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OC.03.5: REFLUX PATTERNS DIFFER AMONG PATIENTS WITH NON-EROSIVE REFLUX DISEASE (NERD), HYPERSENSITIVE ESOPHAGUS (HE) AND FUNCTIONAL HEARTBURN (FH)
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Abstracts of the XVII National Congress of Digestive Diseases / Digestive and Liver Disease 43S (2011) S115–S264 PPI non responder and 6/25 responder patients. Findings of MI-pH are shown in the table. The total reflux number and the proportions of weakly acidic, mixed and proximal reflux did not differ between EE patients (PPI responders and non-responders).
EE EE only/ EE+T NERD HV
Number of refluxes
Weakly acidic (%)
Mixed reflux (%)
Proximal (%)
62 (39-113)* 56 (37-105)/ 66 (46-134) 28 (20-41) 16 (9-27)
51% (34-64%)* 51% (35-68%)/ 50% (31-63%) 32% (16-42%) 43%
71% (43-84%)* 70% (43-84%)/ 75% (54-84%) 54% (45-70%) 58%
68% (59-80%) 68% (61-78%)/ 67% (53-82%) 64% (30-78%) 62%
*p< 0.05. Data are expressed as median and 25th–75th percentile values.
Conclusions: Patients with extra-esophageal symptoms, compared to NERD patients with typical symptoms and HV, are characterized by a higher number of reflux episodes and higher proportion of weakly acidic and mixed refluxes. Although this reflux pattern could explain the reduced response to PPI treatment, MI-pH findings do not seem to predict the PPI response in this group of patients. since they cause underestimation of GERD patients and overestimation of FH patients. Impedance-pH monitoring is more accurate in identifying GERD or FH and should be included in the future iteration of Rome criteria.
OC.03.4
OC.03.5 REFLUX PATTERNS DIFFER AMONG PATIENTS WITH NON-EROSIVE REFLUX DISEASE (NERD), HYPERSENSITIVE ESOPHAGUS (HE) AND FUNCTIONAL HEARTBURN (FH) E. Savarino ∗ , P. Zentilin, E. Marabotto, M. Furnari, G. Sammito, L. Gemignani, A. Malesci, C. Mansi, V. Savarino
PATIENTS WITH EXTRA-ESOPHAGEAL SYMPTOMS, COMPARED TO NERD PATIENTS WITH TYPICAL SYMPTOMS AND HEALTHY VOLUNTEERS, ARE CHARACTERIZED BY A HIGHER NUMBER OF REFLUX EPISODES AND HIGHER PROPORTION OF WEAKLY ACIDIC AND MIXED REFLUX
Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
M. Ribolsi ∗ ,1 , P. Balestrieri 1 , M.C. Addarii 1 , S. Emerenziani 1 , F. Greco 1 , M. Casale 1 , F. Salvinelli 1 , F. Pace 2 , M. Cicala 1 1 Università Campus Bio Medico, Roma, Italy; 2 Ospedale Bolognini, Bergamo, Italy
Background and aim: Although extra-esophageal symptoms are present in >30% of GERD patients, the role of gastric refluxate still remains unclear. In patients with extra-esophageal symptoms, pH monitoring is often in the normal range and the response to PPI therapy is poor. Few data are currently available concerning the properties of reflux in these patients when compared to those in patients with typical or combined typical and atypical symptoms, as well as concerning the predictive value of esophageal multichannel impedance-pH (MI-pH) monitoring for the PPI response. Material and methods: 61 NERD patients presenting with extra-esophageal symptoms underwent, following a 3-week pharmacological washout, MI-pH following stationary manometry (EE group). Patients filled out a questionnaire with symptom score. 32 of the 61 EE presented only extra-esophageal symptoms (EE only), the remaining 29 patients also presented typical GERD symptoms (EE+T). 36 of the 61 EE had not shown a satisfactory response to 8 weeks double dose PPI therapy (<50% improvement). MI-pH findings were compared to those obtained in 54 NERD patients with typical symptoms responding to PPI and to normal values reported in an Italian population of healthy volunteers (HV). Results: 19/61 EE (31%) and 24/54 NERD (44%) patients presented pathological acid exposure time (AET). AET was positive in 10/33 patients of the EE only group and in 9/30 patients of EE+T group. AET was positive in 13/36
Background and aim: Non-erosive reflux disease (NERD) is an heterogeneous condition including patients with different pathophysiological characteristics. There are limited data on reflux patterns in them. To compare reflux patterns in NERD patients subclassified by impedance-pH monitoring (MII-pH). Material and methods: Patients with typical reflux symptoms and normal endoscopy underwent MII-pH off-PPI therapy. PPI therapy was discontinued >30 days prior to testing. Forty-eight healthy volunteers (27F; mean age 42yrs; HV) served as controls. Esophageal acid exposure time (AET), characteristics of reflux episodes (acid/nonacid), mean acid clearance time (MACT), median bolus clearance time (MBCT), proximal migration of refluxate and symptom association probability (SAP) were measured. Results: Of 251 NERD patients (118M; mean age 47yrs), 92 (37%) were pH-POS/SAP+, 10 (4%) pH-POS/SAP-, 86 (34%) were pH-NEG/SAP+ (Hypersensitive Esophagus) and 63 (25%) were pH-NEG/SAP- (Functional Heartburn). The total and acid reflux episodes were significantly higher (p<0.01) in pH-POS/SAP+ (median 60 [25th-75th perc. 45-94] and 44 [33-59]) and pH-POS/SAP- (58 [54-87] and 44 [42-65]) compared to pHNEG/SAP+ (43 [26-64] and 25 [11-37]), pH-NEG/SAP- (30 [17-43] and 16 [8-27]) and HV (32 [19-43] and 17 [8-31]). Patients pH-NEG/SAP+ had a significantly increased number of weakly acidic reflux episodes compared to pH-POS/SAP+, pH-POS/SAP-, pH-NEG/SAP- and HV (27 [15-41] vs. 19 [13-26] vs. 20 [13-57] vs. 22 [15-28] vs. 18 [14-26]; p<0.01). Differences in AET, acid and bolus clearance times and percentage of proximal reflux episode are shown in Table 1. Conclusions: Patients with abnormal AET have the most severe degree of reflux disease. In patients with normal AET and SAP+, an increased number of weakly acidic reflux and a high rate of proximal reflux are the main
Abstract OC.03.5 – Table 1. Reflux parameters in subgroups of NERD patients and HV patients % pH <4 total MACT total MBCT total Prox. extent (%)
pH-POS/SAP+
pH-POS/SAP-
pH-NEG/SAP+
pH-NEG/SAP-
HV
p-value (ANOVA)
6.2 (4.6-9)b,c,d 136 (88-181)a,b,c,d 16 (13-22)b,c,d 52 (39-62)a,c,d
4.5 (4.4-6.3)e,f,g 85 (78-269)a,e,f,g 15 (13-21)e,f,g 33 (22-55)a,e
1.7 (0.7-2.7)b,e,h,i 43 (27-67)b,e 13 (10-18)b,e, 57 (42-69)e,h,i
0.8 (0.3-1.8)c,f,h 41 (22-70)c,f 12 (10-19)c,f 33 (23-49)c,h
0.7 (0.1-1.4)d,g,i 32 (16-50)d,g 12 (8-16)d,g 33 (18-46)d,i
<0.01 <0.01 <0.01 <0.01
Data are presented as median (25th-75th percentile). Post-hoc analysis. a pH-POS/SAP+ vs. pH-POS/SAP-, p<0.05; b pH-POS/SAP+ vs. pH-NEG/SAP+, p<0.05; c pH-POS/SAP+ vs. pH-NEG/SAP-, p<0.05; d pH-POS/SAP+ vs. HV, p<0.05; e pH-POS/SAP- vs. pH-NEG/SAP+, p<0.05; f pH-POS/SAP- vs. pH-NEG/SAP-, p<0.05; g pH-POS/SAP- vs. HV, p<0.05; h pH-NEG/SAP+ vs. pH-NEG/SAP-, p<0.05; i pH-NEG/SAP+ vs. HV, p<0.05.
Abstracts of the XVII National Congress of Digestive Diseases / Digestive and Liver Disease 43S (2011) S115–S264 discriminant features. Finally, the large overlap between FH and HV supports the functional origin of FH.
OC.03.6 PREVALENCE OF ESOPHAGEAL MOTILITY ABNORMALITIES IN PATIENTS WITH “TRUE” NON-EROSIVE REFLUX DISEASE, EROSIVE ESOPHAGITIS, BARRETT ESOPHAGUS AND FUNCTIONAL HEARTBURN L. Gemignani ∗ , E. Savarino, P. Zentilin, E. Marabotto, M. Furnari, G. Sammito, C. Mansi, V. Savarino Division Of Gastroenterology, Department Of Internal Medicine, University Of Genoa, Genoa, Italy Background and aim: Esophageal motility abnormalities are frequently encountered in patients with gastro-esophageal reflux disease (GERD). However, limited data are present on their frequency in well defined subgroups of patients, in particular those with “True” NERD and Functional Heartburn. To evaluate differences in esophageal motility patterns among patients with GERD classified on the basis of upper endoscopy with biopsies and/or impedance-pH testing. Material and methods: We evaluated 755 patients (397F, mean age 51, range 18-87, mean BMI 25) with typical reflux symptoms who underwent upper endoscopy, esophageal manometry and/or impedance-pH testing with symptom association probability (SAP) analysis. Forty-eight healthy volunteers (HV, 27F, median age 48) served as controls. Patients were divided in 4 subgroups, as follows: “True” NERD (endoscopy –, abnormal pH and/or SAP+ to Acid/Nonacid), Erosive Esophagitis (EE, endoscopy + for erosive esophagitis), Barrett Esophagus (BE, biopsy + for intestinal metaplasia) and Functional Heartburn (FH, endoscopy –, normal pH and SAP– to Acid/Nonacid). Manometric patterns were defined according to international criteria and distinguished in: Ineffective Esophageal Motility (IEM), Diffuse Esophageal Spasm (DES) and Normal peristalsis. Results: We identified 239 (141F, mean age 49) patients with “True” NERD, 340 (171F, mean age 49) with EE, 106 (40F, mean age 58) with BE, and 70 (45F, mean age 48) with FH. Data on manometric diagnosis are shown in the Table. Patients with EE had more frequently IEM compared to the other subgroups (p <0.05). Moreover, patients with BE had more frequently IEM than those with “True” NERD, FH and HV (p <0.05). Interestingly, also patients with “True” NERD had higher prevalence of IEM than patients with FH and HV (p <0.05). The frequency of DES was similar in all subgroups (p = ns). No differences were found between FH patients and HV (p = ns). Population True NERD BE EE FH HV P-value (ANOVA)
IEM
DES
Normal Peristalsis
15%a,d,g 34%b,e,h 44%c,f,g,h 8%d,e 4%a,b,c,f p<0.05
14% 14% 15% 20% 13% p=ns
71%a,d,g 52%b,e,h 41%c,f,g,h 72%d,e 83%a,b,c,f p<0.05
Post-hoc anaylis. a HV vs. NERD, p<0.05; b HV vs. BE, p<0.05; c HV vs. EE, p<0.05; d FH vs. NERD, p<0.05; e FH vs. BE, p<0.05; f FH vs. EE, p<0.05; g EE vs. NERD, p<0.05; h EE vs. BE, p<0.05; i BE vs. NERD, p<0.05.
Conclusions: Ineffective esophageal motility, determining an impaired esophageal clearance, may favor mucosal injuries in patients with EE and BE. Identifying “True” NERD by means of impedance-pH testing permits to find relevant motility abnormalities in them compared to FH patients and HV.
OC.03.7 HIGH RESOLUTION MANOMETRY FINDINGS DO NOT PREDICT BOLUS CLEARANCE OF SALINE SWALLOWS IN PATIENTS WITH NON-OBSTRUCTIVE DYSPHAGIA M. Ribolsi ∗ , P. Balestrieri, M.C. Addarii, S. Emerenziani, M. Cicala Campus Bio Medico, Roma, Italy Background and aim: Non-obstructive dysphagia (NOD), defined as diffi-
S125
culty in swallowing liquids and/or solids in the absence of an obstructive lesion in the esophagus, usually suggests impaired clearance of a swallowed bolus. However, stationary esophageal manometry reveals motor abnormalities in less than 50% of NOD patients. High resolution manometry combined with multichannel impedance (HRM-MI) monitoring allows an accurate and simultaneous analysis of bolus clearance and esophageal motility. Aim: To evaluate the specificity of new HRM parameters in the assessment of bolus transit in patients with NOD and absence of motor dysfunctions and in healthy volunteers. Material and methods: 25 consecutive NOD patients underwent HRM-MI monitoring. Patients were analyzed in the supine position, a catheter with 36 solid state pressure sensors, and 9 impedance segments placed between 5-21 cm above LES (MMS, The Netherlands) was used. A total of 10 saline (5 ml) swallows, at 30-sec intervals were analyzed in each subject. 10 healthy volunteers (HV) underwent the same study. At impedance, total bolus transit time (TBTT) of each swallow was calculated according to standardized criteria. Integrated relaxation pressure (IRP 4 seconds), contractile front velocity (CFV) and distal contractile integral (DCI) were calculated and correlated to TBTT values by means of linear regression analysis. HRM tracings were analyzed according to the Chicago classification. Results: Seven patients presenting evidence of nutcracker esophagus, 3 of distal esophageal spasm and 3 of achalasia were excluded. The remaining 12 NOD patients entered the study. HRM-MI monitoring did not reveal any abnormalities in HVs. Mean (±SD) values of TBTT, IRP, CFV and DCI are shown in Table 1. In HV, a significant correlation was found only between TBTT and IRP values (r: 0.7, p< 0.05). No correlation was found between TBTT and DCI, CFV and IRP, in NOD patients. Table 1 TBTT (sec.) DCI (mmHg·s·cm) CVF (cm/sec) IRP (mmHg) NOD patients Healthy volunteers
7.9±0.5 7±1.2
1413±695 1536±624
2.6±0.45 2.7±0.54
10.5±5.5 11.7±2.9
Conclusions: In NOD patients, in the absence of esophageal motor abnormalities, bolus transit and HRM findings are comparable to those observed in asymptomatic subjects. HRM findings are not correlated with bolus clearance of saline swallows in patients with NOD. In these patients, dysphagia might be explained by an increased perception of esophageal bolus passage.
OC.04.1 NICKEL FREE-DIET ENHANCES HELICOBACTER PYLORI ERADICATION RATE M. Campanale ∗ ,1 , E. Nucera 2 , V. Cesario 1 , A. Tortora 1 , F. Purchiaroni 1 , F. Bertucci 1 , T.A. Di Rienzo 1 , T. De Pasquale 2 , G. Gasbarrini 3 , V. Ojetti 1 , D. Schiavino 2 , A. Gasbarrini 1 1 Internal Medicine and Gastroenterology, Catholic University of Rome, Rome, Italy; 2 Allergology Division, Catholic University of Rome, Rome, Italy; 3 Fondazione Ricerca In Medicina, Bologna, Italy
Background and aim: Helicobacter pylori (H.pylori) eradication rate with standard triple therapy is very low. It is known that H.pylori required the nickel-containing metalloenzymes urease and NiFe-hydrogenase to survive at low pH environment in human stomach. Recent in vitro studies showed that media added with nickel increased H.pylori urease activity. Aim: To compare H. pylori eradication rate of a nickel free-diet associated to standard triple therapy and standard triple therapy alone in first- line regimen. Material and methods: 40 sex and age matched patients at first diagnosis of H. pylori infection were randomized 1:1 into 2 different therapeutic schemes: (1) standard LCA: lansoprazole 15 mg bid, clarithromycin 500 mg bid and amoxicillin 1000 mg bid for 7 days with a common diet; (2) standard LCA plus a nickel free-diet (NFD-LCA). Patients undergo 30 days of nickel free diet and LCA is performed at the 15th day. Eradication was confirmed by 13C-urea breath test 4 weeks after the end of therapeutic regimen. Compliance and occurrence of adverse effects were assessed by a validated questionnaire. Results: All pts completed the study. A significant higher eradication rate was observed in LCA: 60% (12/20) vs NFD-LCA: 90% (18/20) p<0.01. A good compliance of the nichel free diet was observed. Mild side effects (diarrhoea and nausea) occur in 3/20 with LCA and 4/20 in NFD-LCA.
Abstracts of the XVII National Congress of Digestive Diseases / Digestive and Liver Disease 43S (2011) S115–S264 PPI non responder and 6/25 responder patients. Findings of MI-pH are shown in the table. The total reflux number and the proportions of weakly acidic, mixed and proximal reflux did not differ between EE patients (PPI responders and non-responders).
EE EE only/ EE+T NERD HV
Number of refluxes
Weakly acidic (%)
Mixed reflux (%)
Proximal (%)
62 (39-113)* 56 (37-105)/ 66 (46-134) 28 (20-41) 16 (9-27)
51% (34-64%)* 51% (35-68%)/ 50% (31-63%) 32% (16-42%) 43%
71% (43-84%)* 70% (43-84%)/ 75% (54-84%) 54% (45-70%) 58%
68% (59-80%) 68% (61-78%)/ 67% (53-82%) 64% (30-78%) 62%
*p< 0.05. Data are expressed as median and 25th–75th percentile values.
Conclusions: Patients with extra-esophageal symptoms, compared to NERD patients with typical symptoms and HV, are characterized by a higher number of reflux episodes and higher proportion of weakly acidic and mixed refluxes. Although this reflux pattern could explain the reduced response to PPI treatment, MI-pH findings do not seem to predict the PPI response in this group of patients. since they cause underestimation of GERD patients and overestimation of FH patients. Impedance-pH monitoring is more accurate in identifying GERD or FH and should be included in the future iteration of Rome criteria.
OC.03.4
OC.03.5 REFLUX PATTERNS DIFFER AMONG PATIENTS WITH NON-EROSIVE REFLUX DISEASE (NERD), HYPERSENSITIVE ESOPHAGUS (HE) AND FUNCTIONAL HEARTBURN (FH) E. Savarino ∗ , P. Zentilin, E. Marabotto, M. Furnari, G. Sammito, L. Gemignani, A. Malesci, C. Mansi, V. Savarino
PATIENTS WITH EXTRA-ESOPHAGEAL SYMPTOMS, COMPARED TO NERD PATIENTS WITH TYPICAL SYMPTOMS AND HEALTHY VOLUNTEERS, ARE CHARACTERIZED BY A HIGHER NUMBER OF REFLUX EPISODES AND HIGHER PROPORTION OF WEAKLY ACIDIC AND MIXED REFLUX
Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
M. Ribolsi ∗ ,1 , P. Balestrieri 1 , M.C. Addarii 1 , S. Emerenziani 1 , F. Greco 1 , M. Casale 1 , F. Salvinelli 1 , F. Pace 2 , M. Cicala 1 1 Università Campus Bio Medico, Roma, Italy; 2 Ospedale Bolognini, Bergamo, Italy
Background and aim: Although extra-esophageal symptoms are present in >30% of GERD patients, the role of gastric refluxate still remains unclear. In patients with extra-esophageal symptoms, pH monitoring is often in the normal range and the response to PPI therapy is poor. Few data are currently available concerning the properties of reflux in these patients when compared to those in patients with typical or combined typical and atypical symptoms, as well as concerning the predictive value of esophageal multichannel impedance-pH (MI-pH) monitoring for the PPI response. Material and methods: 61 NERD patients presenting with extra-esophageal symptoms underwent, following a 3-week pharmacological washout, MI-pH following stationary manometry (EE group). Patients filled out a questionnaire with symptom score. 32 of the 61 EE presented only extra-esophageal symptoms (EE only), the remaining 29 patients also presented typical GERD symptoms (EE+T). 36 of the 61 EE had not shown a satisfactory response to 8 weeks double dose PPI therapy (<50% improvement). MI-pH findings were compared to those obtained in 54 NERD patients with typical symptoms responding to PPI and to normal values reported in an Italian population of healthy volunteers (HV). Results: 19/61 EE (31%) and 24/54 NERD (44%) patients presented pathological acid exposure time (AET). AET was positive in 10/33 patients of the EE only group and in 9/30 patients of EE+T group. AET was positive in 13/36
Background and aim: Non-erosive reflux disease (NERD) is an heterogeneous condition including patients with different pathophysiological characteristics. There are limited data on reflux patterns in them. To compare reflux patterns in NERD patients subclassified by impedance-pH monitoring (MII-pH). Material and methods: Patients with typical reflux symptoms and normal endoscopy underwent MII-pH off-PPI therapy. PPI therapy was discontinued >30 days prior to testing. Forty-eight healthy volunteers (27F; mean age 42yrs; HV) served as controls. Esophageal acid exposure time (AET), characteristics of reflux episodes (acid/nonacid), mean acid clearance time (MACT), median bolus clearance time (MBCT), proximal migration of refluxate and symptom association probability (SAP) were measured. Results: Of 251 NERD patients (118M; mean age 47yrs), 92 (37%) were pH-POS/SAP+, 10 (4%) pH-POS/SAP-, 86 (34%) were pH-NEG/SAP+ (Hypersensitive Esophagus) and 63 (25%) were pH-NEG/SAP- (Functional Heartburn). The total and acid reflux episodes were significantly higher (p<0.01) in pH-POS/SAP+ (median 60 [25th-75th perc. 45-94] and 44 [33-59]) and pH-POS/SAP- (58 [54-87] and 44 [42-65]) compared to pHNEG/SAP+ (43 [26-64] and 25 [11-37]), pH-NEG/SAP- (30 [17-43] and 16 [8-27]) and HV (32 [19-43] and 17 [8-31]). Patients pH-NEG/SAP+ had a significantly increased number of weakly acidic reflux episodes compared to pH-POS/SAP+, pH-POS/SAP-, pH-NEG/SAP- and HV (27 [15-41] vs. 19 [13-26] vs. 20 [13-57] vs. 22 [15-28] vs. 18 [14-26]; p<0.01). Differences in AET, acid and bolus clearance times and percentage of proximal reflux episode are shown in Table 1. Conclusions: Patients with abnormal AET have the most severe degree of reflux disease. In patients with normal AET and SAP+, an increased number of weakly acidic reflux and a high rate of proximal reflux are the main
Abstract OC.03.5 – Table 1. Reflux parameters in subgroups of NERD patients and HV patients % pH <4 total MACT total MBCT total Prox. extent (%)
pH-POS/SAP+
pH-POS/SAP-
pH-NEG/SAP+
pH-NEG/SAP-
HV
p-value (ANOVA)
6.2 (4.6-9)b,c,d 136 (88-181)a,b,c,d 16 (13-22)b,c,d 52 (39-62)a,c,d
4.5 (4.4-6.3)e,f,g 85 (78-269)a,e,f,g 15 (13-21)e,f,g 33 (22-55)a,e
1.7 (0.7-2.7)b,e,h,i 43 (27-67)b,e 13 (10-18)b,e, 57 (42-69)e,h,i
0.8 (0.3-1.8)c,f,h 41 (22-70)c,f 12 (10-19)c,f 33 (23-49)c,h
0.7 (0.1-1.4)d,g,i 32 (16-50)d,g 12 (8-16)d,g 33 (18-46)d,i
<0.01 <0.01 <0.01 <0.01
Data are presented as median (25th-75th percentile). Post-hoc analysis. a pH-POS/SAP+ vs. pH-POS/SAP-, p<0.05; b pH-POS/SAP+ vs. pH-NEG/SAP+, p<0.05; c pH-POS/SAP+ vs. pH-NEG/SAP-, p<0.05; d pH-POS/SAP+ vs. HV, p<0.05; e pH-POS/SAP- vs. pH-NEG/SAP+, p<0.05; f pH-POS/SAP- vs. pH-NEG/SAP-, p<0.05; g pH-POS/SAP- vs. HV, p<0.05; h pH-NEG/SAP+ vs. pH-NEG/SAP-, p<0.05; i pH-NEG/SAP+ vs. HV, p<0.05.
Abstracts of the XVII National Congress of Digestive Diseases / Digestive and Liver Disease 43S (2011) S115–S264 discriminant features. Finally, the large overlap between FH and HV supports the functional origin of FH.
OC.03.6 PREVALENCE OF ESOPHAGEAL MOTILITY ABNORMALITIES IN PATIENTS WITH “TRUE” NON-EROSIVE REFLUX DISEASE, EROSIVE ESOPHAGITIS, BARRETT ESOPHAGUS AND FUNCTIONAL HEARTBURN L. Gemignani ∗ , E. Savarino, P. Zentilin, E. Marabotto, M. Furnari, G. Sammito, C. Mansi, V. Savarino Division Of Gastroenterology, Department Of Internal Medicine, University Of Genoa, Genoa, Italy Background and aim: Esophageal motility abnormalities are frequently encountered in patients with gastro-esophageal reflux disease (GERD). However, limited data are present on their frequency in well defined subgroups of patients, in particular those with “True” NERD and Functional Heartburn. To evaluate differences in esophageal motility patterns among patients with GERD classified on the basis of upper endoscopy with biopsies and/or impedance-pH testing. Material and methods: We evaluated 755 patients (397F, mean age 51, range 18-87, mean BMI 25) with typical reflux symptoms who underwent upper endoscopy, esophageal manometry and/or impedance-pH testing with symptom association probability (SAP) analysis. Forty-eight healthy volunteers (HV, 27F, median age 48) served as controls. Patients were divided in 4 subgroups, as follows: “True” NERD (endoscopy –, abnormal pH and/or SAP+ to Acid/Nonacid), Erosive Esophagitis (EE, endoscopy + for erosive esophagitis), Barrett Esophagus (BE, biopsy + for intestinal metaplasia) and Functional Heartburn (FH, endoscopy –, normal pH and SAP– to Acid/Nonacid). Manometric patterns were defined according to international criteria and distinguished in: Ineffective Esophageal Motility (IEM), Diffuse Esophageal Spasm (DES) and Normal peristalsis. Results: We identified 239 (141F, mean age 49) patients with “True” NERD, 340 (171F, mean age 49) with EE, 106 (40F, mean age 58) with BE, and 70 (45F, mean age 48) with FH. Data on manometric diagnosis are shown in the Table. Patients with EE had more frequently IEM compared to the other subgroups (p <0.05). Moreover, patients with BE had more frequently IEM than those with “True” NERD, FH and HV (p <0.05). Interestingly, also patients with “True” NERD had higher prevalence of IEM than patients with FH and HV (p <0.05). The frequency of DES was similar in all subgroups (p = ns). No differences were found between FH patients and HV (p = ns). Population True NERD BE EE FH HV P-value (ANOVA)
IEM
DES
Normal Peristalsis
15%a,d,g 34%b,e,h 44%c,f,g,h 8%d,e 4%a,b,c,f p<0.05
14% 14% 15% 20% 13% p=ns
71%a,d,g 52%b,e,h 41%c,f,g,h 72%d,e 83%a,b,c,f p<0.05
Post-hoc anaylis. a HV vs. NERD, p<0.05; b HV vs. BE, p<0.05; c HV vs. EE, p<0.05; d FH vs. NERD, p<0.05; e FH vs. BE, p<0.05; f FH vs. EE, p<0.05; g EE vs. NERD, p<0.05; h EE vs. BE, p<0.05; i BE vs. NERD, p<0.05.
Conclusions: Ineffective esophageal motility, determining an impaired esophageal clearance, may favor mucosal injuries in patients with EE and BE. Identifying “True” NERD by means of impedance-pH testing permits to find relevant motility abnormalities in them compared to FH patients and HV.
OC.03.7 HIGH RESOLUTION MANOMETRY FINDINGS DO NOT PREDICT BOLUS CLEARANCE OF SALINE SWALLOWS IN PATIENTS WITH NON-OBSTRUCTIVE DYSPHAGIA M. Ribolsi ∗ , P. Balestrieri, M.C. Addarii, S. Emerenziani, M. Cicala Campus Bio Medico, Roma, Italy Background and aim: Non-obstructive dysphagia (NOD), defined as diffi-
S125
culty in swallowing liquids and/or solids in the absence of an obstructive lesion in the esophagus, usually suggests impaired clearance of a swallowed bolus. However, stationary esophageal manometry reveals motor abnormalities in less than 50% of NOD patients. High resolution manometry combined with multichannel impedance (HRM-MI) monitoring allows an accurate and simultaneous analysis of bolus clearance and esophageal motility. Aim: To evaluate the specificity of new HRM parameters in the assessment of bolus transit in patients with NOD and absence of motor dysfunctions and in healthy volunteers. Material and methods: 25 consecutive NOD patients underwent HRM-MI monitoring. Patients were analyzed in the supine position, a catheter with 36 solid state pressure sensors, and 9 impedance segments placed between 5-21 cm above LES (MMS, The Netherlands) was used. A total of 10 saline (5 ml) swallows, at 30-sec intervals were analyzed in each subject. 10 healthy volunteers (HV) underwent the same study. At impedance, total bolus transit time (TBTT) of each swallow was calculated according to standardized criteria. Integrated relaxation pressure (IRP 4 seconds), contractile front velocity (CFV) and distal contractile integral (DCI) were calculated and correlated to TBTT values by means of linear regression analysis. HRM tracings were analyzed according to the Chicago classification. Results: Seven patients presenting evidence of nutcracker esophagus, 3 of distal esophageal spasm and 3 of achalasia were excluded. The remaining 12 NOD patients entered the study. HRM-MI monitoring did not reveal any abnormalities in HVs. Mean (±SD) values of TBTT, IRP, CFV and DCI are shown in Table 1. In HV, a significant correlation was found only between TBTT and IRP values (r: 0.7, p< 0.05). No correlation was found between TBTT and DCI, CFV and IRP, in NOD patients. Table 1 TBTT (sec.) DCI (mmHg·s·cm) CVF (cm/sec) IRP (mmHg) NOD patients Healthy volunteers
7.9±0.5 7±1.2
1413±695 1536±624
2.6±0.45 2.7±0.54
10.5±5.5 11.7±2.9
Conclusions: In NOD patients, in the absence of esophageal motor abnormalities, bolus transit and HRM findings are comparable to those observed in asymptomatic subjects. HRM findings are not correlated with bolus clearance of saline swallows in patients with NOD. In these patients, dysphagia might be explained by an increased perception of esophageal bolus passage.
OC.04.1 NICKEL FREE-DIET ENHANCES HELICOBACTER PYLORI ERADICATION RATE M. Campanale ∗ ,1 , E. Nucera 2 , V. Cesario 1 , A. Tortora 1 , F. Purchiaroni 1 , F. Bertucci 1 , T.A. Di Rienzo 1 , T. De Pasquale 2 , G. Gasbarrini 3 , V. Ojetti 1 , D. Schiavino 2 , A. Gasbarrini 1 1 Internal Medicine and Gastroenterology, Catholic University of Rome, Rome, Italy; 2 Allergology Division, Catholic University of Rome, Rome, Italy; 3 Fondazione Ricerca In Medicina, Bologna, Italy
Background and aim: Helicobacter pylori (H.pylori) eradication rate with standard triple therapy is very low. It is known that H.pylori required the nickel-containing metalloenzymes urease and NiFe-hydrogenase to survive at low pH environment in human stomach. Recent in vitro studies showed that media added with nickel increased H.pylori urease activity. Aim: To compare H. pylori eradication rate of a nickel free-diet associated to standard triple therapy and standard triple therapy alone in first- line regimen. Material and methods: 40 sex and age matched patients at first diagnosis of H. pylori infection were randomized 1:1 into 2 different therapeutic schemes: (1) standard LCA: lansoprazole 15 mg bid, clarithromycin 500 mg bid and amoxicillin 1000 mg bid for 7 days with a common diet; (2) standard LCA plus a nickel free-diet (NFD-LCA). Patients undergo 30 days of nickel free diet and LCA is performed at the 15th day. Eradication was confirmed by 13C-urea breath test 4 weeks after the end of therapeutic regimen. Compliance and occurrence of adverse effects were assessed by a validated questionnaire. Results: All pts completed the study. A significant higher eradication rate was observed in LCA: 60% (12/20) vs NFD-LCA: 90% (18/20) p<0.01. A good compliance of the nichel free diet was observed. Mild side effects (diarrhoea and nausea) occur in 3/20 with LCA and 4/20 in NFD-LCA.