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S1900 EGJ pH Mapping: A Novel Model for Esophageal pH Monitoring Not Preceded By Lower Esophageal Sphincter Manometry
S1899
I with predominant reflux symptoms (heartburn and/or regurgitation); group II with predominant dyspepsia (epigastric discomfort, bloating, nausea, satiety) and group III with other or poorly defined symptoms. 24-h MII-pH monitoring was performed off proton-pump inhibitors (PPI). A disposable MII-pH probe (Sandhill, Highland Ranch, Co) was used and results were analysed according to previously published normal values (Aliment Pharmacol Ther 2005;22:1011-21). Symptom index (SI) was calculated considering three different types of reflux episodes i.e. acid reflux (pH<4), weakly acidic and weakly alkaline reflux episodes (the two last types were grouped as non-acid reflux episodes). Results. Thirty one patients (19 males; 48 ± 15 yrs) were investigated after an average of 60 (5-300) months following ARS. Sixteen, 10 and 5 patients belonged to groups I, II and III, respectively. Twenty two patients were empirically treated by PPI at the time of the study. All patients but one reported symptoms during the monitoring period. Abnormal findings are summarized in the table. Among patients with a SI>50%, 145 symptoms were reported of which 35 were labelled as acid reflux and 45 as non acid reflux. Overall, 15 patients had at least one abnormal result at MII-pH testing (4 were detected by pH only). Conclusions. 1) the majority of patients complaining of symptoms after ARS do not have any objective evidence of reflux. 2) in these patients, pH-impedance performed off therapy may facilitate the decision to stop PPI therapy ; 3) in patients without reflux predominant symptoms, SI is more informative than quantitative analysis of pH/impedance bolus exposures.
AGA Abstracts
Physiologic Acid Reflux and Positive Symptom-Index, Is It Physiologic? Jose J. Herrera Esquivel, Juan Octavio Alonso-Larraga, García R. Luis Eduardo, Ignacio Guerrero-Hernández, Martha Fernandez Rosales There are patients with reflux symptoms who have physiologic acid reflux and positive index symptom (PSI). By pH-multichannel intraluminal impedance (pH-MII) it is possible to detect abnormal non-acid gastro esophageal reflux, this reflux can explain the presence of symptoms and might allow us to classify the patients as carriers of gastroesophageal reflux disease, even if they have physiologic acid reflux. Our objective was to investigate characteristics of esophageal pH-MII in patients with physiologic acid reflux and PSI and to know how often non acid reflux is related to PIS. Cross-sectional study in adults whose results of pH-MII showed physiologic acid reflux and PSI.Divided into two groups: physiologic acid reflux and PSI and physiologic acid reflux and negative symptoms index (NSI).We analyzed DeMeester score, 24 hours acid exposure, total time of exposure to acid bolus, upright and recumbent exposure to acid bolus, total number of non-acid reflux events and, symptoms index for acid and non-acid reflux. For comparison between groups we used U Mann-Withney Test and for the analysis of proportions X2. Results:We included 50 patients. In group A there were 29 patients with a mean 24 hours acid exposure of 1.71% (0-5%), DeMeester score 5.2 (0.8-14.6). The total time of exposure to acid bolus, upright and recumbent exposures to acid bolus were 8 min (1%), 9.7min (1.7%) and 1.7 min (0.26%).In these patients total number of reflux events had a mean of 57.89 (16-182) of which, 24.04 (1-55) and 16 (1-160) were acid and non- acid respectively. In this group 62% (18) had PSI to acid reflux, 27.5% (8) PSI to non-acid reflux and, 10.3% (3) PSI to both. In group B there were 21 patients with a mean 24 hours acid exposure of 0.78% (0-3.6%), DeMeester Score 2.7 (0.8-11.8) and total number of reflux events of 32.2 (3-91) of which, 12.81 (150) and 12(0-77) were acid and non- acid respectively. The total time of exposure to acid bolus, upright and recumbent exposures to acid bolus were 3 min (0.41%), 3.5 min (0.67%), 0.6 (0.13%) respectively. In total there were 7 patients with more than 73 episodes of reflux in 24 hours, 4 in group A and 3 in group B respectively. When both groups were compared there were higher values of 24 hours acid exposure, DeMeester score, total and upright exposure to acid bolus in group A (p=0.002). Conclusions: We found that only in 27.5% of patients with physiologic acid reflux the presence of non acid reflux is related to symptoms.That means acid is still responsible for symptoms in the remaining patients.
S1902 Soda Water Test in Patients with Gastroesophageal Reflux Disease Guillermo Dima, Luis O. Soifer, Horacio R. Besasso, Angel D. Peralta Introduction: The absence of a protective gastroesophageal barrier in gastroesophageal reflux disease (GERD) pathophysiology could be either a permanent defect or the more common and accepted mechanism of transient lower esophageal sphincter relaxation. In both cases, the belching mechanism is facilitated, thus evidencing impaired gastric air retention capacity. In order to analyze the relationship between gastric air retention capacity and GERD, a simple soda water test (SWT), with proved reproducibility, was performed. Subjects with and without typical symptoms of heartburn and/or regurgitation were included. Aim: To assess the sensitivity and specificity of SWT in subjects with and without symptoms of GERD, in relationship with the 24-hour pH measurement. Material and methods: A prospective crosssectional descriptive study consisting of 43 subjects (21 females), mean age 48 (±15 years) was designed. The volume of soda water intake inducing the first belch episode noticed by the patient was measured before 24-hour esophageal ambulatory pH measurement. The subjects were divided into two groups: 22 normal pH study subjects (12 females, mean age 46±15) and 21 pathological pH study subjects (9 females, mean age 48±16). Volumes were calculated with a measuring container. Patients were asked to swallow every five seconds small amounts of sparkling water while seated. They were asked to stop drinking as soon as they noticed the first belch episode. Then, the minimum volume for inducing belching was measured. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were estimated for the following volumes: 50, 100, 200, 300 and 400 ml. Results: table 1 Conclusions: Acceptable sensitivity and specificity were obtained with volumes of 300 ml and 100 ml, respectively. This simple and inexpensive method, albeit not perfect, could be useful for ambulatory evaluation of patients with GERD symptoms. Table 1
S1900 EGJ pH Mapping: A Novel Model for Esophageal pH Monitoring Not Preceded By Lower Esophageal Sphincter Manometry Fernando Fornari, Luiz A. Lima, Taira P. Liell, Sergio G. Barros Background: Lower esophageal sphincter (LES) location with manometry is mandatory to orientate the positioning of pH-metry catheter. We aimed to perform pH mapping of the esophagogastric junction (EGJ) to estimate positioning of pH catheter without LES location. Methods: Two-hundred and fifty two patients (170 female, aging 43 ± 14 years) were studied with solid-state manometry, pH-metry off PPI and endoscopy. After LES location with manometry, EGJ pH mapping was carried out by pulling the pH catheter 1 by 1 cm from 5 cm below to 5 cm above LES. Each pull was performed with intervals of 10 seconds, during which pH values were annotated. The point where pH changed from below to above 4 in definitive was named pH turning point (PTP, in cm from nose). PTP reproducibility was assessed by repeating EGJ pH mapping in different days in 10 patients. Results: No significant difference was observed between repeated measures of PTP (1st: 45.7 ± 3.4 cm vs. 2nd: 45.4 ± 3.9 cm; P = 0.604). Out of 252 patients, 240 (95.2%) showed an acid gastric environment (pH < 4) at EGJ pH mapping. Of these, 239 had a PTP: inside LES in 207 (86.6%), in the stomach in 18 (7.5%) and in the esophagus in 14 patients (5.9%). The median distance between PTP and place where pH sensor monitored reflux during pHmetry was 8 cm (IQR: 6 - 9 cm; range 0 - 14 cm). Out of 239 patients with PTP, 6 (2.5%) were studied with pH-metry having the pH sensor < 4 cm above PTP. The comparison of this group with two other [distance PTP - pH sensor: 4-7 cm (n = 106) and ≥ 8 cm (n = 127)] revealed a decreasing level of total acid exposure [16.5% (5.4-31.5) vs. 4.7% (1.98.9) vs. 3% (0.8-6.2); P < 0.05]. Heartburn during pH-metry was reported more frequently by patients with PTP - pH sensor ≤ 7 cm than patients with PTP - pH sensor ≥ 8 cm (30% vs. 17%; P = 0.017). A positive symptom index for heartburn (≥ 50%) was equally found between these comparative groups (88% vs. 81%; P = 0.698). The comparison of patients with and without endoscopic hiatal hernia revealed that patients with hernia had a slightly but significantly shorter distance [median (IQR)] between PTP and pH sensor location at pH-metry [7 cm (6-9) vs. 8 cm (7-9); P = 0.008]. Conclusions: EGJ pH mapping with recognition of a pH turning point (PTP) was successful in 19 of 20 patients investigated for GERD. The adoption of 5 cm above LES as reference for pH sensor location during pHmetry actually measured pH at 8 cm above the pH turning point. The use of EGJ pH mapping with the assumption of 5 cm above PTP as reference for pH sensor positioning might improve both test performance and patient acceptance, and decrease costs. S1901 Interpreting Symptoms After Antireflux Surgery (ARS): Does Esophageal Multichannel Intraluminal Impedance (MII)-pH Monitoring Really Help ? Kafia Belhocine, Jean-Paul Galmiche, Estelle Cauchin, Claude Masliah, Stanislas Bruley des Varannes
S1903
Although antireflux surgery (ARS) is an effective alternative to long-term medical treatment in GERD, many patients still complain of symptoms after ARS. Because of the variety and complexity of clinical presentations, interpretation of these symptoms is frequently challenging. One crucial issue is to determine whether reflux is still present and if so whether symptoms are reflux-related or not. The aim of this study was to determine how useful is esophageal MII-pH monitoring in the characterization of symptoms persisting or occurring after ARS. Patients and Methods. All patients were referred for moderate to severe symptoms, interfering with daily activities and/or sleep. Patients were categorized into 3 groups: group
AGA Abstracts
Dominant Epigastric Pain May Be a Symptom of Gastro-Esophageal Reflux Disease (GERD) Siavosh Nasseri-Moghaddam, Anahita Ghorbani, Hadi Razjouyan, Azadeh Mofid, Mansoureh Mamarabadi, Seyed Maysam Alimohamadi, Alireza Abrishami, Shahnaz Tofangchiha, Reza Malekzadeh Background: GERD is diagnosed when patients complain of heartburn (HB) and/or regurgitation (AR). The sensitivity of these symptoms to diagnose GERD has been questioned. This analysis has been performed to assess the association between epigastric pain and concomitant
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I with predominant reflux symptoms (heartburn and/or regurgitation); group II with predominant dyspepsia (epigastric discomfort, bloating, nausea, satiety) and group III with other or poorly defined symptoms. 24-h MII-pH monitoring was performed off proton-pump inhibitors (PPI). A disposable MII-pH probe (Sandhill, Highland Ranch, Co) was used and results were analysed according to previously published normal values (Aliment Pharmacol Ther 2005;22:1011-21). Symptom index (SI) was calculated considering three different types of reflux episodes i.e. acid reflux (pH<4), weakly acidic and weakly alkaline reflux episodes (the two last types were grouped as non-acid reflux episodes). Results. Thirty one patients (19 males; 48 ± 15 yrs) were investigated after an average of 60 (5-300) months following ARS. Sixteen, 10 and 5 patients belonged to groups I, II and III, respectively. Twenty two patients were empirically treated by PPI at the time of the study. All patients but one reported symptoms during the monitoring period. Abnormal findings are summarized in the table. Among patients with a SI>50%, 145 symptoms were reported of which 35 were labelled as acid reflux and 45 as non acid reflux. Overall, 15 patients had at least one abnormal result at MII-pH testing (4 were detected by pH only). Conclusions. 1) the majority of patients complaining of symptoms after ARS do not have any objective evidence of reflux. 2) in these patients, pH-impedance performed off therapy may facilitate the decision to stop PPI therapy ; 3) in patients without reflux predominant symptoms, SI is more informative than quantitative analysis of pH/impedance bolus exposures.
AGA Abstracts
Physiologic Acid Reflux and Positive Symptom-Index, Is It Physiologic? Jose J. Herrera Esquivel, Juan Octavio Alonso-Larraga, García R. Luis Eduardo, Ignacio Guerrero-Hernández, Martha Fernandez Rosales There are patients with reflux symptoms who have physiologic acid reflux and positive index symptom (PSI). By pH-multichannel intraluminal impedance (pH-MII) it is possible to detect abnormal non-acid gastro esophageal reflux, this reflux can explain the presence of symptoms and might allow us to classify the patients as carriers of gastroesophageal reflux disease, even if they have physiologic acid reflux. Our objective was to investigate characteristics of esophageal pH-MII in patients with physiologic acid reflux and PSI and to know how often non acid reflux is related to PIS. Cross-sectional study in adults whose results of pH-MII showed physiologic acid reflux and PSI.Divided into two groups: physiologic acid reflux and PSI and physiologic acid reflux and negative symptoms index (NSI).We analyzed DeMeester score, 24 hours acid exposure, total time of exposure to acid bolus, upright and recumbent exposure to acid bolus, total number of non-acid reflux events and, symptoms index for acid and non-acid reflux. For comparison between groups we used U Mann-Withney Test and for the analysis of proportions X2. Results:We included 50 patients. In group A there were 29 patients with a mean 24 hours acid exposure of 1.71% (0-5%), DeMeester score 5.2 (0.8-14.6). The total time of exposure to acid bolus, upright and recumbent exposures to acid bolus were 8 min (1%), 9.7min (1.7%) and 1.7 min (0.26%).In these patients total number of reflux events had a mean of 57.89 (16-182) of which, 24.04 (1-55) and 16 (1-160) were acid and non- acid respectively. In this group 62% (18) had PSI to acid reflux, 27.5% (8) PSI to non-acid reflux and, 10.3% (3) PSI to both. In group B there were 21 patients with a mean 24 hours acid exposure of 0.78% (0-3.6%), DeMeester Score 2.7 (0.8-11.8) and total number of reflux events of 32.2 (3-91) of which, 12.81 (150) and 12(0-77) were acid and non- acid respectively. The total time of exposure to acid bolus, upright and recumbent exposures to acid bolus were 3 min (0.41%), 3.5 min (0.67%), 0.6 (0.13%) respectively. In total there were 7 patients with more than 73 episodes of reflux in 24 hours, 4 in group A and 3 in group B respectively. When both groups were compared there were higher values of 24 hours acid exposure, DeMeester score, total and upright exposure to acid bolus in group A (p=0.002). Conclusions: We found that only in 27.5% of patients with physiologic acid reflux the presence of non acid reflux is related to symptoms.That means acid is still responsible for symptoms in the remaining patients.
S1902 Soda Water Test in Patients with Gastroesophageal Reflux Disease Guillermo Dima, Luis O. Soifer, Horacio R. Besasso, Angel D. Peralta Introduction: The absence of a protective gastroesophageal barrier in gastroesophageal reflux disease (GERD) pathophysiology could be either a permanent defect or the more common and accepted mechanism of transient lower esophageal sphincter relaxation. In both cases, the belching mechanism is facilitated, thus evidencing impaired gastric air retention capacity. In order to analyze the relationship between gastric air retention capacity and GERD, a simple soda water test (SWT), with proved reproducibility, was performed. Subjects with and without typical symptoms of heartburn and/or regurgitation were included. Aim: To assess the sensitivity and specificity of SWT in subjects with and without symptoms of GERD, in relationship with the 24-hour pH measurement. Material and methods: A prospective crosssectional descriptive study consisting of 43 subjects (21 females), mean age 48 (±15 years) was designed. The volume of soda water intake inducing the first belch episode noticed by the patient was measured before 24-hour esophageal ambulatory pH measurement. The subjects were divided into two groups: 22 normal pH study subjects (12 females, mean age 46±15) and 21 pathological pH study subjects (9 females, mean age 48±16). Volumes were calculated with a measuring container. Patients were asked to swallow every five seconds small amounts of sparkling water while seated. They were asked to stop drinking as soon as they noticed the first belch episode. Then, the minimum volume for inducing belching was measured. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were estimated for the following volumes: 50, 100, 200, 300 and 400 ml. Results: table 1 Conclusions: Acceptable sensitivity and specificity were obtained with volumes of 300 ml and 100 ml, respectively. This simple and inexpensive method, albeit not perfect, could be useful for ambulatory evaluation of patients with GERD symptoms. Table 1
S1900 EGJ pH Mapping: A Novel Model for Esophageal pH Monitoring Not Preceded By Lower Esophageal Sphincter Manometry Fernando Fornari, Luiz A. Lima, Taira P. Liell, Sergio G. Barros Background: Lower esophageal sphincter (LES) location with manometry is mandatory to orientate the positioning of pH-metry catheter. We aimed to perform pH mapping of the esophagogastric junction (EGJ) to estimate positioning of pH catheter without LES location. Methods: Two-hundred and fifty two patients (170 female, aging 43 ± 14 years) were studied with solid-state manometry, pH-metry off PPI and endoscopy. After LES location with manometry, EGJ pH mapping was carried out by pulling the pH catheter 1 by 1 cm from 5 cm below to 5 cm above LES. Each pull was performed with intervals of 10 seconds, during which pH values were annotated. The point where pH changed from below to above 4 in definitive was named pH turning point (PTP, in cm from nose). PTP reproducibility was assessed by repeating EGJ pH mapping in different days in 10 patients. Results: No significant difference was observed between repeated measures of PTP (1st: 45.7 ± 3.4 cm vs. 2nd: 45.4 ± 3.9 cm; P = 0.604). Out of 252 patients, 240 (95.2%) showed an acid gastric environment (pH < 4) at EGJ pH mapping. Of these, 239 had a PTP: inside LES in 207 (86.6%), in the stomach in 18 (7.5%) and in the esophagus in 14 patients (5.9%). The median distance between PTP and place where pH sensor monitored reflux during pHmetry was 8 cm (IQR: 6 - 9 cm; range 0 - 14 cm). Out of 239 patients with PTP, 6 (2.5%) were studied with pH-metry having the pH sensor < 4 cm above PTP. The comparison of this group with two other [distance PTP - pH sensor: 4-7 cm (n = 106) and ≥ 8 cm (n = 127)] revealed a decreasing level of total acid exposure [16.5% (5.4-31.5) vs. 4.7% (1.98.9) vs. 3% (0.8-6.2); P < 0.05]. Heartburn during pH-metry was reported more frequently by patients with PTP - pH sensor ≤ 7 cm than patients with PTP - pH sensor ≥ 8 cm (30% vs. 17%; P = 0.017). A positive symptom index for heartburn (≥ 50%) was equally found between these comparative groups (88% vs. 81%; P = 0.698). The comparison of patients with and without endoscopic hiatal hernia revealed that patients with hernia had a slightly but significantly shorter distance [median (IQR)] between PTP and pH sensor location at pH-metry [7 cm (6-9) vs. 8 cm (7-9); P = 0.008]. Conclusions: EGJ pH mapping with recognition of a pH turning point (PTP) was successful in 19 of 20 patients investigated for GERD. The adoption of 5 cm above LES as reference for pH sensor location during pHmetry actually measured pH at 8 cm above the pH turning point. The use of EGJ pH mapping with the assumption of 5 cm above PTP as reference for pH sensor positioning might improve both test performance and patient acceptance, and decrease costs. S1901 Interpreting Symptoms After Antireflux Surgery (ARS): Does Esophageal Multichannel Intraluminal Impedance (MII)-pH Monitoring Really Help ? Kafia Belhocine, Jean-Paul Galmiche, Estelle Cauchin, Claude Masliah, Stanislas Bruley des Varannes
S1903
Although antireflux surgery (ARS) is an effective alternative to long-term medical treatment in GERD, many patients still complain of symptoms after ARS. Because of the variety and complexity of clinical presentations, interpretation of these symptoms is frequently challenging. One crucial issue is to determine whether reflux is still present and if so whether symptoms are reflux-related or not. The aim of this study was to determine how useful is esophageal MII-pH monitoring in the characterization of symptoms persisting or occurring after ARS. Patients and Methods. All patients were referred for moderate to severe symptoms, interfering with daily activities and/or sleep. Patients were categorized into 3 groups: group
AGA Abstracts
Dominant Epigastric Pain May Be a Symptom of Gastro-Esophageal Reflux Disease (GERD) Siavosh Nasseri-Moghaddam, Anahita Ghorbani, Hadi Razjouyan, Azadeh Mofid, Mansoureh Mamarabadi, Seyed Maysam Alimohamadi, Alireza Abrishami, Shahnaz Tofangchiha, Reza Malekzadeh Background: GERD is diagnosed when patients complain of heartburn (HB) and/or regurgitation (AR). The sensitivity of these symptoms to diagnose GERD has been questioned. This analysis has been performed to assess the association between epigastric pain and concomitant
A-288