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Ambulatory pH monitoring for atypical GERD symptoms. Results of testing on and off antisecretory therapy
AJG – September, Suppl., 2001
Two had total acid exposures greater than 9% of the time, two less than 2% of the time, and three at 4%, the upper limit of normal. Conclusion: These data confirm patients with MER have normal esophageal muscle and mucosal thickness. The mucosa is laden with eosinophils. There is equivocal and inconclusive evidence that MER results from GERD based on the findings of esophageal manometry and 24 hour pH tests. 44 Motility disorders are not a marker for gastroesophageal reflux disease (GERD) B Gonzales, E Vinjinrayer, N Bracey, D Katzka, DC Metz. UPHS, Philadelphia, PA. Background: GERD may present with esophageal or supraesophageal symptoms. Certain authorities claim that ineffective motility (IEM) is a marker for supraesophageal GERD specifically. Aims: To examine the frequency of motility disorders in GERD patients with esophageal and supraesophageal symptoms. Methods: We evaluated 128 outpatients with stationary esophageal manometry and ambulatory 24 hour pH monitoring between Nov. 1999 and March 2001. GERD was defined as total proximal (20cm above the LES) esophageal acid exposure time (pH ⬍ 4) ⬎1.1%, or distal (5cm above the LES) exposure ⬎6.3% (upright), ⬎1.2% (recumbent) or ⬎4.2% (total). In the presence of therapy, GERD was defined as total distal exposure ⬎1.9%. We defined IEM as ⬎3/10 ineffective peristaltic waves (amplitude ⬍30mmHg), aperistalsis as total absence of peristaltic activity and esophageal spasm as ⬎2/10 simultaneous contractions. IEM was graded as mild (4 –5 ineffective waves), moderate (6 –7) or severe (⬎8). Primary presenting symptoms were classified as esophageal (heartburn, dysphagia or chest pain) or supraesophageal (cough, hoarseness or asthma). Results: 97 pts (75.8%) had esophageal and 31 (24.2%) had supraesophageal symptoms. GERD was present in 57/97 pts (58.7%) with esophageal and in 15/31 pts (48.3%) with supraesophageal symptoms (p ⫽ NS). 39 studies (30.5%) were performed on therapy. 18/32 pts (56.2%) with esophageal symptoms had GERD as compared with 3/7 pts (42.8%) with supraesophageal symptoms (p ⫽ NS). Motility disorders were observed in 22/72 pts (30.5%) with GERD as compared with 15/56 pts (26.7%) without GERD (p ⫽ NS). Motility disorders were seen in 11/39 pts (28.2%) with esophageal symptoms (8 IEM, 2 aperistalsis, 1 spasm) and 5/12 pts (41.6%) with supraesophageal symptoms (all IEM) (p ⫽ NS). Moderate IEM was the most frequent disorder observed and its prevalence was similar in both groups. Of 27 patients undergoing EGD (9 on therapy) only one patient had esophagitis. Conclusions: 1) The frequency of motility disorders in patients with and without GERD is similar, 2) GERD prevalence is similar in patients with esophageal and supraesophageal symptoms and 3) IEM does not predict GERD or supraesophageal GERD in our population. 45 Ambulatory pH monitoring for atypical GERD symptoms. Results of testing on and off antisecretory therapy Amine Hila, MD1, Philip O. Katz, MD, FACG1 and Donald O. Castell, MD, FACG1*. 1Department of Medicine, Graduate Hospital, Philadelphia, PA, United States. Purpose: The value of ambulatory pH monitoring in assessing symptom correlation in patients with atypical symptoms, potentially due to GERD, who are on antisecretory therapy has not been extensively evaluated. This study’s aim is to compare symptom association with acid reflux events on or off therapy in patients with atypical GERD symptoms. Methods: Chart review identified patients diagnosed with GERD (abnormal 24-hr pH study), and who have an atypical GERD symptom as their main complaint. 128 patients met these criteria. 77 (23 males, 54 females; mean age 53 yrs) were done off therapy and 51 on antisecretory therapy (20 males, 31 females; mean age 52 yrs). Heartburn and regurgitation were assessed though not the primary symptom. Positive symptom association was defined by a drop to pH ⬍ 4 within the 5 minutes preceding the onset
Abstracts
S15
of the symptom. The data were analyzed by comparing the symptom association on and off therapy using Chi square. Results: For symptoms with what frequency Symptoms
# symptoms off Rx (% association)
# symptoms on Rx (% association)
p value for symptom association
Heartburn Regurgitation Chest pain Cough Belching Sore throat Total
124 (46%) 27 (59%) 127 (54%) 171 (34.5%) 77 (53%) 35 (71%) 561 (48%)
32 (15%) 10 (10%) 122 (23%) 53 (17%) 11 (18%) 7 (14%) 235 (20%)
0.0012 0.0099 ⬍0.0001 0.0166 0.0499 0.0081 ⬍0.0001
Conclusions: These results show a significantly better GERD symptom association for both typical and atypical symptoms when patients are tested off antisecretory therapy. Symptom association with acid reflux is low in patients tested on antisecretory therapy. In conclusion: 1) This review establishes the clinical value of a negative symptom association while on antisecretory therapy. 2) The etiology of continuing GERD symptoms in patients on antisecretory therapy is unknown, but is not likely to be due to acid reflux. 3) Further investigation into the etiology of these symptoms with impedance monitoring to enhance the value of ambulatory monitoring on therapy is needed. 46 A retrospective analysis of endoscopic treatment in patients with symptomatic Schatzki’s rings Nathanael S Horne, MDGH, Felice R Zwas, MD, FACGGH*, Nicholas W Cirillo, DOWC and Amy E Parrish, Ph.D.GH. 1Greenwich Hospital/Yale University, Greenwich, CT; and 2Wilkes Regional Medical Center, Wilkesboro, NC. Purpose: The aim of this study was to compare the efficacy of three treatment modalities, Maloney Dilators (MD), Balloon Dilators (BD), and Needle Knife Electrocautery (NN) in patients (pts) initially presenting with symptomatic Schatzki’s Rings (SRs). Methods: A retrospective chart review identified all pts with solid food dysphagia and SRs seen on upper endoscopy who were treated (tx) initially with MD, BD, or NN from 10/95 until 5/01. Pts with erosive esophagitis, benign or malignant strictures, or documented motility disorders were excluded. Patient interviews and/or chart review were conducted to determine severity of presenting symptoms (sx), response to treatment, and sx-free interval. Sx-free pts were excluded if their follow up (f/u) period was less than 12 months (mo); however, pts with sx recurrence within 12 mo were included in the data analysis. MD, BD, and NN were compared at 12 mo f/u. A longer term analysis of BD and MD was also performed; this analysis excluded pts tx with NN due to an insufficient f/u period. The data was evaluated using Chi-square and univariate analyses. Results: Of the 138 patients with symptomatic SRs, 4 were lost to f/u, 36 were excluded because their symptom free f/u was ⬍12 mo, leaving 98 for evaluation. There were 51 females and 47 males with an average age of 58 years (range 21–90). Pts in the three treatment groups did not differ in age, gender, or severity of initial sx. At 12 mo f/u, pts tx with BD or NN were more likely to remain asymptomatic than pts tx with MD (Chi-square ⫽ 8.04, p ⬍ 0.018). At long-term f/u (mean:23 mo, range:9 – 67 mo) pts tx with BD were much more likely to remain asymptomatic than pts tx with MD (Chi-square ⫽ 17.55, p ⬍ .0001). (Table 1) 12 MO F/U
#PTS
SYMPTOM FREE AT F/U
% SYMPTOM FREE
MD BD NN 67 MO F/U MD BD
35 45 18
22 40 15
63% 89%* 83%*
35 45
13 37
37% 82%**
* p ⬍ .018 ** p ⬍ .0001
Two had total acid exposures greater than 9% of the time, two less than 2% of the time, and three at 4%, the upper limit of normal. Conclusion: These data confirm patients with MER have normal esophageal muscle and mucosal thickness. The mucosa is laden with eosinophils. There is equivocal and inconclusive evidence that MER results from GERD based on the findings of esophageal manometry and 24 hour pH tests. 44 Motility disorders are not a marker for gastroesophageal reflux disease (GERD) B Gonzales, E Vinjinrayer, N Bracey, D Katzka, DC Metz. UPHS, Philadelphia, PA. Background: GERD may present with esophageal or supraesophageal symptoms. Certain authorities claim that ineffective motility (IEM) is a marker for supraesophageal GERD specifically. Aims: To examine the frequency of motility disorders in GERD patients with esophageal and supraesophageal symptoms. Methods: We evaluated 128 outpatients with stationary esophageal manometry and ambulatory 24 hour pH monitoring between Nov. 1999 and March 2001. GERD was defined as total proximal (20cm above the LES) esophageal acid exposure time (pH ⬍ 4) ⬎1.1%, or distal (5cm above the LES) exposure ⬎6.3% (upright), ⬎1.2% (recumbent) or ⬎4.2% (total). In the presence of therapy, GERD was defined as total distal exposure ⬎1.9%. We defined IEM as ⬎3/10 ineffective peristaltic waves (amplitude ⬍30mmHg), aperistalsis as total absence of peristaltic activity and esophageal spasm as ⬎2/10 simultaneous contractions. IEM was graded as mild (4 –5 ineffective waves), moderate (6 –7) or severe (⬎8). Primary presenting symptoms were classified as esophageal (heartburn, dysphagia or chest pain) or supraesophageal (cough, hoarseness or asthma). Results: 97 pts (75.8%) had esophageal and 31 (24.2%) had supraesophageal symptoms. GERD was present in 57/97 pts (58.7%) with esophageal and in 15/31 pts (48.3%) with supraesophageal symptoms (p ⫽ NS). 39 studies (30.5%) were performed on therapy. 18/32 pts (56.2%) with esophageal symptoms had GERD as compared with 3/7 pts (42.8%) with supraesophageal symptoms (p ⫽ NS). Motility disorders were observed in 22/72 pts (30.5%) with GERD as compared with 15/56 pts (26.7%) without GERD (p ⫽ NS). Motility disorders were seen in 11/39 pts (28.2%) with esophageal symptoms (8 IEM, 2 aperistalsis, 1 spasm) and 5/12 pts (41.6%) with supraesophageal symptoms (all IEM) (p ⫽ NS). Moderate IEM was the most frequent disorder observed and its prevalence was similar in both groups. Of 27 patients undergoing EGD (9 on therapy) only one patient had esophagitis. Conclusions: 1) The frequency of motility disorders in patients with and without GERD is similar, 2) GERD prevalence is similar in patients with esophageal and supraesophageal symptoms and 3) IEM does not predict GERD or supraesophageal GERD in our population. 45 Ambulatory pH monitoring for atypical GERD symptoms. Results of testing on and off antisecretory therapy Amine Hila, MD1, Philip O. Katz, MD, FACG1 and Donald O. Castell, MD, FACG1*. 1Department of Medicine, Graduate Hospital, Philadelphia, PA, United States. Purpose: The value of ambulatory pH monitoring in assessing symptom correlation in patients with atypical symptoms, potentially due to GERD, who are on antisecretory therapy has not been extensively evaluated. This study’s aim is to compare symptom association with acid reflux events on or off therapy in patients with atypical GERD symptoms. Methods: Chart review identified patients diagnosed with GERD (abnormal 24-hr pH study), and who have an atypical GERD symptom as their main complaint. 128 patients met these criteria. 77 (23 males, 54 females; mean age 53 yrs) were done off therapy and 51 on antisecretory therapy (20 males, 31 females; mean age 52 yrs). Heartburn and regurgitation were assessed though not the primary symptom. Positive symptom association was defined by a drop to pH ⬍ 4 within the 5 minutes preceding the onset
Abstracts
S15
of the symptom. The data were analyzed by comparing the symptom association on and off therapy using Chi square. Results: For symptoms with what frequency Symptoms
# symptoms off Rx (% association)
# symptoms on Rx (% association)
p value for symptom association
Heartburn Regurgitation Chest pain Cough Belching Sore throat Total
124 (46%) 27 (59%) 127 (54%) 171 (34.5%) 77 (53%) 35 (71%) 561 (48%)
32 (15%) 10 (10%) 122 (23%) 53 (17%) 11 (18%) 7 (14%) 235 (20%)
0.0012 0.0099 ⬍0.0001 0.0166 0.0499 0.0081 ⬍0.0001
Conclusions: These results show a significantly better GERD symptom association for both typical and atypical symptoms when patients are tested off antisecretory therapy. Symptom association with acid reflux is low in patients tested on antisecretory therapy. In conclusion: 1) This review establishes the clinical value of a negative symptom association while on antisecretory therapy. 2) The etiology of continuing GERD symptoms in patients on antisecretory therapy is unknown, but is not likely to be due to acid reflux. 3) Further investigation into the etiology of these symptoms with impedance monitoring to enhance the value of ambulatory monitoring on therapy is needed. 46 A retrospective analysis of endoscopic treatment in patients with symptomatic Schatzki’s rings Nathanael S Horne, MDGH, Felice R Zwas, MD, FACGGH*, Nicholas W Cirillo, DOWC and Amy E Parrish, Ph.D.GH. 1Greenwich Hospital/Yale University, Greenwich, CT; and 2Wilkes Regional Medical Center, Wilkesboro, NC. Purpose: The aim of this study was to compare the efficacy of three treatment modalities, Maloney Dilators (MD), Balloon Dilators (BD), and Needle Knife Electrocautery (NN) in patients (pts) initially presenting with symptomatic Schatzki’s Rings (SRs). Methods: A retrospective chart review identified all pts with solid food dysphagia and SRs seen on upper endoscopy who were treated (tx) initially with MD, BD, or NN from 10/95 until 5/01. Pts with erosive esophagitis, benign or malignant strictures, or documented motility disorders were excluded. Patient interviews and/or chart review were conducted to determine severity of presenting symptoms (sx), response to treatment, and sx-free interval. Sx-free pts were excluded if their follow up (f/u) period was less than 12 months (mo); however, pts with sx recurrence within 12 mo were included in the data analysis. MD, BD, and NN were compared at 12 mo f/u. A longer term analysis of BD and MD was also performed; this analysis excluded pts tx with NN due to an insufficient f/u period. The data was evaluated using Chi-square and univariate analyses. Results: Of the 138 patients with symptomatic SRs, 4 were lost to f/u, 36 were excluded because their symptom free f/u was ⬍12 mo, leaving 98 for evaluation. There were 51 females and 47 males with an average age of 58 years (range 21–90). Pts in the three treatment groups did not differ in age, gender, or severity of initial sx. At 12 mo f/u, pts tx with BD or NN were more likely to remain asymptomatic than pts tx with MD (Chi-square ⫽ 8.04, p ⬍ 0.018). At long-term f/u (mean:23 mo, range:9 – 67 mo) pts tx with BD were much more likely to remain asymptomatic than pts tx with MD (Chi-square ⫽ 17.55, p ⬍ .0001). (Table 1) 12 MO F/U
#PTS
SYMPTOM FREE AT F/U
% SYMPTOM FREE
MD BD NN 67 MO F/U MD BD
35 45 18
22 40 15
63% 89%* 83%*
35 45
13 37
37% 82%**
* p ⬍ .018 ** p ⬍ .0001