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Twenty-four hour esophageal pH monitoring by telemetry
Twenty-Four Hour Esophageal pH Monitoring by Telemetry Cost-Effective Use in Outpatients
William H. Falor, MD, Akron, Ohio Benjamin Chang, Akron, Ohio Harold A. White, Akron, Ohio Jane M. Kraus, MD, Akron, Ohio Bruce Taylor, PhD, Akron, Ohio John R. Hansel, MD, Akron, Ohio Fred C. Kraus, Akron, Ohio
Twenty-four hour esophageal pH monitoring, introduced in 1974 by Johnson and DeMeester [I] to quantify gastroesophageal reflux, has become one of the most widely accepted and informative of the multiple tests. The test utilizes an indwelling lower esophageal pH electrode connected to a pH meter and wired to a slowly moving strip chart recorder on which the patient may record significant subjective symptoms as well as changes in body position. The electrical connections limit the activities of the patient to the confines of the hospital bed. By adapting the technique of telemetry to 24 hour esophageal pH monitoring, we eliminated the electrical connections between recorder and patient. Thus, the patient is mobile and able to pursue normal activities in the physiologic environment of his home. Methods Twenty-four hour esophageal pH monitoring by telemetry utilizes a 1.5 mm indwelling pH microelectrode (Microelectrodes, Inc., Grenier Industrial Village, Londonderry, New Hampshire) positioned 5 cm above the patient’s distal esophageal sphincter. The pH electrode and a skin-reference electrode are connected to a 1.5 pound battery-powered pH meter and transmitter worn in a shoulder harness. The pH determinations are transmitted to a remote strip chart recorder calibrated to read in pH units. The test commonly is continued for 24 or more hours; however, it is terminated in a shorter time if significant reflux is manifest. The test is numerically scored by From the Esophageal Laboratory of tha Thoracic and Cardiovascular Service, Akron City Hospital, Akron, Ohio. Requests for reprints should be addressed to William H. Falor. MD, Department of Thoracic and Cardiovascular Surgery, Northeastern Ohio Universities College of Medicine, Akron City Hospital, Akron, Ohio 44309.
514
Johnson and DeMeester’s analysis of six different components of the record and includes the number, duration and body position of episodes of pH less than 4 and any associated symptoms.
Case Reports Case I. A 59 year old white woman was admitted with a 3 year history of increasing nausea and mid-epigastric burning or aching pain occuring 1 half to two hours after eating and exacerbated by spicy foods, alcohol and smoking. She also described the feeling of food sticking in the bottom of her throat followed by severe epigastric pain and water brash. A hiatus hernia without reflux had been demonstrated on esophagraphy. Fiberoptic esophagoscopy revealed (1) a white membrane covering the mucosa in the distal third of the esophagus, (2) a hiatal hernia, (3) mild antral gastritis, and (4) focal acanthosis on biopsy. Preoperatively, a 24 hour telemetric pH study of the lower esophagus demonstrated frequent episodes of reflux while the patient was upright and recumbent (Figure 1, left). Nissen fundoplication and diaphragmatic hernioplasty were performed. Four months later a postoperative outpatient 24 hour telemetric pH examination showed only physiologic reflux (Figure 1, right). The composite score using the DeMeester and Skinner profile dropped in 4 months from a high of 154.11, diagnostic of pathologic refli.u~ai; 2.81, a normal score. The patient is now asympCase II. Three years after a Nissen fundoplication performed for reflux esophagitis, a 72 year old white woman was admitted with dysphagia and a sense of a “lump” beneath her ribs. A 24 hour esophageal telemetric pH study in her home, using the same DeMeester and Skinner scoring technique, gave a high score of 53.5. Case III. A 13 month old black male with a history of
encephalitis,
meningitis
and delayed
development
The American
was
Journal of Surgery
Esophageal
OH
PH IO
Figure 7. Case 1.Left, extract from preoperative 24 hour esophageal pH study: read from right to left. Note the frequent episodes of decreased pH, indicative of acid reflux. Right, extract from postoperative esophagea/pH study. Note the physiologic, infrequent episodes of reffux.
II:00
I
Time p.m.
for regurgitation and weight loss. Endoscopy revealed a sliding hiatal hernia but no esophagitis. The composite score of a 24 hour esophageal pH telemetric study performed in the hospital was 14.86, well within admitted
normal
1o:oo
TABLE I
Evaluation of Objective Measurements of Gastroesophageal Reflux (From [ 31) Percentage of Positive Test Results Severely Asymptomatic Symptomatic Patients Patients
limits.
Comments Through the electronics of telemetry, the 24 hour esophageal pH study may be performed as an outpatient procedure. The patient remains mobile within the 300 foot telemetric range and is able to carry on customary activities in the physiologic environment of the home. Diet is limited to foods with a pH above 5, eliminating alcohol and drugs. The diary maintained during the test is correlated with the recorded pH to identify possible relationships between decreases in pH below 4, and symptoms and positional changes. The procedure is cost-effective, eliminating 2 or 3 days in the hospital. The 1.5 pound weight of the patient’s battery-powered, shock-proof pH meter and transmitter is comfortable in its cotton shoulder harness. The strip chart receiver runs on house current. Twenty-four hour esophageal pH monitoring has proved an accurate physiologic index of acid reflux and has been the basis for development of the most precise quantitative evaluation of all the tests [2,3] (Table I). The test calibrates two important determinants of reflux esophagitis: (1) reflux secondary to an incompetent cardioesophageal junction, and (2) the rate of esophageal clearing of refluxed gastric juice [4]. In the severely symptomatic patient the test has a 92 percent accuracy rate with no false-positive findings. The acid perfusion test of Bernstein and Baker [5] indicates sensitivity of the esophagus to exogenous acid, but fails to measure the frequency, duration and degree of the decreases in pH common in patients with reflux. The 24 hour pH test has a high level of patient acceptability, in large part re-
Volume 142, October 1991
pH Monitoring by Telemetry
Acid perfusion test Radiographic reflux Endoscopic esophageal manometry Esophageal biopsy Standard acid reflux test 24 hour OH monitorino
? 25 5
100 58 34
10 20 0
75 a0 92
lated to the flexible, tiny 1.5 mm pH indwelling microelectrode introduced as a package with a removable balloon catheter. The test is used routinely in assessing clear-cut reflux (case I) but has added utility in clarifying the diagnosis when suspected reflux is complicated by the presence of angina, gallstone, hiatus hernia or some other abnormality of the same anatomic area. The test is the ultimate proof of the success or failure of an antireflux operation (case II). Telemetry is of particular value in pediatric patients, allowing reasonable mobility and a better assay of the relative effects of upright, recumbent or prone position on the amount of reflux [1,6]. In infants the test is a precise determinant of the frequency, duration and severity of reflux and provides an objective basis on which to recommend surgery. However, the 24 hour pH assay may document the absence of reflux (case III) and mandate a search for another diagnosis. Johnson and DeMeester’s calculation of a derived composite reflux score based on six components of
515
Falor et al
the 24 hour pH record establishes a grade of 17.92 as the upper limit of normal reflux. Further analysis of the record clearly identifies three subsets of patients with pathologic reflux based on body position: supine, upright, and combined supine-upright. The patient with upright reflux rapidly clears acid and, although symptomatic, has the smallest risk of esophagitis. The patient with supine reflux may have nocturnal pyrosis and require only medical therapy; however, he may be unaware of the acid irritation and first present with advanced esophagitis and even stricture. Combined supine-upright reflux is the most common and carries the greatest risk of esophagitis and stricture. Thus, the test score and the body position during major reflux are both important factors bearing on the final therapeutic decision. Summary Twenty-four hour determinations of the distal esophageal pH by telemetry provides outpatient monitoring of gastroesophageal reflux in the ambulant patient in his natural environment. In our overweight, physically unfit and anxiety-ridden population, indigestion is a frequent complaint originating from a variety of causes including gastro-
516
esophageal reflux. Long-term esophageal pH monitoring quantifies and is the best current means of differentiating physiologic from pathologic reflux. Acknowledgment: We thank Robert T. Stone, MD, of the Children’s Hospital Medical Center of Akron for supplying case III.
References 1. Johnson LF, DeMeester TR. Twenty-four hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol 1974;62:325-32. 2. DeMeester TR, Wernly JA, Bryant GH, Little AG, Skinner DB. Clinical and in vitro analysis of determinants of gastroesophageal competence. A study of the principles of antireflux surgery. Am J Surg 1979; 137:39-46. 3. DeMeester TR, Johnson LF. The evaluation of objective mesurements of gastroesophageal reflux and their contribution to patient management. Surg Clin North Am 1976;56:3953. 4. Johnson LF, DeMeester TR, Haggitt RC. Esophageal epithelial response to gastroesophageal reflux. A quantitative study. Digest Dis 1978;23:498-509. 5. Bernstein LM, Baker LA. A clinical test for esophagitis. Gastroenterology 1958;34:760-81. 6. Hill JL, Pelligrini JD, Burrington JD, Reyes HM, DeMeester TR. Technique and experience with 24 hour esophageal pH monitoring in children. J Pediatr Surg 1977;12:877-87.
The American Journal of Surgery
William H. Falor, MD, Akron, Ohio Benjamin Chang, Akron, Ohio Harold A. White, Akron, Ohio Jane M. Kraus, MD, Akron, Ohio Bruce Taylor, PhD, Akron, Ohio John R. Hansel, MD, Akron, Ohio Fred C. Kraus, Akron, Ohio
Twenty-four hour esophageal pH monitoring, introduced in 1974 by Johnson and DeMeester [I] to quantify gastroesophageal reflux, has become one of the most widely accepted and informative of the multiple tests. The test utilizes an indwelling lower esophageal pH electrode connected to a pH meter and wired to a slowly moving strip chart recorder on which the patient may record significant subjective symptoms as well as changes in body position. The electrical connections limit the activities of the patient to the confines of the hospital bed. By adapting the technique of telemetry to 24 hour esophageal pH monitoring, we eliminated the electrical connections between recorder and patient. Thus, the patient is mobile and able to pursue normal activities in the physiologic environment of his home. Methods Twenty-four hour esophageal pH monitoring by telemetry utilizes a 1.5 mm indwelling pH microelectrode (Microelectrodes, Inc., Grenier Industrial Village, Londonderry, New Hampshire) positioned 5 cm above the patient’s distal esophageal sphincter. The pH electrode and a skin-reference electrode are connected to a 1.5 pound battery-powered pH meter and transmitter worn in a shoulder harness. The pH determinations are transmitted to a remote strip chart recorder calibrated to read in pH units. The test commonly is continued for 24 or more hours; however, it is terminated in a shorter time if significant reflux is manifest. The test is numerically scored by From the Esophageal Laboratory of tha Thoracic and Cardiovascular Service, Akron City Hospital, Akron, Ohio. Requests for reprints should be addressed to William H. Falor. MD, Department of Thoracic and Cardiovascular Surgery, Northeastern Ohio Universities College of Medicine, Akron City Hospital, Akron, Ohio 44309.
514
Johnson and DeMeester’s analysis of six different components of the record and includes the number, duration and body position of episodes of pH less than 4 and any associated symptoms.
Case Reports Case I. A 59 year old white woman was admitted with a 3 year history of increasing nausea and mid-epigastric burning or aching pain occuring 1 half to two hours after eating and exacerbated by spicy foods, alcohol and smoking. She also described the feeling of food sticking in the bottom of her throat followed by severe epigastric pain and water brash. A hiatus hernia without reflux had been demonstrated on esophagraphy. Fiberoptic esophagoscopy revealed (1) a white membrane covering the mucosa in the distal third of the esophagus, (2) a hiatal hernia, (3) mild antral gastritis, and (4) focal acanthosis on biopsy. Preoperatively, a 24 hour telemetric pH study of the lower esophagus demonstrated frequent episodes of reflux while the patient was upright and recumbent (Figure 1, left). Nissen fundoplication and diaphragmatic hernioplasty were performed. Four months later a postoperative outpatient 24 hour telemetric pH examination showed only physiologic reflux (Figure 1, right). The composite score using the DeMeester and Skinner profile dropped in 4 months from a high of 154.11, diagnostic of pathologic refli.u~ai; 2.81, a normal score. The patient is now asympCase II. Three years after a Nissen fundoplication performed for reflux esophagitis, a 72 year old white woman was admitted with dysphagia and a sense of a “lump” beneath her ribs. A 24 hour esophageal telemetric pH study in her home, using the same DeMeester and Skinner scoring technique, gave a high score of 53.5. Case III. A 13 month old black male with a history of
encephalitis,
meningitis
and delayed
development
The American
was
Journal of Surgery
Esophageal
OH
PH IO
Figure 7. Case 1.Left, extract from preoperative 24 hour esophageal pH study: read from right to left. Note the frequent episodes of decreased pH, indicative of acid reflux. Right, extract from postoperative esophagea/pH study. Note the physiologic, infrequent episodes of reffux.
II:00
I
Time p.m.
for regurgitation and weight loss. Endoscopy revealed a sliding hiatal hernia but no esophagitis. The composite score of a 24 hour esophageal pH telemetric study performed in the hospital was 14.86, well within admitted
normal
1o:oo
TABLE I
Evaluation of Objective Measurements of Gastroesophageal Reflux (From [ 31) Percentage of Positive Test Results Severely Asymptomatic Symptomatic Patients Patients
limits.
Comments Through the electronics of telemetry, the 24 hour esophageal pH study may be performed as an outpatient procedure. The patient remains mobile within the 300 foot telemetric range and is able to carry on customary activities in the physiologic environment of the home. Diet is limited to foods with a pH above 5, eliminating alcohol and drugs. The diary maintained during the test is correlated with the recorded pH to identify possible relationships between decreases in pH below 4, and symptoms and positional changes. The procedure is cost-effective, eliminating 2 or 3 days in the hospital. The 1.5 pound weight of the patient’s battery-powered, shock-proof pH meter and transmitter is comfortable in its cotton shoulder harness. The strip chart receiver runs on house current. Twenty-four hour esophageal pH monitoring has proved an accurate physiologic index of acid reflux and has been the basis for development of the most precise quantitative evaluation of all the tests [2,3] (Table I). The test calibrates two important determinants of reflux esophagitis: (1) reflux secondary to an incompetent cardioesophageal junction, and (2) the rate of esophageal clearing of refluxed gastric juice [4]. In the severely symptomatic patient the test has a 92 percent accuracy rate with no false-positive findings. The acid perfusion test of Bernstein and Baker [5] indicates sensitivity of the esophagus to exogenous acid, but fails to measure the frequency, duration and degree of the decreases in pH common in patients with reflux. The 24 hour pH test has a high level of patient acceptability, in large part re-
Volume 142, October 1991
pH Monitoring by Telemetry
Acid perfusion test Radiographic reflux Endoscopic esophageal manometry Esophageal biopsy Standard acid reflux test 24 hour OH monitorino
? 25 5
100 58 34
10 20 0
75 a0 92
lated to the flexible, tiny 1.5 mm pH indwelling microelectrode introduced as a package with a removable balloon catheter. The test is used routinely in assessing clear-cut reflux (case I) but has added utility in clarifying the diagnosis when suspected reflux is complicated by the presence of angina, gallstone, hiatus hernia or some other abnormality of the same anatomic area. The test is the ultimate proof of the success or failure of an antireflux operation (case II). Telemetry is of particular value in pediatric patients, allowing reasonable mobility and a better assay of the relative effects of upright, recumbent or prone position on the amount of reflux [1,6]. In infants the test is a precise determinant of the frequency, duration and severity of reflux and provides an objective basis on which to recommend surgery. However, the 24 hour pH assay may document the absence of reflux (case III) and mandate a search for another diagnosis. Johnson and DeMeester’s calculation of a derived composite reflux score based on six components of
515
Falor et al
the 24 hour pH record establishes a grade of 17.92 as the upper limit of normal reflux. Further analysis of the record clearly identifies three subsets of patients with pathologic reflux based on body position: supine, upright, and combined supine-upright. The patient with upright reflux rapidly clears acid and, although symptomatic, has the smallest risk of esophagitis. The patient with supine reflux may have nocturnal pyrosis and require only medical therapy; however, he may be unaware of the acid irritation and first present with advanced esophagitis and even stricture. Combined supine-upright reflux is the most common and carries the greatest risk of esophagitis and stricture. Thus, the test score and the body position during major reflux are both important factors bearing on the final therapeutic decision. Summary Twenty-four hour determinations of the distal esophageal pH by telemetry provides outpatient monitoring of gastroesophageal reflux in the ambulant patient in his natural environment. In our overweight, physically unfit and anxiety-ridden population, indigestion is a frequent complaint originating from a variety of causes including gastro-
516
esophageal reflux. Long-term esophageal pH monitoring quantifies and is the best current means of differentiating physiologic from pathologic reflux. Acknowledgment: We thank Robert T. Stone, MD, of the Children’s Hospital Medical Center of Akron for supplying case III.
References 1. Johnson LF, DeMeester TR. Twenty-four hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol 1974;62:325-32. 2. DeMeester TR, Wernly JA, Bryant GH, Little AG, Skinner DB. Clinical and in vitro analysis of determinants of gastroesophageal competence. A study of the principles of antireflux surgery. Am J Surg 1979; 137:39-46. 3. DeMeester TR, Johnson LF. The evaluation of objective mesurements of gastroesophageal reflux and their contribution to patient management. Surg Clin North Am 1976;56:3953. 4. Johnson LF, DeMeester TR, Haggitt RC. Esophageal epithelial response to gastroesophageal reflux. A quantitative study. Digest Dis 1978;23:498-509. 5. Bernstein LM, Baker LA. A clinical test for esophagitis. Gastroenterology 1958;34:760-81. 6. Hill JL, Pelligrini JD, Burrington JD, Reyes HM, DeMeester TR. Technique and experience with 24 hour esophageal pH monitoring in children. J Pediatr Surg 1977;12:877-87.
The American Journal of Surgery