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48 Hour BRAVO (Wireless) Esophageal pH Monitoring Improves Symptom Correlation as Compared to 24 Hour Studies Alone
Sa1201 Is Combined Multichannel Intraluminal Impedance-pH Monitoring Superior to the Conventional 24 Hour pH Meter in the Evaluation of Patients With Laryngorespiratory Symptoms Suspected to Be Due to Gastroesophageal Reflux Disease: A Study in Asian Patients Daphne Ang, Tiing Leong Ang, Choo Hean Poh, Jeannie Ong, Jessica Tan, Eng Kiong Teo, Kwong Ming Fock
Sa1199 48 Hour BRAVO (Wireless) Esophageal pH Monitoring Improves Symptom Correlation as Compared to 24 Hour Studies Alone Bani Chander, Nicole Hanley-Williams, Yanhong Deng, Anish A. Sheth
Objective: Laryngo-respiratory symptoms (LRS) are associated with gastroesophageal reflux disease (GERD). However, in the absence of typical reflux symptoms or endoscopic features of erosive oesophagitis, the association of LRS with GERD is controversial. Apart from acid reflux (AR), non-acid reflux (NAR) may contribute to LRS pathogenesis. The aim of this study was (1) characterize the reflux events in patients with laryngorespiratory symptoms (LRS) using combined multichannel intraluminal impedance-pH (MII-pH) monitoring; (2) determine the prevalence of acid reflux in patients presenting with LRS in the absence of typical GERD symptoms of heartburn and/or regurgitation and (3) evaluate the incremental diagnostic yield of MII-pH. Methods: Prospective study of patients with LRS (unexplained chronic cough, sore throat, globus, hoarse voice) who were referred for GERD evaluation between January 2009 and June 2010. All patients underwent oesophageal manometry, gastroscopy and MII-pH study while off PPI therapy. Intraluminal impedance catheters were positioned 5 cm above the manometrically determined LES. Distal oesophageal acid exposure time (AET)and bolus exposure(BE) time; as well as numbers of AR(pH<4) and NAR (pH≥4) reflux episodes in the distal (5cm above the LES) and proximal (15cm above the LES) oesophagus were measured. A raised distal oesophageal AET was defined by % total time pH<4 for >4.2%. As previously reported, abnormal BE time was defined by BE>1.4% in the distal oesophagus; abnormal reflux numbers were defined by >73 or >31 total reflux numbers (AR and NAR) in the distal or proximal oesophagus respectively. Results: 42 patients (19M, mean age 47.6 ± 13.9 years) underwent MII-pH for evaluation of unexplained chronic cough (n=20, 47.6%), globus (n=7, 16.7%), sore throat (n=13,31.0%) and hoarse voice (n=2,4.8%). Gastroscopy was normal in 36(85.7%) patients; whilst 5(11.9%) and 1(2.4%) patient had LA grade A and B oesophagitis respectively. Elevated AET occurred in 6(14.3%) patients [chronic cough(4), sore throat(2)]. The total number of reflux episodes in the distal oesophagus was elevated in 5(11.9%) patients; 4 of whom recorded concomitant raised reflux episodes in the proximal oesophagus. Another 5(11.9%)patients recorded increased numbers of reflux episodes in the proximal oesophagus only. In these 10 patients, 6 had a normal distal AET. Two of 11 patients with a raised BE time had a normal distal AET and normal total reflux numbers. Excluding patients with a high distal AET, MII-pH enhanced the diagnostic yield in 8 (19.0%) patients. Conclusion: A raised oesophageal AET is uncommon in patients with LRS. The use of MII-pH led to an improved diagnostic yield. However, the significance of a raised distal BE time and increased total reflux numbers despite a normal AET deserves further study. No. of patients with abnormal findings on MII-pH study.
Background: Historical ambulatory pH monitoring systems for the evaluation of GERD have been catheter-based and uncomfortable for patients, commonly limiting both their diet and activities. These studies may also underestimate the amount of reflux a patient has in a routine day. Compared to conventional catheter based pH monitoring systems, wireless (Bravo) pH monitoring is better tolerated by patients and allows for an increased duration of pH recording. Currently, there is lack of data regarding the optimal duration of wireless studies and concern that day 1 results are not typical of a patient's routine lifestyle given the effects of sedation. Few studies have evaluated the merits of 24 versus 48 hour wireless pH monitoring. Aims: The aims of this study were: 1)To identify differences in reflux parameters between day 1 and day 2 as measured by wireless pH monitoring and 2)To assess the effect of 48 hour studies on the number of reflux episodes and symptom correlation as compared to 24 hour studies. Methods: A retrospective chart review of 124 consecutive patients who underwent 48 hour wireless esophageal pH monitoring studies. All patients underwent EGD using IV conscious sedation prior to wireless capsule placement. Acid reflux variables [including total reflux time, number of reflux episodes, and total percent time of pH<4] as well as SAP [symptom association probability] scores were compared for day 1 vs day 2 vs total. Results: There were no statistical differences noted between the two days for total percent time pH <4. However, 48 hour SAP scores were significantly higher when compared to the first 24 hours for all reported primary symptoms. SAP scores were calculated at 24 and 48 hours respectively for heartburn (56% vs 65%, p=0.003), regurgitation (65% vs 80%, p=0.002), chest pain (59% vs 78%, p=0.003), and cough (55% vs 64%, p=0.04). In addition, the percentage of SAP scores >95 was significantly higher at 48 hrs vs 24 hrs for both heartburn and regurgitation (31% vs 22%, p=0.003 and 21% vs 13%, p= 0.005). As expected, 48 hour testing also captured a significantly higher number of reflux episodes as compared to 24 hour results alone (97 vs 47, p<0.0001). Conclusions: 48 hour wireless (Bravo) pH monitoring strengthens symptom correlation as compared to 24 hour results alone and yields a greater percentage of SAP scores >95 for typical symptoms of GERD. Prolonged recording of patient symptoms and/or sedation effects may account for the better symptom correlation. Although there were no statistical differences seen in this study between 24 and 48 hour studies for total percent time pH <4, 48 hr studies captured significantly more reflux episodes as compared to 24 hr monitoring alone. These results suggest that patients undergoing wireless pH monitoring should have 48 hour studies performed as standard of practice. Sa1200 Diagnosis of Nonerosive Reflux Disease: High Resolution Magnified Endoscopy and Fujinon Intelligent Chromo Endoscopy (FICE) Sadettin Hülagü, Altay Celebi, Goktug Sirin, Omer Senturk, Ugur Korkmaz, Ali Erkan Duman Background: Nonerosive reflux disease(NERD)constitutes the major manifestation of gastroesophageal reflux disease (GERD). A gold standard technique for diagnosis for NERD does not still excist. Fujinon intelligent chromoendoscopy (FICE), a virtual chromoendoscopic technique, has recently been used for the diagnosis of several gastrointestinal lesions but not in GERD yet. Aim: We aimed to evaluate the subtle mucosal changes in NERD with magnified endoscopy and FICE and to correlate these changes with symptoms, pH study and histology. In addition we evaluated diagnostic validity of given endoscopic criteria in NERD. Patients: Patients with more then two typical reflux symptoms per week (regurgitation and/or pyrosis) were defined as having GERD. Patients without any reflux symptoms served as controls. A total of 44 patients with no evidence of esophagitis on previous endoscopy and not on PPI therapy for at least four weeks were enrolled to study as 29 NERD (21 female, mean age 39±12,5) and 15 control subjects(8 female, mean age 45,9±10,2). Metod: This study was performed at the Gastroenterology Department of Kocaeli University Medical Faculty Hospital, between March 2009 and April 2010. The study protocol was rewieved and approved by the local Ethics Committee and informed consent was obtained from all patients participating in the study.Frequency, duration and severity of pyrosis and regurgitation were evaluated in NERD group.24-hour pH monitoring was performed with double channel catheter.High resolution magnification endoscope with FICE mode (490 ZW 5 Fuji Photo Optical Co.Saitama, Japan) was used for further endoscopic evaluation .First squamocolumnar junction (SCJ) was inspected without using the magnification and FICE mode. In all patients targeted biopsies were taken from the above noted mucosal breaks if present.In addition two more biopsies were taken from the SCJ without mucosal break and esophagus 1cm above SCJ. Histological evaluation of each specimen was done by a single pathologist and endoscopy was done by a single endoscopist in a blinded manner. Results: Throughout endoscopic criteria; apical mucosal breaks and increased visibility of palisade zone vessels parameters were found significantly higher in NERD (P= 0,040, P=0,024 respectively). Also horizontal mucosal breaks and triangular shaped viliform lesions were only seen in NERD group. Among these parameters horizontal mucosal breaks and/or triangular shaped viliform lesions were seen in 13 patients with NERD, but none in control group. Conclusions: This study has proposed and investigated seven endoscopic criteria and concluded that four of these criteria may be helpful in diagnosing NERD.As horizontal mucosal breaks, triangular shaped viliform lesions or apical mucosal breaks together with increased visibility of palisade blood vessels may be used in the diagnosis of NERD.
AET: acid exposure time Sa1202 Gastroesophageal Reflux is More Relevant Than Motor Dysfunction in Provoking Non-Cardiac Chest Pain Edoardo Savarino, Patrizia Zentilin, Elisa Marabotto, Giorgio Sammito, Lorenzo Gemignani, Alberto Malesci, Carlo Mansi, Manuele Furnari, Vincenzo Savarino Introduction: Non-cardiac chest pain (NCCP) is a common esophageal symptom observed in endoscopy negative patients. The aetiology of NCCP is unknown, but previous studies demonstrated that both visceral hyperalgesia to esophageal distension or even chemostimulation provoked by gastro-esophageal reflux and esophageal motor dysfunction are frequently involved. Limited data are present on the frequency of these abnormalities in endoscopy negative NCCP patients. Aim: To assess the frequency of esophageal motility abnormalities and reflux disease in endoscopy negative patients with NCCP using conventional manometry and impedance-pH testing (MII-pH). Methods: Consecutive endoscopy negative NCCP patients underwent manometry and MII-pH monitoring off-PPI therapy. Manometric pattern was defined as follows: Normal peristalsis (NP; normal wave amplitude and progression), Ineffective Esophageal Motility (IEM; lower distal wave amplitude in ≥30% of wet swallows), Distal Esophageal Spasm (DES; simultaneous wave progression in >10% of wet swallows with normal or high distal amplitude), Nutcracker Esophagus (NE; normal wave progression and high distal wave amplitude). Moreover we measured distal esophageal acid exposure time (AET; % pH<4), number of reflux episodes (acid/weakly acidic) and symptom association probability (SAP). Gastro-Esophageal Reflux Disease (GERD) was diagnosed in case of abnormal AET and/or positive association between symptoms and reflux episodes and/or abnormal number of reflux episodes. Results: Ninety endoscopy negative NCCP patients (53F, mean age 50) were enrolled. At manometry testing, NP was found in 60 (67%) patients, 20 (22%) had DES, 4 (4%) had a NE and 6 (7%) had IEM. At impedance-pH monitoring we found 32 (36%) patients with an abnormal AET. Out of the remaining 58 (64%) patients, 34 (38%) experienced NCCP during the monitoring day. Of them, 4 (7%) had a positive SAP to acid reflux only, 7 (13%) to weakly acidic reflux only and 8 (15%) to both acid and weakly acidic reflux. Fifteen (28%) patients had no association between reflux and symptoms. Finally, in the group with normal AET and who did not experience symptoms, 7 (13%) patients had an abnormal number of reflux episodes. Thus, at manometry testing 30 (33%) patients had esophageal motility abnormalities, while at MII-pH monitoring 58 (64%) patients
S-251
AGA Abstracts
AGA Abstracts
during impedance-pH-monitoring. Gender specific normal values should be established for reflux monitoring procedures.
Sa1199 48 Hour BRAVO (Wireless) Esophageal pH Monitoring Improves Symptom Correlation as Compared to 24 Hour Studies Alone Bani Chander, Nicole Hanley-Williams, Yanhong Deng, Anish A. Sheth
Objective: Laryngo-respiratory symptoms (LRS) are associated with gastroesophageal reflux disease (GERD). However, in the absence of typical reflux symptoms or endoscopic features of erosive oesophagitis, the association of LRS with GERD is controversial. Apart from acid reflux (AR), non-acid reflux (NAR) may contribute to LRS pathogenesis. The aim of this study was (1) characterize the reflux events in patients with laryngorespiratory symptoms (LRS) using combined multichannel intraluminal impedance-pH (MII-pH) monitoring; (2) determine the prevalence of acid reflux in patients presenting with LRS in the absence of typical GERD symptoms of heartburn and/or regurgitation and (3) evaluate the incremental diagnostic yield of MII-pH. Methods: Prospective study of patients with LRS (unexplained chronic cough, sore throat, globus, hoarse voice) who were referred for GERD evaluation between January 2009 and June 2010. All patients underwent oesophageal manometry, gastroscopy and MII-pH study while off PPI therapy. Intraluminal impedance catheters were positioned 5 cm above the manometrically determined LES. Distal oesophageal acid exposure time (AET)and bolus exposure(BE) time; as well as numbers of AR(pH<4) and NAR (pH≥4) reflux episodes in the distal (5cm above the LES) and proximal (15cm above the LES) oesophagus were measured. A raised distal oesophageal AET was defined by % total time pH<4 for >4.2%. As previously reported, abnormal BE time was defined by BE>1.4% in the distal oesophagus; abnormal reflux numbers were defined by >73 or >31 total reflux numbers (AR and NAR) in the distal or proximal oesophagus respectively. Results: 42 patients (19M, mean age 47.6 ± 13.9 years) underwent MII-pH for evaluation of unexplained chronic cough (n=20, 47.6%), globus (n=7, 16.7%), sore throat (n=13,31.0%) and hoarse voice (n=2,4.8%). Gastroscopy was normal in 36(85.7%) patients; whilst 5(11.9%) and 1(2.4%) patient had LA grade A and B oesophagitis respectively. Elevated AET occurred in 6(14.3%) patients [chronic cough(4), sore throat(2)]. The total number of reflux episodes in the distal oesophagus was elevated in 5(11.9%) patients; 4 of whom recorded concomitant raised reflux episodes in the proximal oesophagus. Another 5(11.9%)patients recorded increased numbers of reflux episodes in the proximal oesophagus only. In these 10 patients, 6 had a normal distal AET. Two of 11 patients with a raised BE time had a normal distal AET and normal total reflux numbers. Excluding patients with a high distal AET, MII-pH enhanced the diagnostic yield in 8 (19.0%) patients. Conclusion: A raised oesophageal AET is uncommon in patients with LRS. The use of MII-pH led to an improved diagnostic yield. However, the significance of a raised distal BE time and increased total reflux numbers despite a normal AET deserves further study. No. of patients with abnormal findings on MII-pH study.
Background: Historical ambulatory pH monitoring systems for the evaluation of GERD have been catheter-based and uncomfortable for patients, commonly limiting both their diet and activities. These studies may also underestimate the amount of reflux a patient has in a routine day. Compared to conventional catheter based pH monitoring systems, wireless (Bravo) pH monitoring is better tolerated by patients and allows for an increased duration of pH recording. Currently, there is lack of data regarding the optimal duration of wireless studies and concern that day 1 results are not typical of a patient's routine lifestyle given the effects of sedation. Few studies have evaluated the merits of 24 versus 48 hour wireless pH monitoring. Aims: The aims of this study were: 1)To identify differences in reflux parameters between day 1 and day 2 as measured by wireless pH monitoring and 2)To assess the effect of 48 hour studies on the number of reflux episodes and symptom correlation as compared to 24 hour studies. Methods: A retrospective chart review of 124 consecutive patients who underwent 48 hour wireless esophageal pH monitoring studies. All patients underwent EGD using IV conscious sedation prior to wireless capsule placement. Acid reflux variables [including total reflux time, number of reflux episodes, and total percent time of pH<4] as well as SAP [symptom association probability] scores were compared for day 1 vs day 2 vs total. Results: There were no statistical differences noted between the two days for total percent time pH <4. However, 48 hour SAP scores were significantly higher when compared to the first 24 hours for all reported primary symptoms. SAP scores were calculated at 24 and 48 hours respectively for heartburn (56% vs 65%, p=0.003), regurgitation (65% vs 80%, p=0.002), chest pain (59% vs 78%, p=0.003), and cough (55% vs 64%, p=0.04). In addition, the percentage of SAP scores >95 was significantly higher at 48 hrs vs 24 hrs for both heartburn and regurgitation (31% vs 22%, p=0.003 and 21% vs 13%, p= 0.005). As expected, 48 hour testing also captured a significantly higher number of reflux episodes as compared to 24 hour results alone (97 vs 47, p<0.0001). Conclusions: 48 hour wireless (Bravo) pH monitoring strengthens symptom correlation as compared to 24 hour results alone and yields a greater percentage of SAP scores >95 for typical symptoms of GERD. Prolonged recording of patient symptoms and/or sedation effects may account for the better symptom correlation. Although there were no statistical differences seen in this study between 24 and 48 hour studies for total percent time pH <4, 48 hr studies captured significantly more reflux episodes as compared to 24 hr monitoring alone. These results suggest that patients undergoing wireless pH monitoring should have 48 hour studies performed as standard of practice. Sa1200 Diagnosis of Nonerosive Reflux Disease: High Resolution Magnified Endoscopy and Fujinon Intelligent Chromo Endoscopy (FICE) Sadettin Hülagü, Altay Celebi, Goktug Sirin, Omer Senturk, Ugur Korkmaz, Ali Erkan Duman Background: Nonerosive reflux disease(NERD)constitutes the major manifestation of gastroesophageal reflux disease (GERD). A gold standard technique for diagnosis for NERD does not still excist. Fujinon intelligent chromoendoscopy (FICE), a virtual chromoendoscopic technique, has recently been used for the diagnosis of several gastrointestinal lesions but not in GERD yet. Aim: We aimed to evaluate the subtle mucosal changes in NERD with magnified endoscopy and FICE and to correlate these changes with symptoms, pH study and histology. In addition we evaluated diagnostic validity of given endoscopic criteria in NERD. Patients: Patients with more then two typical reflux symptoms per week (regurgitation and/or pyrosis) were defined as having GERD. Patients without any reflux symptoms served as controls. A total of 44 patients with no evidence of esophagitis on previous endoscopy and not on PPI therapy for at least four weeks were enrolled to study as 29 NERD (21 female, mean age 39±12,5) and 15 control subjects(8 female, mean age 45,9±10,2). Metod: This study was performed at the Gastroenterology Department of Kocaeli University Medical Faculty Hospital, between March 2009 and April 2010. The study protocol was rewieved and approved by the local Ethics Committee and informed consent was obtained from all patients participating in the study.Frequency, duration and severity of pyrosis and regurgitation were evaluated in NERD group.24-hour pH monitoring was performed with double channel catheter.High resolution magnification endoscope with FICE mode (490 ZW 5 Fuji Photo Optical Co.Saitama, Japan) was used for further endoscopic evaluation .First squamocolumnar junction (SCJ) was inspected without using the magnification and FICE mode. In all patients targeted biopsies were taken from the above noted mucosal breaks if present.In addition two more biopsies were taken from the SCJ without mucosal break and esophagus 1cm above SCJ. Histological evaluation of each specimen was done by a single pathologist and endoscopy was done by a single endoscopist in a blinded manner. Results: Throughout endoscopic criteria; apical mucosal breaks and increased visibility of palisade zone vessels parameters were found significantly higher in NERD (P= 0,040, P=0,024 respectively). Also horizontal mucosal breaks and triangular shaped viliform lesions were only seen in NERD group. Among these parameters horizontal mucosal breaks and/or triangular shaped viliform lesions were seen in 13 patients with NERD, but none in control group. Conclusions: This study has proposed and investigated seven endoscopic criteria and concluded that four of these criteria may be helpful in diagnosing NERD.As horizontal mucosal breaks, triangular shaped viliform lesions or apical mucosal breaks together with increased visibility of palisade blood vessels may be used in the diagnosis of NERD.
AET: acid exposure time Sa1202 Gastroesophageal Reflux is More Relevant Than Motor Dysfunction in Provoking Non-Cardiac Chest Pain Edoardo Savarino, Patrizia Zentilin, Elisa Marabotto, Giorgio Sammito, Lorenzo Gemignani, Alberto Malesci, Carlo Mansi, Manuele Furnari, Vincenzo Savarino Introduction: Non-cardiac chest pain (NCCP) is a common esophageal symptom observed in endoscopy negative patients. The aetiology of NCCP is unknown, but previous studies demonstrated that both visceral hyperalgesia to esophageal distension or even chemostimulation provoked by gastro-esophageal reflux and esophageal motor dysfunction are frequently involved. Limited data are present on the frequency of these abnormalities in endoscopy negative NCCP patients. Aim: To assess the frequency of esophageal motility abnormalities and reflux disease in endoscopy negative patients with NCCP using conventional manometry and impedance-pH testing (MII-pH). Methods: Consecutive endoscopy negative NCCP patients underwent manometry and MII-pH monitoring off-PPI therapy. Manometric pattern was defined as follows: Normal peristalsis (NP; normal wave amplitude and progression), Ineffective Esophageal Motility (IEM; lower distal wave amplitude in ≥30% of wet swallows), Distal Esophageal Spasm (DES; simultaneous wave progression in >10% of wet swallows with normal or high distal amplitude), Nutcracker Esophagus (NE; normal wave progression and high distal wave amplitude). Moreover we measured distal esophageal acid exposure time (AET; % pH<4), number of reflux episodes (acid/weakly acidic) and symptom association probability (SAP). Gastro-Esophageal Reflux Disease (GERD) was diagnosed in case of abnormal AET and/or positive association between symptoms and reflux episodes and/or abnormal number of reflux episodes. Results: Ninety endoscopy negative NCCP patients (53F, mean age 50) were enrolled. At manometry testing, NP was found in 60 (67%) patients, 20 (22%) had DES, 4 (4%) had a NE and 6 (7%) had IEM. At impedance-pH monitoring we found 32 (36%) patients with an abnormal AET. Out of the remaining 58 (64%) patients, 34 (38%) experienced NCCP during the monitoring day. Of them, 4 (7%) had a positive SAP to acid reflux only, 7 (13%) to weakly acidic reflux only and 8 (15%) to both acid and weakly acidic reflux. Fifteen (28%) patients had no association between reflux and symptoms. Finally, in the group with normal AET and who did not experience symptoms, 7 (13%) patients had an abnormal number of reflux episodes. Thus, at manometry testing 30 (33%) patients had esophageal motility abnormalities, while at MII-pH monitoring 58 (64%) patients
S-251
AGA Abstracts
AGA Abstracts
during impedance-pH-monitoring. Gender specific normal values should be established for reflux monitoring procedures.