Gender Differences in Results of Reflux Monitoring Studies in Patients With Symptomatic GERD

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a week and had evidence of endoscopic esophagitis. We used a custom designed HRM catheter equipped with 36 solid-state pressure transducers, located 1 cm apart. The HRM tests were performed in semirecumbent position during one hour after intake of mixed liquid/solid meal (500 kcal) with 200 ml of orange juice. The characteristics of TLESRs were determined from the HRM. Results: Mean number of TLESRs per a subject was 2.8 in GERD group and 1.1 in healthy controls during one hour recording (p=0.0371). Duration of TLESRs was 16.3±1.0 (mean±SE) seconds in GERD group and 16.0±4.0 seconds in healthy controls (p=0.863). LES lift was 4.3±0.4 cm in GERD group and 4.6±0.6 cm in healthy controls (p=0.372). Conclusions: Our study shows that GERD patients have significantly more TLESRs in comparison with healthy subjects. We speculate that increased frequency of LM contractions which induce TLESRs may have a major role in GERD.

AGA Abstracts

The Effect of a pH Neutral Meal on Acid Gastroesophageal Reflux Karthik Ravi, David A. Katzka, Dawn L. Francis, Jacalyn A. See, Debra M. Geno Background: The standard clinical practice of excluding the meal period during ambulatory pH monitoring has largely been based upon the idea that the ingested meal completely buffers stomach acid and that early acid reflux may represent acidic foods rather than gastric acid. Aims: Isolate and measure early postprandial acid reflux and gastric buffering capacity by performing ambulatory pH monitoring with a pH neutral meal. Methods: Eighteen patients undergoing clinically indicated ambulatory pH monitoring off all reflux therapy consumed a meal consisting of potatoes, hamburger, ice cream, and milk with a total of 1126 calories, 53g of fat, and a pH of 5.9 while in the upright position. In addition to usual data analysis, monitoring of esophageal pH during the meal and during 15 minute intervals for 1 hour postprandially was included. Results: Pathologic gastroesophageal reflux was present in 44% (8/18) of patients, while 56% (10/18) had physiologic esophageal acid exposure. Isolated upright reflux occurred in 38% (3/8) with pathologic reflux, while 62% (5/8) had recumbent reflux. One patient had esophageal acid exposure during the meal (pH <4 for 0.6% of time). Gastroesophageal acid reflux was seen in 33% (6/18) of patients within 60 minutes of the meal, with 22% (4/18) demonstrating an esophageal pH <4 for >4.2% of the time. Total esophageal acid exposure was abnormal in 50% (3/6) of patients with acid reflux within one hour of the meal. Esophageal acid exposure time during the first hour after the meal tended to be greater in patients with pathologic esophageal acid exposure versus those with physiologic acid exposure, but this did not reach statistical significance (5.9% ± 3.5% versus 0.5% ± 0.5%, p=0.1). Isolated upright reflux was seen in 50% (3/6) patients with postprandial esophageal acid exposure, while the other half had recumbent reflux. Gastroesophageal reflux was seen within 15 minutes of the meal in 11% (2/18) of patients, with 9% (1/18) demonstrating an esophageal pH <4 for >4.2% during this period. In a subset of 5 patients who had gastric and esophageal pH monitoring, the percent of time with gastric pH <4 during the meal was 19.2%, 23.5%, 30%, 97.1%, and 99.9% while for 1 hour postprandial it was 21.2%, 21.8%, 41.4%, 70.4%, and 99.9% . This was consistent with incomplete buffering of gastric acid by the pH neutral meal. Further, 2 patients demonstrated esophageal acid exposure within 30 minutes of the meal despite a gastric pH > 4, suggesting gastroesophageal reflux of pooled acid in the gastric cardia despite buffering of acid in the gastric body. Conclusions: The use of a pH neutral meal during pH monitoring may unmask early postprandial reflux of gastric acid and provide data on true gastric buffering. Whether this protocol should become standard for ambulatory monitoring needs further study.

Sa1197 Wireless pH Capsule Testing: The Effects of Diabetes and Narcotic Use and the Safety of Clopidogrel and Warfarin During Testing Brian E. Lacy, Raymond T. Finn, Michael D. Crowell Background: Wireless pH capsule testing is routinely performed to measure acid reflux. The impact of diabetes and narcotic use on wireless pH testing is unknown, while the safety of wireless pH capsule testing in patients on clopidogrel and warfarin has not been examined. Aim: To evaluate the impact of diabetes and narcotic use on wireless pH monitoring and to evaluate the safety of wireless pH monitoring in patients taking clopidogrel or warfarin. Methods: Data was collected from consecutive patients referred for wireless pH capsule testing. Demographics, BMI, symptoms (heartburn, regurgitation, chest pain, chronic cough, asthma, ENT symptoms), and the type, dose, and frequency of acid suppression were recorded at the time of pH capsule placement. Charts were reviewed to determine whether the patient was on narcotics, warfarin, or clopidogrel at the time of testing, and to determine whether the patient was diabetic (insulin requiring or oral medication). Patients remained on clopidogrel during the study but stopped warfarin 3 days before the test. Standard pH data was calculated and analyzed for Day 1, Day 2 and 48 hours (total). A study was considered abnormal if the total fraction of time with acid reflux > 4.2% or if the 48hour DeMeester score > 14.72.Adverse events were monitored by phone call after capsule placement and at the time the receiver was returned. Results: 1554 patients were evaluated with a mean (SD) age of 49.7 years (13.2) and a BMI of 28.8 (6.2). 42.3% were women and 99% were Caucasian. 69% (n = 1077) of Pts had the wireless capsule placed transorally in the motility lab after manometry while 31% were placed after upper endoscopy. The primary reason for testing was reflux symptoms (heartburn and regurgitation) in 74.5% of Pts, chest pain in 9.1%, ENT symptoms in 4.6% and pulmonary symptoms in 4.4%. 69.5% of Pts were studied off PPI therapy, while 30% were studied on PPI therapy. Of those studied on PPI therapy, 33.4% (n = 156) were on a q.d. PPI, while 58% (n = 271) were on a b.i.d. PPI. 26 Pts were on clopidogrel (n = 1.7%) while 17 were on warfarin (1.1%). No complications occurred for Pts studied on either warfarin or clopidogrel. Premature detachment of the capsule occurred in 4.5% of Pts. 58 Pts had diabetes (3.8% of total); most of these had Type 2 DM (n = 37). 52 Pts (3.3%) were on chronic narcotics while 89 (5.7%) were on p.r.n. narcotics. pH parameters were not significantly different for those Pts with DM or those on narcotics, either on or off PPI therapy, compared to those Pts without diabetes or not on narcotics. Conclusions: The results of wireless pH monitoring do not seem to be affected by the use of narcotics or co-existing diabetes. No complications occurred in the group of patients taking clopidogrel or warfarin. Routinely stopping clopidogrel for wireless pH capsule testing may not be necessary.

Sa1195 Characteristics of Upright and Recumbent Reflux in Patients on PPI Thearpy Shahid Ali, Nasser Hajar, Sonia Brar, Ronald Szyjkowski, Amine Hila BACKGROUND: 24-hour multichannel intraluminal impedance and pH (MII-pH) esophageal monitoring allows detection gastroesophageal reflux (GER). MII-pH allows identification of acid and nonacid reflux, changes in esophageal pH, proximal extent of the refluxate and total duration of the reflux episodes. AIM: To assess reflux characteristics regarding proximal extent, acidity, and duration of the reflux episodes between upright position and recumbency. METHODS: We reviewed 59 consecutive ambulatory MII-pH studies performed in our laboratory between 2008 and 2009 (42 females; mean age = 48.3 yrs). All patients were tested while on acid suppressive therapy (PPI once or twice daily). Impedance detected the reflux episodes, pH defined their acidity. All tracings were analyzed and all reflux episodes were assessed for: - bolus clearance time at 3 and 5 cm above the LES. The longest BCT was retained as indicative of the duration of reflux. - baseline pre-reflux esophageal pH, lowest pH, and change in pH, calculated as the difference between baseline pH just prior to reflux, and the nadir. - proximal extent of the refluxate, as seen on the MII segments for every reflux episode. All reflux episodes (both acid and non-acid) were included. Patient's position for each reflux episode was noted. RESULT: We had a total of 3032 MII-pH detected reflux episodes, of which 481 (16%) occurred during recumbency. Comparing reflux characteristics between upright and recumbency we found that recumbent reflux compared to upright position: 1) lasted significantly longer (mean BCT 58.3 vs 33.5 sec respectively; p<0.0001, unpaired t test). 2) had a significantly lower baseline pH (mean baseline pH 5.4 vs 6.6 respectively; p<0.0001, unpaired t test). 3) was significantly more acid (mean pH nadir 4.1 vs 5 respectively; p<0.0001, unpaired t test). 4) showed significantly less change in pH (mean pH change 1.2 vs 1.6 respectively; p=0.014, unpaired t test). 5) did not reach higher in the esophagus (mean height 11.6 vs 11.8 cm respectively; p=0.36, unpaired t test). CONCLUSION: In patients on PPI therapy, nocturnal reflux lasts longer, is more acid, and causes less change in pH than daytime reflux in patients on PPI therapy. However, nocturnal reflux in these patients clearly did not reach higher in the esophagus. Since nocturnal reflux is known to have a higher risk of complications, this indicates that longer esophageal exposure time to reflux is probably a greater factor for damage than proximal extent of reflux.

Sa1198 Gender Differences in Results of Reflux Monitoring Studies in Patients With Symptomatic GERD Johannes Lenglinger, Margit Eisler, Claudia Ringhofer, Martin Riegler Background and aim: Symptomatic gastro-esophageal reflux Disease (GERD) is equally prevalent in both genders, while complications are predominantly encountered in males. Gender differences in results of pH monitoring in healthy volunteers have been reported previously, but no gender specific norm values are established. The aim of this study is to investigate gender differences in the results of pH- und impedance-pH-monitoring studies in GERD patients. Methods: Distal esophageal acid exposure (% time with pH<4), number of reflux events, and symptom correlation (using the symptom index [SI]) were rcompared between male and female GERD patients. A retrospective analysis of reflux monitoring data of adult GERD patients without previous foregut surgery or significant comorbidities, was performed. Reflux studies performed off proton pump inhibitor medication and a duration of 20 hours or more were included. 4.2% of recording time with pH<4, a reflux count of 73 in impedance-pH studies and a SI of 50% were used as discriminators between positive and negative test interpretation. Results: A total of 1721 data sets were eligible (1206 pHand 515 impedance-pH-monitoring procedures). Gender distribution was balanced in pHmonitoring (m=49.7%, f=50.3%, n.s.) whereas significantly more females underwent impedance pH-monitoring (m=34.9%, f=65.1%, p<0.001). Acid exposure in upright position was comparable between both types of procedures (pH<4 over 4.50% vs. 4.35% of recording time, n.s.). In recumbent position significantly higher acid exposure was found with pHmonitoring (4.0% vs. 0.5 %, p<0.001). Males had higher acid exposure than females (pH<4 over 4.5% vs. 2.7%, p<0.001) and a higher number of reflux episodes (62 vs. 48, p<0.001). Symptom frequency of the main symptom was similar (2 vs. 3 events during monitoring, n.s.). Cough as main symptom was reported by a significantly higher percentage of females (9.0% vs. 4.1%, p<0.001). A positive SI was encountered in a comparable proportion of patients (m=35.2%, f=33.6%, n.s.). The rate of positive test results was higher in males than females (m=75.4%, f=61.9%, p=0.003). A positive SI in studies with both acid exposure and number or refluxes in the normal range were more freuquently encountered in females than males (11.0% vs. 5.1%, p=0.016). Conclusion: Results of reflux monitoring in symptomatic GERD patients exhibit significant gender differences. Abnormal esophageal acid exposure and number of reflux events are significantly more frequently encountered in male than female GERD patients, possibly explaining a higher prevalence of acid related complications in males. Significantly more females than males have a positive SI as single positive parameter

Sa1196 Increased Frequency of Transient Lower Esophageal Sphincter Relaxations: A Characteristic in GERD Patients Hoon Il Kim, Su Jin Hong, Jae Pil Han, Seung Hyo Han, Won Young Cho, Tae Hee Lee, Joo Young Cho, Joon Seong Lee, Moon Sung Lee Background: Transient lower esophageal sphincter relaxations (TLESRs) have been reported as the main mechanism of gastroesophageal reflux disease (GERD). Longitudinal muscle (LM) contraction is related to development of TLESRs and lower esophageal sphincter (LES) lift is a possible surrogate marker of the LM contraction. Aim: Goal of this study was to compare the characteristics (the LES lift, frequency and duration of TLESRs) between the GERD patients and the normal subjects by using high-resolution manometry (HRM). The pressure and impedance data were displayed as superimposed color plots using the Sierra Scientific program. Methods: Studies were conducted in 9 patients with symptomatic GERD and 9 asymptomatic volunteers. All patients had typical symptoms of GERD more than once

AGA Abstracts

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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

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AGA Abstracts

AGA Abstracts

during impedance-pH-monitoring. Gender specific normal values should be established for reflux monitoring procedures.