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P.10 “GASTROPANEL TEST” IN THE CLINICAL OUTCOME OF GERD: PROSPECTIVE SIX MONTHS CLINICAL STUDY
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Abstracts / Digestive and Liver Disease 42S (2010) S61–S192
P.10 “GASTROPANEL TEST” IN THE CLINICAL OUTCOME OF GERD: PROSPECTIVE SIX MONTHS CLINICAL STUDY L. Guida ∗ ,1 , P. Perazzo 1 , S. Bertolini 1 , E. Morana 1 , D. Vaira 2 , C. Scarpignato 1 , V. Savarino 3 , L. Gatta 1 , L. Cavallaro 4 , G. Cavestro 1 , M. Rugge 3 , A. Franzè 5 , F. Di Mario 1 1 Università
di Parma, Parma; 2 Università di Bologna, Bologna; 3 Università di Padova, Padova; 4 Ospedale di Belluno, Belluno; 5 Ospedale Maggiore di Parma, Parma
Background and aim: GERD is claimed to be a chronic acid-related disease, characterized by high number of relapses (40-85%) in a six-months period after withdrawal of antisecretory therapy. Gastropanel is based on a four parameters panel (pepsinogen I, pepsinogen II, gastrin-17 and IgG anti H. pylori) assessed by a blood sample. In subjects with antisecretory treatment, both pepsinogen I and II are increased as well as gastrin-17, because of acid-gastrin negative feed-back. To assess “Gastropanel test” in order to select patients who might have more easy new episodes of early relapses of GERD after PPI therapy. Material and methods: 104 consecutive patients (M: 55, mean age: 47 years, range: 27-76) affected by esophagitis (A and B stages, according with Los Angeles Classification) were treated with antisecretory therapy (Rabeprazole 20 mg b.i.d. for 6-8 weeks). After this period 92 patient were asymptomatic and interrupted the PPI therapy though continued with antiacids, at low dose In the 6 months period after the PPI therapy, all patients were asked to contact the endoscopic reference center in case of 4 days long symptoms relapseepisodes. A blood sample was performed in order to assess Gastropanel baseline values and those after the PPI therapy (ELISA, Biohit, Helsinki, Finland) (normal values: PGI = 30-165 μg/dl; PGII = 3-10 μg/dl; G-17: 1-10 μg/dl; IgG against Hp < 30). Results: Five of 92 patients dropped out during the follow-up period. 55 out of the remaining 87 subjects evaluable at the end of the six-months period of follow-up experienced at least one relapse episode. In the relapser group, the mean values of blood parameters were: Baseline: PGI= 94±38; PGII= 7±3; G-17= 1.6±0.7; after therapy: PGI= 164±48; PGII= 13±6; G-17= 3.8±3.7). In the non-relapsers group, the mean values were respectively: Baseline: PGI= 101±29; PGII= 8.2±4; G-17= 1.9±1.3; after therapy: PGI= 203±66; PGII= 27±8; G-17= 12±4.7). The differences in increases of PGI, PGII and G-17 were statistically significant between relapsers and non relapsers (p= 0.01, p minor 0.001 and p minor 0.01 respectively). Conclusions: The assessment of PGI, PGII and G-17 before and after a short treatment period with PPIs (“Gastropanel test”) can be useful who might have early relapse episodes. # A. Oesophagus - 1. GERD
P.11 IS NONACID ACIDIC REFLUX INCREASED IN CHOLECYSTECTOMIZED PATIENTS WITH TYPICAL REFLUX SYMPTOMS? A STUDY USING IMPEDANCE-pH MONITORING G. Sammito ∗ , E. Savarino, L. Gemignani, E. Marabotto, P. Zentilin, V. Savarino Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa Background and aim: Previous studies demonstrated that patients with colecystectomy have a reduced circadian gastric acidity and an increased Duodeno-Gastro-Esophageal Reflux using pH-metry and Bilitec devices, respectively. Still, limited data are present on the frequency of nonacid reflux in patients with colecystectomy. To evaluate impedance-pH patterns in gastro-esophageal reflux disease patients with and without cholecystectomy. Material and methods: We evaluated 164 consecutive patients with typical reflux symptoms (82F, median age 55) using impedance-pH and upper endoscopy. We divided them in cholecystectomized (CCE-group: n=62) and non-cholecystectomized (nCCE-group: n=62) patients. Forty-eight healthy volunteers (27F, median age 42) served as controls. PPI therapy was dis-
continued >30 days prior to testing. We evaluated distal (5cm above LES) esophageal acid exposure time (AET, % time pH<4), number and characteristics of reflux episodes (acid, nonacid) and proximal (15 cm above LES) migration of the refluxate. Results: Data are shown in the Table. Out of 62 nCCE patients, 30 had an abnormal AET, while among CCE patients 21 (48% vs. 34%, p=ns) had an abnormal AET. Patients without cholecystectomy had higher AET and number of acid reflux events compared to patients with cholecystectomy and HV (p<0.05). CCE patients had an increased number of nonacid reflux compared to nCCE patients and HV (p<0.05). The proportion of reflux episodes that was acidic and nonacidic in patients and controls was significantly different among them (p<0.05). Patients without cholecystectomy had more frequently erosive esophagitis than patients with cholecystectomy (p<0.05). Table 1. Endoscopic and impedance-pH features in healthy volunteers, CCE and nCCE patients HV (N=48)
CCE pts (N=62)
nCCE pts (N=62)
Nonerosive reflux disease, n negative endoscopy 57 49 Erosive esophagitis, n negative endoscopy 3 13 Barrett esophagus, n negative endoscopy 2 0 1.6 (0.2-4.5) a,c 3.8 (1.5-6.4) b,c % pH < 4 total 0.7 (0.2-1.4) a,b a,b a GER total 32 (19-43) 44 (29-65) 52 (35-72) b GER acid 17.5 (9-31) b 15 (6-32) c 34 (17-47) b,c 22 (15-34) a,c 16 (14-23) c Ger nonacid 18 (14-26) a Acid/nonacid (%) 49/51 b 41/59 c 65/35 b,c Prox. extent (%) 29 (18-44) a,b 40 (29-61) a 45 (33-61) b
p-value (ANOVA) <0.05 <0.05 ns <0.05 <0.05 <0.05 <0.05 <0.05 <0.05
Data presented as median (25th-75th perc). Post-hoc analysis a HV vs. CCE pts, p<0.05; b HV vs. nCCE pts, p<0.05; c CCE pts vs. nCCE pts, p<0.05.
Conclusions: Colecystectomy do not increase the overall number of reflux episodes compared to patients without colecystectomy, but modifies significantly the composition of the refluxate raising the frequency of nonacid reflux. The different proportion of acid/nonacid reflux may explain the higher presence of erosive esophagitis in nCCE patients. # A. Oesophagus - 1. GERD
P.12 NUMBER OF PROXIMAL ACID REFLUXES, BUT NOT PROXIMAL OR DISTAL ACID EXPOSURE, IDENTIFIES PATIENTS WITH RESPIRATORY MANIFESTATIONS OF GERD. RESULTS OF A MULTICENTER STUDY IN 582 PATIENTS UNDERGOING pH MONITORING F. Agugiaro ∗ , A. Rostello, P. Campagnola, P. Ferrari, C. Sembenini, L. Frulloni, A. Garribba, M. Ferrari, A. Gabbrielli, I. Vantini, L. Benini Policlinico G.B.Rossi, Verona Background and aim: Few studies addressed the question of which pH monitoring parameters better identify patients with reflux as the cause of respiratory or ENT symptoms. Aim of our study was therefore to investigate which pH monitoring parameters better separate patients complaining of frequent respiratory or ENT symptoms. Material and methods: Patients undergoing 24 hour pH monitoring of the upper and lower esophagus in 5 hospitals in North East Italy completed a questionnaire on the severity and frequency of digestive and extradigestive symptoms. These symptoms were then classified as present if their frequency was >1/week. The following pH-monitoring parameters were considered: distal and proximal acid exposure, number of refluxes lasting >5 min, total number of proximal refluxes. Mean ± 1 SEM are shown. The Student’s t test was used to test the statistical difference of values between patients with and without each symptom. Results: Out of 635 consecutive patients, 582 (237 males; age 47.5±15.5 years) entered this study. Table 1 summarises our results. Patients with frequent heartburn and regurgitation show high values of distal acid exposure and of the number of refluxes lasting >5 minutes. On the contrary patients with cough and with wheezing present only an increased number of proximal refluxes. No difference was found in pH parameters between patients with and without current or past asthma, throat clearing, sore throat.
Abstracts / Digestive and Liver Disease 42S (2010) S61–S192
P.10 “GASTROPANEL TEST” IN THE CLINICAL OUTCOME OF GERD: PROSPECTIVE SIX MONTHS CLINICAL STUDY L. Guida ∗ ,1 , P. Perazzo 1 , S. Bertolini 1 , E. Morana 1 , D. Vaira 2 , C. Scarpignato 1 , V. Savarino 3 , L. Gatta 1 , L. Cavallaro 4 , G. Cavestro 1 , M. Rugge 3 , A. Franzè 5 , F. Di Mario 1 1 Università
di Parma, Parma; 2 Università di Bologna, Bologna; 3 Università di Padova, Padova; 4 Ospedale di Belluno, Belluno; 5 Ospedale Maggiore di Parma, Parma
Background and aim: GERD is claimed to be a chronic acid-related disease, characterized by high number of relapses (40-85%) in a six-months period after withdrawal of antisecretory therapy. Gastropanel is based on a four parameters panel (pepsinogen I, pepsinogen II, gastrin-17 and IgG anti H. pylori) assessed by a blood sample. In subjects with antisecretory treatment, both pepsinogen I and II are increased as well as gastrin-17, because of acid-gastrin negative feed-back. To assess “Gastropanel test” in order to select patients who might have more easy new episodes of early relapses of GERD after PPI therapy. Material and methods: 104 consecutive patients (M: 55, mean age: 47 years, range: 27-76) affected by esophagitis (A and B stages, according with Los Angeles Classification) were treated with antisecretory therapy (Rabeprazole 20 mg b.i.d. for 6-8 weeks). After this period 92 patient were asymptomatic and interrupted the PPI therapy though continued with antiacids, at low dose In the 6 months period after the PPI therapy, all patients were asked to contact the endoscopic reference center in case of 4 days long symptoms relapseepisodes. A blood sample was performed in order to assess Gastropanel baseline values and those after the PPI therapy (ELISA, Biohit, Helsinki, Finland) (normal values: PGI = 30-165 μg/dl; PGII = 3-10 μg/dl; G-17: 1-10 μg/dl; IgG against Hp < 30). Results: Five of 92 patients dropped out during the follow-up period. 55 out of the remaining 87 subjects evaluable at the end of the six-months period of follow-up experienced at least one relapse episode. In the relapser group, the mean values of blood parameters were: Baseline: PGI= 94±38; PGII= 7±3; G-17= 1.6±0.7; after therapy: PGI= 164±48; PGII= 13±6; G-17= 3.8±3.7). In the non-relapsers group, the mean values were respectively: Baseline: PGI= 101±29; PGII= 8.2±4; G-17= 1.9±1.3; after therapy: PGI= 203±66; PGII= 27±8; G-17= 12±4.7). The differences in increases of PGI, PGII and G-17 were statistically significant between relapsers and non relapsers (p= 0.01, p minor 0.001 and p minor 0.01 respectively). Conclusions: The assessment of PGI, PGII and G-17 before and after a short treatment period with PPIs (“Gastropanel test”) can be useful who might have early relapse episodes. # A. Oesophagus - 1. GERD
P.11 IS NONACID ACIDIC REFLUX INCREASED IN CHOLECYSTECTOMIZED PATIENTS WITH TYPICAL REFLUX SYMPTOMS? A STUDY USING IMPEDANCE-pH MONITORING G. Sammito ∗ , E. Savarino, L. Gemignani, E. Marabotto, P. Zentilin, V. Savarino Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa Background and aim: Previous studies demonstrated that patients with colecystectomy have a reduced circadian gastric acidity and an increased Duodeno-Gastro-Esophageal Reflux using pH-metry and Bilitec devices, respectively. Still, limited data are present on the frequency of nonacid reflux in patients with colecystectomy. To evaluate impedance-pH patterns in gastro-esophageal reflux disease patients with and without cholecystectomy. Material and methods: We evaluated 164 consecutive patients with typical reflux symptoms (82F, median age 55) using impedance-pH and upper endoscopy. We divided them in cholecystectomized (CCE-group: n=62) and non-cholecystectomized (nCCE-group: n=62) patients. Forty-eight healthy volunteers (27F, median age 42) served as controls. PPI therapy was dis-
continued >30 days prior to testing. We evaluated distal (5cm above LES) esophageal acid exposure time (AET, % time pH<4), number and characteristics of reflux episodes (acid, nonacid) and proximal (15 cm above LES) migration of the refluxate. Results: Data are shown in the Table. Out of 62 nCCE patients, 30 had an abnormal AET, while among CCE patients 21 (48% vs. 34%, p=ns) had an abnormal AET. Patients without cholecystectomy had higher AET and number of acid reflux events compared to patients with cholecystectomy and HV (p<0.05). CCE patients had an increased number of nonacid reflux compared to nCCE patients and HV (p<0.05). The proportion of reflux episodes that was acidic and nonacidic in patients and controls was significantly different among them (p<0.05). Patients without cholecystectomy had more frequently erosive esophagitis than patients with cholecystectomy (p<0.05). Table 1. Endoscopic and impedance-pH features in healthy volunteers, CCE and nCCE patients HV (N=48)
CCE pts (N=62)
nCCE pts (N=62)
Nonerosive reflux disease, n negative endoscopy 57 49 Erosive esophagitis, n negative endoscopy 3 13 Barrett esophagus, n negative endoscopy 2 0 1.6 (0.2-4.5) a,c 3.8 (1.5-6.4) b,c % pH < 4 total 0.7 (0.2-1.4) a,b a,b a GER total 32 (19-43) 44 (29-65) 52 (35-72) b GER acid 17.5 (9-31) b 15 (6-32) c 34 (17-47) b,c 22 (15-34) a,c 16 (14-23) c Ger nonacid 18 (14-26) a Acid/nonacid (%) 49/51 b 41/59 c 65/35 b,c Prox. extent (%) 29 (18-44) a,b 40 (29-61) a 45 (33-61) b
p-value (ANOVA) <0.05 <0.05 ns <0.05 <0.05 <0.05 <0.05 <0.05 <0.05
Data presented as median (25th-75th perc). Post-hoc analysis a HV vs. CCE pts, p<0.05; b HV vs. nCCE pts, p<0.05; c CCE pts vs. nCCE pts, p<0.05.
Conclusions: Colecystectomy do not increase the overall number of reflux episodes compared to patients without colecystectomy, but modifies significantly the composition of the refluxate raising the frequency of nonacid reflux. The different proportion of acid/nonacid reflux may explain the higher presence of erosive esophagitis in nCCE patients. # A. Oesophagus - 1. GERD
P.12 NUMBER OF PROXIMAL ACID REFLUXES, BUT NOT PROXIMAL OR DISTAL ACID EXPOSURE, IDENTIFIES PATIENTS WITH RESPIRATORY MANIFESTATIONS OF GERD. RESULTS OF A MULTICENTER STUDY IN 582 PATIENTS UNDERGOING pH MONITORING F. Agugiaro ∗ , A. Rostello, P. Campagnola, P. Ferrari, C. Sembenini, L. Frulloni, A. Garribba, M. Ferrari, A. Gabbrielli, I. Vantini, L. Benini Policlinico G.B.Rossi, Verona Background and aim: Few studies addressed the question of which pH monitoring parameters better identify patients with reflux as the cause of respiratory or ENT symptoms. Aim of our study was therefore to investigate which pH monitoring parameters better separate patients complaining of frequent respiratory or ENT symptoms. Material and methods: Patients undergoing 24 hour pH monitoring of the upper and lower esophagus in 5 hospitals in North East Italy completed a questionnaire on the severity and frequency of digestive and extradigestive symptoms. These symptoms were then classified as present if their frequency was >1/week. The following pH-monitoring parameters were considered: distal and proximal acid exposure, number of refluxes lasting >5 min, total number of proximal refluxes. Mean ± 1 SEM are shown. The Student’s t test was used to test the statistical difference of values between patients with and without each symptom. Results: Out of 635 consecutive patients, 582 (237 males; age 47.5±15.5 years) entered this study. Table 1 summarises our results. Patients with frequent heartburn and regurgitation show high values of distal acid exposure and of the number of refluxes lasting >5 minutes. On the contrary patients with cough and with wheezing present only an increased number of proximal refluxes. No difference was found in pH parameters between patients with and without current or past asthma, throat clearing, sore throat.