2%, 1.6%) vs. 0.1% (0%, 0.9%), p= 0.04) were higher in subjects with CTRS than those in subjects without. Subjects with CTRS also had a higher rate of incompetent lower esophageal sphincter pressure (defined by < 10 mmHg) (43% vs. 19%, p= 0.02) and a higher rate of ineffective esophageal motility (43% vs. 21%, p= 0.05), a lower median (IQR) resting upper sphincter pressure (20(11,30)mmHg vs. 29(19,40)mmHg, p= 0.01), and a higher rate of positive Bernstein test (55% vs. 19%, p= 0.0006). Response to a 12-week course of high dose PPI therapy defined by >50% improvement in primary laryngeal symptoms was similar between two groups (59% vs. 61%, p= 0.9). Conclusions: Patients with isolated LPR symptoms had less proximal acid exposure and were less sensitive to esophageal acid infusion test compared to those in patients with CTRS. Motorsensorial characteristics may differentiate LPR symptomatic phenotypes between patients with and without CTRS, implying a distinct pathogenesis.
598 THE INFLUENCE OF ACID REFLUX ON THE HEART RATE VARIABILITY (HRV) IN PATIENTS WITH AND WITHOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) Liliana Marra, Antonio Francesco Ciccaglione, Antonio Sepe, Roberta Tavani, Sila Cocciolillo, Massimiliano di Berardino, Carla Di Giacomo, Valentina Vecchione, Laurino Grossi, Leonardo Marzio BACKGROUND AND AIM Some authors have suggested that there is a strong correlation between GERD and heart rhythm abnormalities. However there are no studies that have evaluated the influence of spontaneously induced reflux on HRV. The aim of this study was to evaluate the relationship between the spontaneous gastroesophageal reflux(GER) and HRV in patients with and without GERD. MATERIAL AND METHODS Fourteen patients with a negative cardiac screening and symptoms suggestive for GERD were enrolled in the study. Each patient underwent to a simultaneous 24h esophageal pHmetry and an ECG recording. Based on the results obtained from the pHmetric data,patients were divided into patients with and without GERD based on normal Ph parameters as indicated by DeMeestrer et al.Reflux were analyzed as total numbers in the 24h and stratified on the basis of duration
S-131
AGA Abstracts
AGA Abstracts
in less than 1min, between 1-2min, between 2-3min and up to 3min.ECG data were analyzed by a specific software to calculate the heart rate(HR),the variability of RR intervals and a Fourier spectral analysis of HRV in the domain frequency which includes bands of high frequency(HF) and low frequency(LF).In addition,it was estimated the relationship between LF and HF which expresses the balance between the activity of the sympathetic and parasympathetic nervous system. ECG analysis was performed in the 15 min before and four consecutive 15 min intervals after a single GER or of after several reflux.A Five consecutive 15 min periods without reflux were chosen in each patients and analyzed with the same ECG analysis and considered as a control period. RESULTS In patients with GERD, in the four consecutive 15 min period after a single reflux and also during multiple reflux, a statistically significant increase of RR interval and HF and a statistically significant reduction of HR and LF/HF ratio(table 1) was computed. The variations of HRV were more evident for the refluxes longer than 3 min(table 2). In patients without GERD, there was only a statistically significant reduction of LF in the fourth 15 min after a single reflux and in the presence of multiple reflux. In the five consecutive 15 min periods in the absence of reflux there was no variations of HRV either in patients with and in those without GERD. CONCLUSIONS The results of our work show that GER is associated with changes in heart rate variability with parasympathetic stimulation only in patients whose number and quality of reflux are considered pathological. This would strengthen the hypothesis that patients with GERD may have an anatomical and/or functional alteration of the esophagus that favors the activation of the afferent and efferent stimuli to the Central Nervous system through the retrodiffusion of acid. Such damage could be explained by the theory of dilatation of the intercellular spaces of esophageal mucosa present only in GERD patients.
597 MEAN NOCTURNAL BASELINE IMPEDANCE ON MULTICHANNEL INTRALUMINAL IMPEDANCE MONITORING PREDICTS ONE-YEAR PULMONARY FUNCTION DECLINE IN PATIENTS WITH IDIOPATHIC PULMONARY FIBROSIS Lawrence F. Borges, Kelly Hathorn, Sravanya Gavini, Wai-Kit Lo, Robert Burakoff, Natan Feldman, Walter W. Chan
Table 1. Variations in HRV in patients with GERD
Background: Gastro-esophageal reflux (GER) has been associated with poor outcomes in patients with idiopathic pulmonary fibrosis (IPF). Mean nocturnal baseline impedance (MNBI) is a novel measure of esophageal mucosal integrity that has been shown to correlate with GER, and may represent a marker for reflux burden among patients with typical esophageal symptoms. However, the value of MNBI in predicting outcomes in extra-esophageal manifestations of GER such as IPF remains unknown. Aim: To assess the association between MNBI as measured on multichannel intraluminal impedance and pH testing (MIIpH) and change in pulmonary function testing (PFT) parameters over 1 year in IPF patients. Methods: This was a retrospective cohort study of adults with IPF who underwent prelung transplant evaluation with MII-pH off acid suppression at a tertiary care center in 6/ 2008-11/2015. Patients with fundoplication prior to MII-pH were excluded. PFT data was collected for all patients at the time of MII-pH and at 12-month follow-up. Three stable 10-minute periods (around 1 am, 2 am, and 3 am) on MII-pH were selected for calculation of baseline impedance, which were averaged to determine the MNBI for each impedance channel. Distal MNBI was defined by averaging values at channels 3, 5, 7, and 9 cm, while proximal MNBI was calculated as the mean of channels at 15 and 17 cm. Pearson correlation coefficient was used to assess the relationship between MNBI and PFT decline in 1 year. The association between dichotomized MNBI and change in PFT parameters over 1 year was evaluated using Student's t-test. Results: 44 subjects (mean age= 60.1 yrs, 61.4% male) met criteria for inclusion. Distal MNBI was positively correlated with 1-year decline in forced expiratory volume in 1 second (FEV1) (r=0.50, p=0.03) and forced vital capacity (FVC) (r= 0.47, p=0.05). Proximal MNBI was also significantly correlated with 1-year decrease in FEV1 (r=0.47, p=0.05), with a similar trend for positive correlation with FVC change at 12 months (r=0.44, p=0.07). When MNBI was dichotomized into low vs high at 2750 ohms (optimal cutoff identified on sensitivity analyses), both low distal and low proximal MNBI were associated with more severe decline in PFT parameters at 12 months (see table 1). Conclusion: Low distal and proximal MNBI on MII-pH predict more severe decline in lung function over 1 year on PFT among pre-lung transplant IPF patients. MNBI may be a useful metric in addition to traditional parameters on MII-pH in evaluating these patients. The correlation between lower MNBI and decline in lung function also supports a role for reflux in IPF pathogenesis. Table 1. Association between MNBI and change in pulmonary function over 1 year in patients with IPF.
Table 2. Variations in HRV for reflux duration > 3 minutes
599 PHYSIOLOGICAL CHARACTERISTICS OF ISOLATED LARYNGOPHARYNGEAL REFLUX SYMPTOMS Han-Chung Lien Background: Patients with Isolated laryngopharyngeal reflux (LPR) symptoms are frequently encountered in otolaryngologic clinics. Aim: We compared their endoscopic and physiological features with those of LPR patients with concomitant typical reflux symptoms (CTRS). Methods: Patients with predominant LPR symptoms were recruited for upper endoscopy, esophageal manometry, 24h esophagopharyngeal pH monitoring off proton pump inhibitors (PPI), and Bernstein test. Subjects with abnormal esophagopharyngeal pH were divided into two groups: LPR symptoms with and without CTRS. CTRS was defined by the presence of heartburn and/or regurgitation with mild severity for at least twice a week or moderate severity for at least once a week. The endoscopic esophagitis, manometric findings, acid reflux parameters, esophageal acid sensitivity, and response to PPI therapy were compared between 2 groups. Results: We performed 24h esophagopharyngeal pH test in 253 subjects with suspected LPR. Of them, 108 had abnormal pH results and were divided into two groups on the basis of presence (n= 66) or absence (n= 42) of CTRS. The median (IQR) percent time of distal esophageal acid exposure (5.6% (3.3%, 10.7%) vs. 5.1% (4.1%, 8.4%), p= 0.7) and rate of reflux esophagitis (26% vs. 24%, p= 0.9) were comparable between two groups. However, the median (IQR) number of pharyngeal acid reflux events (predominantly in upright position, 1(0, 5) vs. 0(0, 1), p= 0.0001) and the median (IQR) percent time of proximal esophageal acid exposure (0.5% (0.2%, 1.6%) vs. 0.1% (0%, 0.9%), p= 0.04) were higher in subjects with CTRS than those in subjects without. Subjects with CTRS also had a higher rate of incompetent lower esophageal sphincter pressure (defined by < 10 mmHg) (43% vs. 19%, p= 0.02) and a higher rate of ineffective esophageal motility (43% vs. 21%, p= 0.05), a lower median (IQR) resting upper sphincter pressure (20(11,30)mmHg vs. 29(19,40)mmHg, p= 0.01), and a higher rate of positive Bernstein test (55% vs. 19%, p= 0.0006). Response to a 12-week course of high dose PPI therapy defined by >50% improvement in primary laryngeal symptoms was similar between two groups (59% vs. 61%, p= 0.9). Conclusions: Patients with isolated LPR symptoms had less proximal acid exposure and were less sensitive to esophageal acid infusion test compared to those in patients with CTRS. Motorsensorial characteristics may differentiate LPR symptomatic phenotypes between patients with and without CTRS, implying a distinct pathogenesis.
598 THE INFLUENCE OF ACID REFLUX ON THE HEART RATE VARIABILITY (HRV) IN PATIENTS WITH AND WITHOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) Liliana Marra, Antonio Francesco Ciccaglione, Antonio Sepe, Roberta Tavani, Sila Cocciolillo, Massimiliano di Berardino, Carla Di Giacomo, Valentina Vecchione, Laurino Grossi, Leonardo Marzio BACKGROUND AND AIM Some authors have suggested that there is a strong correlation between GERD and heart rhythm abnormalities. However there are no studies that have evaluated the influence of spontaneously induced reflux on HRV. The aim of this study was to evaluate the relationship between the spontaneous gastroesophageal reflux(GER) and HRV in patients with and without GERD. MATERIAL AND METHODS Fourteen patients with a negative cardiac screening and symptoms suggestive for GERD were enrolled in the study. Each patient underwent to a simultaneous 24h esophageal pHmetry and an ECG recording. Based on the results obtained from the pHmetric data,patients were divided into patients with and without GERD based on normal Ph parameters as indicated by DeMeestrer et al.Reflux were analyzed as total numbers in the 24h and stratified on the basis of duration
S-131
AGA Abstracts
AGA Abstracts
in less than 1min, between 1-2min, between 2-3min and up to 3min.ECG data were analyzed by a specific software to calculate the heart rate(HR),the variability of RR intervals and a Fourier spectral analysis of HRV in the domain frequency which includes bands of high frequency(HF) and low frequency(LF).In addition,it was estimated the relationship between LF and HF which expresses the balance between the activity of the sympathetic and parasympathetic nervous system. ECG analysis was performed in the 15 min before and four consecutive 15 min intervals after a single GER or of after several reflux.A Five consecutive 15 min periods without reflux were chosen in each patients and analyzed with the same ECG analysis and considered as a control period. RESULTS In patients with GERD, in the four consecutive 15 min period after a single reflux and also during multiple reflux, a statistically significant increase of RR interval and HF and a statistically significant reduction of HR and LF/HF ratio(table 1) was computed. The variations of HRV were more evident for the refluxes longer than 3 min(table 2). In patients without GERD, there was only a statistically significant reduction of LF in the fourth 15 min after a single reflux and in the presence of multiple reflux. In the five consecutive 15 min periods in the absence of reflux there was no variations of HRV either in patients with and in those without GERD. CONCLUSIONS The results of our work show that GER is associated with changes in heart rate variability with parasympathetic stimulation only in patients whose number and quality of reflux are considered pathological. This would strengthen the hypothesis that patients with GERD may have an anatomical and/or functional alteration of the esophagus that favors the activation of the afferent and efferent stimuli to the Central Nervous system through the retrodiffusion of acid. Such damage could be explained by the theory of dilatation of the intercellular spaces of esophageal mucosa present only in GERD patients.