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Mo1125 Quantitative Assessment of Acid Reflux and Its Clinical Significance
AGA Abstracts
median (25th-75th) BI impedance was 961.3 (734.3-1610.8) V at 3cm, 1114.9 (845.4 to 1512.7) V at 5 cm, and 2222.4 (1511.6 to 2734.3) V at the most proximal impedance recording site. All these BI values were lower than those observed in NERD patients, not only in the distal esophagus [at 3cm 1409.2 (1264.1 to 2118.6) V, p=0.0065; at 5 cm 1650.1 (1228.4 to 2266.4) V, p=0.0054], but also in the proximal esophagus [at 17cm 2678.7 (2183.0 to 3309.1) V, p=0.036]. They are displayed in the figure. Conclusion: Despite the lesser percentage of patients with abnormal AET, all BI values in SSc patients were lower than in NERD patients, suggesting that BI levels are related not only to oesophageal AET, but also to oesophageal tissue SSc-related damage. This finding is further corroborated by the differences observed at the proximal oesophagus. Thus, BI levels may be used as indirect markers of alteration of the oesophageal wall and, therefore, of oesophageal involvement in patients with SSc.
Figure 1: ROC curves for predicting esophagitis based on 4 parameter model. The model was robust across the two institutions. Mo1125 Quantitative Assessment of Acid Reflux and Its Clinical Significance Nina Zhang, Liyi Ma, Xiaomeng Sun, Boli Yang, Xinjun Wang, John O. Clarke, Ellen M. Stein, Sameer Dhalla, Pankaj J. Pasricha, Jiande Chen Aims: Impedance measurement has been added to pH monitoring for the assessment of nonacid reflux. The aim of this study was to investigate whether the severity of acid reflux might predict extraesophageal symptoms and esophagitis; and whether there is a correlation between the severity of acid reflux and hiatal hernia and impaired esophageal motility. Methods: In a retrospective study, data were gathered from patients who presented with typical GERD symptoms between 2012 and 2014. They underwent 24-h MII-pH monitoring, upper endoscopy and high resolution esophageal manometry. A new software was developed in collaboration with a software engineer to calculate 1) the height (H) of acid reflux based on impedance and pH <4; 2) the duration (D) of acid reflux: total time with pH <4; 3) the area of acid reflux (A): summation of each reflux episode of H×D and 4) a composite reflux index (CRI): summation of each reflux episode calculated as H×D×(14-pH). These parameters were compared between different paired-groups: 1) with and without extraesophageal symptoms, such as chronic cough, non-allergic asthmatics, chronic laryngitis and noncardiac chest pain; 2) with and without erosive esophagitis; 3) with and without hiatal hernia. Results: A total of 119 patients were included in the analysis and it was found: 1) Patients with extraesophageal symptoms showed a higher height of reflux than those without extraesophageal symptoms (11.6±2.6cm vs. 10.2±3.2cm, P=0.04). However, none of other reflux parameters, including, D, A and CRI showed a significant difference between the two groups, suggesting that the height of reflux is the single most important factor predicting extraesophagel symptoms. 2) Compared with the patients without erosive esophagitis, the patients with erosive esophagitis showed longer duration of acid reflux (128.7±16.1s vs. 71.68±11.02s, P=0.02), suggesting that sustained acid reflux causes erosive esophagitis. 3) Hiatal hernia contributed to the acid exposure in the distal esophagus. The total duration of acid reflux was doubled in patients with hiatal hernia (129.4±19.1s vs. 66.6±10.5s, P= 0.008). 4) Impaired esophageal motility worsened acid reflux. Among various esophageal motility parameters, the distal contractile integral was found to be most significantly correlated with the duration of acid reflux (r=-0.32, P<0.001), the area of acid reflux (r=-0.42, P<0.001) and CRI (r=-0,24, P=0.01)). Conclusions: A number of acid reflux parameters are useful in assessing GERD and its symptoms. The height of acid reflux predicts extraesophageal symptom. The duration of acid reflux is predictive of erosive esophagitis. Hiatal hernia worsens acid reflux. Impaired distal esophageal motility is correlated with the severity of acid reflux.
Mo1124 Gastroesophageal Reflux Disease: Can We Predict Who Will Develop Esophagitis? Dhyanesh Patel, James C. Slaughter, Amit Patel, Ami Patel, Tina Higginbotham, Fehmi Ates, C. Prakash Gyawali, Michael F. Vaezi Objectives: Patients with GERD often have waxing and waning symptoms. Most patients with GERD (70%) do not develop erosive esophagitis. However, it is essential to differentiate patients at risk of developing erosive esophagitis as long term acid suppressive therapies may be needed. The aims of this study were to assess demographic, endoscopic, and pH characteristics of a large cohort of patients with GERD in order to: 1) identify best predictors for esophagitis, 2) develop a clinical model for predicting esophagitis, and 3) externally validate the model using data from another major academic medical center. Methods: Patients with suspected GERD-related symptoms underwent both EGD and 48-hour wireless pH monitoring one week off acid suppressive treatment. Those with a prior history of fundoplication, radiation, and malignancy were excluded. Endoscopic evidence of esophagitis was graded using the Los Angeles classification (A, B, C, and D). Elastic net regression was used to identify the best predictors for esophagitis and C-index and Akaike information criteria (AIC) were used to compare predictive accuracy of different models. Subsequently, data was obtained from similar population at a different academic esophageal center and linear predictor model was used to assess generalizability of the model. Results: 693 patients with suspected GERD-related symptoms were studied [71% female, median (IQR) age 54 yrs (43-62)]. 16% of patients had endoscopic evidence of esophagitis. % time pH <4 was significantly greater in patients with esophagitis (11.6% vs. 5.6%, p-value <0.001). The most important predictor for development of esophagitis was % time pH <4, followed by hiatal hernia size (HHS), number of reflux events (total), and BMI. Equation 1 shows the regression model with the above parameters (AUC of 0.817). The model was externally validated based on 170 patients [64% female, median (IQR) age 54 yrs (44-64)]. The ROC curve for the internal and external data predicting presence of esophagitis is shown in Figure 1. Conclusion: We found total % time pH <4, HHS, number of events, and BMI to be the best predictors for development of erosive esophagitis. This is the first study to develop an externally validated clinical model that can be used by clinicians to calculate risk for development of esophagitis in daily practice.
Mo1126 GERD-Related Symptom Recurrence in Patients Stopping PPIs for 48-Hour Bravo Esophageal Wireless pH Monitoring Study Sai P. Alla, Ron Schey, Henry P. Parkman Background: Patients presenting with gastroesophageal reflux disease (GERD) related symptoms are often prescribed proton pump inhibitors (PPIs) for treatment. Improvement in the patient's symptoms with PPIs suggest the diagnosis of GERD (a therapeutic PPI trial). Patients with persistent symptoms, may undergo esophageal pH monitoring during which time PPI therapy may be stopped. Perhaps worsening of symptoms with stopping PPIs also suggests GERD - a reverse PPI trial. Aims: 1) To assess symptom change as worsening or no change/ better in patients upon discontinuing PPIs for Bravo wireless pH monitoring study. 2) To determine factors that impact these overall symptoms change Methods: 363 patients who underwent the 48-hour Bravo esophageal pH monitoring from January 2012 to July 2014 were retrospectively included in this study. Patients needed to meet three criteria for this study: 1) Discontinue PPI usage for >7 days; 2) Complete a survey the day of probe placement about their GERD-related symptomology and PPI usage; and. 3) Complete a modified PAGISYM (Patient Assessment of GI Symptoms) assessing symptoms during the 2-day test and characterize their overall symptomology as "better/same" or "worse" after stopping PPIs. The Bravo pH test was considered positive for acid reflux if the percent time esophageal pH <4 was >4.5% of the total recording time. Results: 205 patients were eligible for the study. 113 patients described their symptoms as being worsened and 92 described their symptoms as being same/better after stopping their PPI for the test. Of the 92 patients whose symptoms were the same/better, 44 (48%) had documented acid reflux during the Bravo studies. Of the other 113 patients with worse symptoms after stopping PPIs, 65 (58%) had documented acid reflux. The total time pH<4 was correlated with percentage of patients with worsening of symptoms after stopping PPIs (r=0.95; Fig. 1). 65 of the 109 (59.6%) patients who had acid reflux felt a worsening of symptoms while only 48 out of the 96 (50.0%) of patients without reflux felt a worsening of symptoms (p=0.043). Symptom scores for patients' whose
Equation 1
S-613
AGA Abstracts
median (25th-75th) BI impedance was 961.3 (734.3-1610.8) V at 3cm, 1114.9 (845.4 to 1512.7) V at 5 cm, and 2222.4 (1511.6 to 2734.3) V at the most proximal impedance recording site. All these BI values were lower than those observed in NERD patients, not only in the distal esophagus [at 3cm 1409.2 (1264.1 to 2118.6) V, p=0.0065; at 5 cm 1650.1 (1228.4 to 2266.4) V, p=0.0054], but also in the proximal esophagus [at 17cm 2678.7 (2183.0 to 3309.1) V, p=0.036]. They are displayed in the figure. Conclusion: Despite the lesser percentage of patients with abnormal AET, all BI values in SSc patients were lower than in NERD patients, suggesting that BI levels are related not only to oesophageal AET, but also to oesophageal tissue SSc-related damage. This finding is further corroborated by the differences observed at the proximal oesophagus. Thus, BI levels may be used as indirect markers of alteration of the oesophageal wall and, therefore, of oesophageal involvement in patients with SSc.
Figure 1: ROC curves for predicting esophagitis based on 4 parameter model. The model was robust across the two institutions. Mo1125 Quantitative Assessment of Acid Reflux and Its Clinical Significance Nina Zhang, Liyi Ma, Xiaomeng Sun, Boli Yang, Xinjun Wang, John O. Clarke, Ellen M. Stein, Sameer Dhalla, Pankaj J. Pasricha, Jiande Chen Aims: Impedance measurement has been added to pH monitoring for the assessment of nonacid reflux. The aim of this study was to investigate whether the severity of acid reflux might predict extraesophageal symptoms and esophagitis; and whether there is a correlation between the severity of acid reflux and hiatal hernia and impaired esophageal motility. Methods: In a retrospective study, data were gathered from patients who presented with typical GERD symptoms between 2012 and 2014. They underwent 24-h MII-pH monitoring, upper endoscopy and high resolution esophageal manometry. A new software was developed in collaboration with a software engineer to calculate 1) the height (H) of acid reflux based on impedance and pH <4; 2) the duration (D) of acid reflux: total time with pH <4; 3) the area of acid reflux (A): summation of each reflux episode of H×D and 4) a composite reflux index (CRI): summation of each reflux episode calculated as H×D×(14-pH). These parameters were compared between different paired-groups: 1) with and without extraesophageal symptoms, such as chronic cough, non-allergic asthmatics, chronic laryngitis and noncardiac chest pain; 2) with and without erosive esophagitis; 3) with and without hiatal hernia. Results: A total of 119 patients were included in the analysis and it was found: 1) Patients with extraesophageal symptoms showed a higher height of reflux than those without extraesophageal symptoms (11.6±2.6cm vs. 10.2±3.2cm, P=0.04). However, none of other reflux parameters, including, D, A and CRI showed a significant difference between the two groups, suggesting that the height of reflux is the single most important factor predicting extraesophagel symptoms. 2) Compared with the patients without erosive esophagitis, the patients with erosive esophagitis showed longer duration of acid reflux (128.7±16.1s vs. 71.68±11.02s, P=0.02), suggesting that sustained acid reflux causes erosive esophagitis. 3) Hiatal hernia contributed to the acid exposure in the distal esophagus. The total duration of acid reflux was doubled in patients with hiatal hernia (129.4±19.1s vs. 66.6±10.5s, P= 0.008). 4) Impaired esophageal motility worsened acid reflux. Among various esophageal motility parameters, the distal contractile integral was found to be most significantly correlated with the duration of acid reflux (r=-0.32, P<0.001), the area of acid reflux (r=-0.42, P<0.001) and CRI (r=-0,24, P=0.01)). Conclusions: A number of acid reflux parameters are useful in assessing GERD and its symptoms. The height of acid reflux predicts extraesophageal symptom. The duration of acid reflux is predictive of erosive esophagitis. Hiatal hernia worsens acid reflux. Impaired distal esophageal motility is correlated with the severity of acid reflux.
Mo1124 Gastroesophageal Reflux Disease: Can We Predict Who Will Develop Esophagitis? Dhyanesh Patel, James C. Slaughter, Amit Patel, Ami Patel, Tina Higginbotham, Fehmi Ates, C. Prakash Gyawali, Michael F. Vaezi Objectives: Patients with GERD often have waxing and waning symptoms. Most patients with GERD (70%) do not develop erosive esophagitis. However, it is essential to differentiate patients at risk of developing erosive esophagitis as long term acid suppressive therapies may be needed. The aims of this study were to assess demographic, endoscopic, and pH characteristics of a large cohort of patients with GERD in order to: 1) identify best predictors for esophagitis, 2) develop a clinical model for predicting esophagitis, and 3) externally validate the model using data from another major academic medical center. Methods: Patients with suspected GERD-related symptoms underwent both EGD and 48-hour wireless pH monitoring one week off acid suppressive treatment. Those with a prior history of fundoplication, radiation, and malignancy were excluded. Endoscopic evidence of esophagitis was graded using the Los Angeles classification (A, B, C, and D). Elastic net regression was used to identify the best predictors for esophagitis and C-index and Akaike information criteria (AIC) were used to compare predictive accuracy of different models. Subsequently, data was obtained from similar population at a different academic esophageal center and linear predictor model was used to assess generalizability of the model. Results: 693 patients with suspected GERD-related symptoms were studied [71% female, median (IQR) age 54 yrs (43-62)]. 16% of patients had endoscopic evidence of esophagitis. % time pH <4 was significantly greater in patients with esophagitis (11.6% vs. 5.6%, p-value <0.001). The most important predictor for development of esophagitis was % time pH <4, followed by hiatal hernia size (HHS), number of reflux events (total), and BMI. Equation 1 shows the regression model with the above parameters (AUC of 0.817). The model was externally validated based on 170 patients [64% female, median (IQR) age 54 yrs (44-64)]. The ROC curve for the internal and external data predicting presence of esophagitis is shown in Figure 1. Conclusion: We found total % time pH <4, HHS, number of events, and BMI to be the best predictors for development of erosive esophagitis. This is the first study to develop an externally validated clinical model that can be used by clinicians to calculate risk for development of esophagitis in daily practice.
Mo1126 GERD-Related Symptom Recurrence in Patients Stopping PPIs for 48-Hour Bravo Esophageal Wireless pH Monitoring Study Sai P. Alla, Ron Schey, Henry P. Parkman Background: Patients presenting with gastroesophageal reflux disease (GERD) related symptoms are often prescribed proton pump inhibitors (PPIs) for treatment. Improvement in the patient's symptoms with PPIs suggest the diagnosis of GERD (a therapeutic PPI trial). Patients with persistent symptoms, may undergo esophageal pH monitoring during which time PPI therapy may be stopped. Perhaps worsening of symptoms with stopping PPIs also suggests GERD - a reverse PPI trial. Aims: 1) To assess symptom change as worsening or no change/ better in patients upon discontinuing PPIs for Bravo wireless pH monitoring study. 2) To determine factors that impact these overall symptoms change Methods: 363 patients who underwent the 48-hour Bravo esophageal pH monitoring from January 2012 to July 2014 were retrospectively included in this study. Patients needed to meet three criteria for this study: 1) Discontinue PPI usage for >7 days; 2) Complete a survey the day of probe placement about their GERD-related symptomology and PPI usage; and. 3) Complete a modified PAGISYM (Patient Assessment of GI Symptoms) assessing symptoms during the 2-day test and characterize their overall symptomology as "better/same" or "worse" after stopping PPIs. The Bravo pH test was considered positive for acid reflux if the percent time esophageal pH <4 was >4.5% of the total recording time. Results: 205 patients were eligible for the study. 113 patients described their symptoms as being worsened and 92 described their symptoms as being same/better after stopping their PPI for the test. Of the 92 patients whose symptoms were the same/better, 44 (48%) had documented acid reflux during the Bravo studies. Of the other 113 patients with worse symptoms after stopping PPIs, 65 (58%) had documented acid reflux. The total time pH<4 was correlated with percentage of patients with worsening of symptoms after stopping PPIs (r=0.95; Fig. 1). 65 of the 109 (59.6%) patients who had acid reflux felt a worsening of symptoms while only 48 out of the 96 (50.0%) of patients without reflux felt a worsening of symptoms (p=0.043). Symptom scores for patients' whose
Equation 1
S-613
AGA Abstracts