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P.04.3 ROLE OF WEAKLY ACIDIC REFLUXES IN THE ATYPICAL SYMPTOMS OF GERD. A pH-IMPEDANCE STUDY PERFORMED OFF-PPI THERAPY
Abstracts of the 19th National Congress of Digestive Diseases / Digestive and Liver Disease 45S (2013) S55–S218
S111
Abstract P.04.2 – Table 1 HV NERD EE BE
AETa
MBCTb
MACTc
GER ACIDd
GER non-ACIDe
Liquid and mixedf
Gasg
0.8 (0.2–2.4) 4.9 (2.4–9) 10.1 (5.6–16.6) 15.6 (2.8–30.3)
12 (8.5–15.5) 17 (13–24) 18.5 (13.5–33) 20.5 (15–28)
27 (7.5–49) 70 (51–105) 73 (42–129) 89 (43–157.5)
6 (3.5–8.5) 11 (6.5–14.5) 15 (10–24) 18 (5–26)
9 (4.5–11) 6.6 (4–11) 7 (3–13) 5.5 (2.5–13.5)
15 (10.5–20) 20.5 (14–31) 22.5 (18–36) 24.5 (18–38)
1 (0–4) 2 (1–3.5) 2 (1–3) 3.5 (1.5–7)
Values are expressed as median and 25th–75th percentiles. a p<0.05 HV vs EE, HV vs BE, HV vs NERD, NERD vs EE, NERD vs BE. b p<0.05 HV vs EE, HV vs BE, NERD vs EE, NERD vs BE. c p<0.05 HV vs EE, HV vs BE, HV vs NERD, NERD vs EE, NERD vs BE. d p<0.05 HV vs EE, HV vs BE, NERD vs EE. f p<0.05 HV vs EE, HV vs BE, NERD vs BE.
number of acid and non-acid GER events, MACT compared to HVs (p<0.05). Finally, a gradual increase in pure liquid and mixed liquid–gas reflux episodes was found in the patients with increasing degrees of esophageal damage (p<0.05). Conclusions: Our findings show that postprandial impedance parameters increase in parallel with the severity of mucosal damage. These data suggest that BE and EE patients may have more TLESRs as result of impaired gastric accommodation, thus favoring the backflow of the content of acid pocket during the postprandial period.
P.04.3 ROLE OF WEAKLY ACIDIC REFLUXES IN THE ATYPICAL SYMPTOMS OF GERD. A pH-IMPEDANCE STUDY PERFORMED OFF-PPI THERAPY L. Grossi ∗ , A.M. Di Tullio, M. Pagliaro, R. Tavani, S. Cocciolillo, A.F. Ciccaglione, L. Marzio G. d’Annunzio University, School of Gastroenterology c/o Digestive Physiopathology Ospedale Spirito Santo, Pescara, Italy Background and aim: Gastro-esophageal Reflux Disease (GERD) is characterized by typical or atypical symptoms. Its diagnosis for decades relied on pH-metry, able to identify only the acid reflux episodes. With the advent of pH-impedance (MII-pH) it has been established that also weakly acidic refluxes (WAR) play a role in the pathogenesis and in the natural history of the disease. However the majority of data on WAR has been reported during acid-suppressive therapy (on-PPI) and still little is known about the relationship between the quality of reflux and the clinical appearance of GERD in patients not receiving PPI treatment (off-PPI). Aim of this study has been to analyze a group of patients undergoing pH-impedance for typical or atypical symptoms of GERD to demonstrate a relationship between the quality of refluxes and their clinical pattern. Material and methods: 55 consecutive patients underwent 24-hr esophageal MII-pH for suspected GERD. All these patients were studied off-PPI and stratified according to the quality of their symptoms as typical or atypical. The amount of acidic and weakly acidic refluxes was computed and X2 test was then performed combining the clinical aspects and the quality of reflux events detected. Results: 5 patients with normal pH-impedance profile were not considered for analysis. Among the 50 patients positive for GERD, 31 resulted referred atypical and 19 typical symptoms. Patients with respiratory, ENT features or chest pain showed a greater amount of WAR as compared to AR (58.5±7 vs 24.5±3, mean±STD) whilst the AR were more frequent in the group of patients with pyrosis and regurgitation (86.7±15 vs 35.5±8, mean±STD). X2 test demonstrated a significant correlation (p=0.03) between atypical symptoms and WAR. No significant difference was evidenced in the proximal extent of refluxate. Conclusions: Weakly acidic refluxes are more frequent than acidic refluxes in patients with atypical symptoms of GERD, whereas acidic refluxes still represent the most common phenomenon in GERD patients with typical symptoms. Since these data are obtained prior to acid-suppressive therapy, it seems reasonable a role of MII-pH in the early steps of diagnostic protocols of suspected atypical GERD symptoms to identify patients with WAR. These patients could infact partially benefit from the conventional antisecretory treatment and require better pharmacological approaches.
P.04.4 GASTROESOPHAGEAL REFLUX AND CHRONIC UNEXPLAINED COUGH: PRELIMINARY RESULTS OF A GISMAD MULTICENTER STUDY R. Solimando ∗ ,1 , F. Baldi 1 , G. Cataudella 2 , M. Cicala 3 , R. Penagini 4 , D. Pugliese 4 , M. Ribolsi 3 1 Policlininico 3 Campus
S.Orsola-Malpighi, Bologna, Italy; 2 ULSS n.6, Vicenza, Italy; Biomedico, Roma, Italy; 4 Ospedale Maggiore, Milano, Italy
Background and aim: Gastroesophageal reflux (GER) is one of the three most common causes of chronic unexplained cough (CUC). Although the importance of acid is generally accepted, the role played by other components of reflux is not well established and the response rate of pts with CUC to PPI tx is poorly predictable. The aims of this multicenter study were: 1) to assess the clinical features, the esophageal function and the reflux characteristics of pts with CUC in comparison with a group of pts with Non Erosive Reflux Disease (NERD) and 2) to evaluate the presence of factors predictive of the response of CUC pts to PPI tx. Material and methods: 19 pts (7 M, mean age 57.3±11 yrs, mean BMI 25.6±3.7) with CUC from ≥2 months were enrolled. Inclusion criteria were normal chest X-ray, no smoking, no ACE-inhibitors and negative pneumo and ENT evaluation. 25 pts (11 M, mean age 47.7±14.9 yrs, mean BMI 23.2±2.5) with typical reflux symptoms from ≥3 months, without esophageal lesions and who reported a positive response to PPI (NERD) served as control group. All the pts underwent to a clinical evaluation with specific symptom questionnaires, to a standard esophageal manometry and to a 24-h pH-MII study off-tx with the same device (Ohmega-MMS). Subsequently the CUC pts were given a PPI tx (standard dose bid) for 3 mos followed by a second clinical evaluation. The response to tx was considered positive if pts reported a reduction ≥50% of cough severity according to a VAS. Results: The analysis was done in 3 groups of pts (NERD n=25, CUCResponders n=10, CUC-Non Reponders n=9). No significant differences were found among the groups as regards age, gender and BMI. Reflux symptoms were similarly reported in basal conditions by the 2 CUC groups (50% vs 33% in CUC-R vs CUC-NR, respectively). The functional parameters are shown in the table, expressed as median (95% CI). The % of pts with Symptom Association Probability (SAP) + was lower in the CUC-NR compared with the CUC-R group (22% vs 60%) although the difference did not reach statistical significance. Table 1 LESp (mmHg) Ineffective esophageal motility (% pt) Liquid-mix GERs (n/24h) Weakly acidic (%) Supine (%) Prox propagation (%) Pure gas GERs (n/24h)
NERD (n=25)
CUC-R (n=10)
CUC-NR (n=9)
13.5 (8.2–21) 8 92 (55.3–127.3) 44 (24.9–55) 9 (4.7–10.4) 34 (19.9–45.9) 12 (0–40)
10 (4–18.9) 10 57 (34.6–65.5)† 39 (21.7–96.2) 12 (0.5–18.7) 22 (8.3–34.8) 15 (1.7–23.4)
14 (6.4–18.1) 44.4† 55 (14.1–107.1)° 45 (25.5–60.7) 5 (0–37.8) 26 (7.3–43.9) 43 (17–109.9)*#
*† # p<0.05 vs NERD; °p=0.05 vs NERD; # p=0.003 vs CUC-R. For categorical data: Fishers’s exact test. For continue data: Mann-Whitney test.
Conclusions: Our preliminary results show that both CUC groups have a total number of GERs significantly lower than that of the NERD group, but with a similar reflux pattern. CUC-NR pts had an impairment of the esophageal function and an higher proportion of pure gas refluxes. Further outcome studies will elucidate if these features may have a predictive value.
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Abstract P.04.2 – Table 1 HV NERD EE BE
AETa
MBCTb
MACTc
GER ACIDd
GER non-ACIDe
Liquid and mixedf
Gasg
0.8 (0.2–2.4) 4.9 (2.4–9) 10.1 (5.6–16.6) 15.6 (2.8–30.3)
12 (8.5–15.5) 17 (13–24) 18.5 (13.5–33) 20.5 (15–28)
27 (7.5–49) 70 (51–105) 73 (42–129) 89 (43–157.5)
6 (3.5–8.5) 11 (6.5–14.5) 15 (10–24) 18 (5–26)
9 (4.5–11) 6.6 (4–11) 7 (3–13) 5.5 (2.5–13.5)
15 (10.5–20) 20.5 (14–31) 22.5 (18–36) 24.5 (18–38)
1 (0–4) 2 (1–3.5) 2 (1–3) 3.5 (1.5–7)
Values are expressed as median and 25th–75th percentiles. a p<0.05 HV vs EE, HV vs BE, HV vs NERD, NERD vs EE, NERD vs BE. b p<0.05 HV vs EE, HV vs BE, NERD vs EE, NERD vs BE. c p<0.05 HV vs EE, HV vs BE, HV vs NERD, NERD vs EE, NERD vs BE. d p<0.05 HV vs EE, HV vs BE, NERD vs EE. f p<0.05 HV vs EE, HV vs BE, NERD vs BE.
number of acid and non-acid GER events, MACT compared to HVs (p<0.05). Finally, a gradual increase in pure liquid and mixed liquid–gas reflux episodes was found in the patients with increasing degrees of esophageal damage (p<0.05). Conclusions: Our findings show that postprandial impedance parameters increase in parallel with the severity of mucosal damage. These data suggest that BE and EE patients may have more TLESRs as result of impaired gastric accommodation, thus favoring the backflow of the content of acid pocket during the postprandial period.
P.04.3 ROLE OF WEAKLY ACIDIC REFLUXES IN THE ATYPICAL SYMPTOMS OF GERD. A pH-IMPEDANCE STUDY PERFORMED OFF-PPI THERAPY L. Grossi ∗ , A.M. Di Tullio, M. Pagliaro, R. Tavani, S. Cocciolillo, A.F. Ciccaglione, L. Marzio G. d’Annunzio University, School of Gastroenterology c/o Digestive Physiopathology Ospedale Spirito Santo, Pescara, Italy Background and aim: Gastro-esophageal Reflux Disease (GERD) is characterized by typical or atypical symptoms. Its diagnosis for decades relied on pH-metry, able to identify only the acid reflux episodes. With the advent of pH-impedance (MII-pH) it has been established that also weakly acidic refluxes (WAR) play a role in the pathogenesis and in the natural history of the disease. However the majority of data on WAR has been reported during acid-suppressive therapy (on-PPI) and still little is known about the relationship between the quality of reflux and the clinical appearance of GERD in patients not receiving PPI treatment (off-PPI). Aim of this study has been to analyze a group of patients undergoing pH-impedance for typical or atypical symptoms of GERD to demonstrate a relationship between the quality of refluxes and their clinical pattern. Material and methods: 55 consecutive patients underwent 24-hr esophageal MII-pH for suspected GERD. All these patients were studied off-PPI and stratified according to the quality of their symptoms as typical or atypical. The amount of acidic and weakly acidic refluxes was computed and X2 test was then performed combining the clinical aspects and the quality of reflux events detected. Results: 5 patients with normal pH-impedance profile were not considered for analysis. Among the 50 patients positive for GERD, 31 resulted referred atypical and 19 typical symptoms. Patients with respiratory, ENT features or chest pain showed a greater amount of WAR as compared to AR (58.5±7 vs 24.5±3, mean±STD) whilst the AR were more frequent in the group of patients with pyrosis and regurgitation (86.7±15 vs 35.5±8, mean±STD). X2 test demonstrated a significant correlation (p=0.03) between atypical symptoms and WAR. No significant difference was evidenced in the proximal extent of refluxate. Conclusions: Weakly acidic refluxes are more frequent than acidic refluxes in patients with atypical symptoms of GERD, whereas acidic refluxes still represent the most common phenomenon in GERD patients with typical symptoms. Since these data are obtained prior to acid-suppressive therapy, it seems reasonable a role of MII-pH in the early steps of diagnostic protocols of suspected atypical GERD symptoms to identify patients with WAR. These patients could infact partially benefit from the conventional antisecretory treatment and require better pharmacological approaches.
P.04.4 GASTROESOPHAGEAL REFLUX AND CHRONIC UNEXPLAINED COUGH: PRELIMINARY RESULTS OF A GISMAD MULTICENTER STUDY R. Solimando ∗ ,1 , F. Baldi 1 , G. Cataudella 2 , M. Cicala 3 , R. Penagini 4 , D. Pugliese 4 , M. Ribolsi 3 1 Policlininico 3 Campus
S.Orsola-Malpighi, Bologna, Italy; 2 ULSS n.6, Vicenza, Italy; Biomedico, Roma, Italy; 4 Ospedale Maggiore, Milano, Italy
Background and aim: Gastroesophageal reflux (GER) is one of the three most common causes of chronic unexplained cough (CUC). Although the importance of acid is generally accepted, the role played by other components of reflux is not well established and the response rate of pts with CUC to PPI tx is poorly predictable. The aims of this multicenter study were: 1) to assess the clinical features, the esophageal function and the reflux characteristics of pts with CUC in comparison with a group of pts with Non Erosive Reflux Disease (NERD) and 2) to evaluate the presence of factors predictive of the response of CUC pts to PPI tx. Material and methods: 19 pts (7 M, mean age 57.3±11 yrs, mean BMI 25.6±3.7) with CUC from ≥2 months were enrolled. Inclusion criteria were normal chest X-ray, no smoking, no ACE-inhibitors and negative pneumo and ENT evaluation. 25 pts (11 M, mean age 47.7±14.9 yrs, mean BMI 23.2±2.5) with typical reflux symptoms from ≥3 months, without esophageal lesions and who reported a positive response to PPI (NERD) served as control group. All the pts underwent to a clinical evaluation with specific symptom questionnaires, to a standard esophageal manometry and to a 24-h pH-MII study off-tx with the same device (Ohmega-MMS). Subsequently the CUC pts were given a PPI tx (standard dose bid) for 3 mos followed by a second clinical evaluation. The response to tx was considered positive if pts reported a reduction ≥50% of cough severity according to a VAS. Results: The analysis was done in 3 groups of pts (NERD n=25, CUCResponders n=10, CUC-Non Reponders n=9). No significant differences were found among the groups as regards age, gender and BMI. Reflux symptoms were similarly reported in basal conditions by the 2 CUC groups (50% vs 33% in CUC-R vs CUC-NR, respectively). The functional parameters are shown in the table, expressed as median (95% CI). The % of pts with Symptom Association Probability (SAP) + was lower in the CUC-NR compared with the CUC-R group (22% vs 60%) although the difference did not reach statistical significance. Table 1 LESp (mmHg) Ineffective esophageal motility (% pt) Liquid-mix GERs (n/24h) Weakly acidic (%) Supine (%) Prox propagation (%) Pure gas GERs (n/24h)
NERD (n=25)
CUC-R (n=10)
CUC-NR (n=9)
13.5 (8.2–21) 8 92 (55.3–127.3) 44 (24.9–55) 9 (4.7–10.4) 34 (19.9–45.9) 12 (0–40)
10 (4–18.9) 10 57 (34.6–65.5)† 39 (21.7–96.2) 12 (0.5–18.7) 22 (8.3–34.8) 15 (1.7–23.4)
14 (6.4–18.1) 44.4† 55 (14.1–107.1)° 45 (25.5–60.7) 5 (0–37.8) 26 (7.3–43.9) 43 (17–109.9)*#
*† # p<0.05 vs NERD; °p=0.05 vs NERD; # p=0.003 vs CUC-R. For categorical data: Fishers’s exact test. For continue data: Mann-Whitney test.
Conclusions: Our preliminary results show that both CUC groups have a total number of GERs significantly lower than that of the NERD group, but with a similar reflux pattern. CUC-NR pts had an impairment of the esophageal function and an higher proportion of pure gas refluxes. Further outcome studies will elucidate if these features may have a predictive value.