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Sa1320 SI or SAP? A Closer Look at Symptom Association in Suspected GERD Patients
AGA Abstracts
reduced LES tone. Obtaining esophageal manometry simply to determine LESRP in patients with supine GER on quantitative reflux testing appears to have minimal benefit. Correlation Between pH-Metry Findings and Lower Esophageal Sphincter Pressure
Lower Esophageal Sphincter Pressure By Reflux Type Sa1318 Predictors for Persistent Reflux as Measured by Impedance-pH Monitoring in Refractory GERD Junichi Akiyama, Masahiro Hata, Hidetaka Okubo, Kazuhiro Watanabe, Koh Imbe, Toshiyuki Sakurai, Naoyoshi Nagata, Yasushi Kojima, Masao Kobayakawa, Chizu Yokoi, Mikio Yanase, Hiroko Hosaka, Shiko Kuribayashi, Yasuyuki Shimoyama, Osamu Kawamura, Masanobu Yamada, Motoyasu Kusano Background and Aim: Although acid suppressive therapy with proton pump inhibitor (PPI) is highly effective in treating gastroesophageal reflux disease (GERD), there are a substantial number of patients who do not respond to PPI and seek further medical care. Esophageal reflux monitoring can be used to establish whether an abnormal amount of reflux is present and to identify patients who need more aggressive anti-reflux therapy. However, it is impractical to perform esophageal reflux monitoring for every refractory GERD patient in daily clinical practice. The aim of this study was to determine predictors for persistent gastroesophageal reflux (GER) as measured by impedance-pH monitoring in PPI refractory GERD patients. Methods: Forty-eight patients (Age 70±11 years, 48% female) with refractory GERD despite a minimum of 8-week standard-dose PPI therapy were investigated. Symptom severity by Gastrointestinal Symptom Rating Scale, the presence of erosive esophagitis (EE), large hiatal hernia (HH > 3cm) and columnar lined esophagus (CLE > 1cm) by endoscopy, and the amount of GER utilizing ambulatory 24-hour impedance-pH monitoring on PPI therapy were assessed. Persistent GER was confirmed by abnormal esophageal acid exposure (EAE ‡ 4%) or abnormal number of total reflux events (TRE ‡ 48). Results: 1) Twenty-six (54%) patients exhibited persistent GER (abnormal EAE 10 (21%), abnormal TRE 25 (52%)) detected by impedance-pH monitoring. The presence of concomitant EE was associated with EAE (EE 2.3%, no EE 0.7%; p=0.003), but not with TRE (60, 46; p=0.93). 2) In patients with persistent GER, male gender (73%, 27%; p<0.01), large HH (54%, 18%; p= 0.01), EE (23%, 5%; p=0.08), and CLE (54%, 9%; p<0.01) were more prevalent than those with normal GER, but there were no differences in age (73, 71; p=0.78), BMI>25 (23%, 27%; p=0.73), or reflux symptom score (2.8, 3.0; p=0.52). 3) Multivariate logistic regression analysis revealed male gender (OR 7.0, p=0.02), EE (OR 15.2, p=0.06), CLE (OR 8.5, p= 0.048) were independent predictors for persistent GER. Prediction model incorporating these factors had an AUC of 0.85 (95%CI: 0.73-0.96) with a sensitivity of 89% and specificity of 64%. Conclusions: Approximately half of PPI refractory GERD patients exhibit persistent GER and may require more aggressive anti-reflux therapy. Male gender, the presence of concomitant erosive esophagitis and columnar lined esophagus are predictors for persistent GER.
Sa1320 SI or SAP? A Closer Look at Symptom Association in Suspected GERD Patients Crystal L. Zhang, Mustafa Abdul-Hussein, Donald O. Castell Background Symptom index (SI) and symptom association probability (SAP) are popular methods currently used to measure symptom association in patients with gastro-esophageal reflux disease (GERD). Hypothesis To investigate whether these two methods yield similar results in analysis of both typical and atypical GERD symptoms. Methods Combined impedance-pH reflux studies of 1471 patients tested for possible GERD symptoms from January 2010- May 2015 were reviewed. SI and SAP were analyzed for typical and atypical GERD symptoms including heartburn, regurgitation, indigestion, chest pain, cough and throat clearing (TC). Patients who reported less than 3 symptom events /24 hours were excluded. On and Off PPI groups were reviewed. Kappa coefficient ( k) rather than simple percentage was used to measure the agreement rate. Results On PPI therapy, there was a good k between SI and SAP for regurgitation (0.68) and indigestion (0.64), moderate for heartburn (0.48) and chest pain (0.51), and poor for cough (0.33) and TC (0.29). There was a lower k OFF PPI therapy for heartburn (0.36), regurgitation (0.44), and indigestion (0.50). But there was no difference in k for chest pain (0.61), cough (0.29) and TC (0.33). Simple percentage agreement is a less reliable method compared to k. Results are shown in table 1 below. Conclusion SI and SAP showed better agreement for patients with typical GERD symptoms and even better when tested ON PPI. A better symptom association method is needed for patients with atypical GERD symptoms.
Sa1319 Reduced Lower Esophageal Sphincter Pressure Predicts Increased Reflux But Is Still Uncommon In Supine-Only Disease Inki Hong, Sanjana Luther, Henry P. Parkman, Michael S. Smith Background: The lower esophageal sphincter (LES) provides a barrier to gastroesophageal reflux (GER) at the esophago-gastric junction. Defects in function, such as diminished LES resting pressure (LESRP), are thought to facilitate GER by compromising the efficacy of this structure in preventing retrograde flow of gastric contents. It is hypothesized that decreased LES tone is most deleterious in the supine position, when gravity is less able to keep potential refluxate in the stomach. Our aims were to confirm that patients with decreased LESRP have more supine reflux, and to evaluate whether abnormal supine reflux on quantitative reflux testing predicts abnormally low LESRP. Methods: A retrospective analysis was performed on all patients undergoing both 48 hour wireless capsule pH-metry (BRAVO®, Medtronic) and high resolution esophageal manometry between January 2012 and October 2015 at a single high volume center. Patients were excluded if less than 36 hours of pHmetry data were collected. De-identified demographic data and results were aggregated for analysis. Statistical analysis was performed using t-tests. Results: A total of 234 patients were included, with a mean age of 48.5 years (71% female). Most patients (206) had a normal LESRP, while 28 had an abnormally low value defined as <13 mmHg on manometry. Abnormal GER was defined as having a distal esophageal pH less than 4 >= 8.4% of upright time, >= 3.5% of supine time or >= 4.5% of total time. Patients with abnormally low LESRP had statistically significantly more reflux episodes (109 vs 79, p=0.043) and percent supine time with pH<4 (6.3% vs 2.9%, p=0.0018) when compared to patients with normal LESRP. Patients with supine-only GER were more likely to have a low LESRP (24%) compared to patients with upright-only GER (9%) and both supine and upright GER (17%). However, 76% of patients with supine-only GER were found to have normal LESRP. Conclusion: Reduced LESRP predicts a statistically significant increase in both the number of reflux episodes and the amount of time a patient has supine acidic GER during wireless capsule pH-metry, when compared to patients with normal LES tone. However, while patients with supine-only GER are more likely to have reduced LESRP, three quarters of patients still had normal LESRP. Therefore, results of pH-metry testing cannot reliably be used to predict
Sa1321 The Esophagogastric Junction Contractile Integral (EGJ-CI) is the Parameter of High Resolution Manometry Predicting GERD in the Impedance pH testing and Erosive Esophagitis Yu Kyung Cho, Chul-Hyun Lim, Jin Su Kim, Jae Myung Park, Inseok Lee, Young-Seok Cho, Myung-Gyu Choi, Myung-Ki Baek, Bo-In Lee Background: The clinical role of esophagogastric junction contractile integral (EGJ-CI) measured by high-resolution manometry (HRM) in assessing GERD is unclear. Aims: We aimed to correlate EGJ-CI with impedance pH parameters and endoscopic findings in patients with suspected GERD. Methods: Consecutive patients with typical and atypical suspected GERD symptoms were enrolled. All patients underwent upper endoscopy, HRM, and impedance-pH testing. The EGJ-CI was calculated using the distal contractile integral tool box during three consecutive respiratory cycles. The value was then divided by the duration of these cycles. We assessed EGJ morphology, reflux esophagitis, hiatal hernia, abnormal esophageal acid exposure, pathologic bolus exposure and symptom association analysis (SAA). Results: Among 103 patients (42 males, 51+15years) we enrolled, 17 had erosive esophagitis (EE) and 10 had hiatal hernia. By the results of impedance pH, 22 was positive
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AGA Abstracts
reduced LES tone. Obtaining esophageal manometry simply to determine LESRP in patients with supine GER on quantitative reflux testing appears to have minimal benefit. Correlation Between pH-Metry Findings and Lower Esophageal Sphincter Pressure
Lower Esophageal Sphincter Pressure By Reflux Type Sa1318 Predictors for Persistent Reflux as Measured by Impedance-pH Monitoring in Refractory GERD Junichi Akiyama, Masahiro Hata, Hidetaka Okubo, Kazuhiro Watanabe, Koh Imbe, Toshiyuki Sakurai, Naoyoshi Nagata, Yasushi Kojima, Masao Kobayakawa, Chizu Yokoi, Mikio Yanase, Hiroko Hosaka, Shiko Kuribayashi, Yasuyuki Shimoyama, Osamu Kawamura, Masanobu Yamada, Motoyasu Kusano Background and Aim: Although acid suppressive therapy with proton pump inhibitor (PPI) is highly effective in treating gastroesophageal reflux disease (GERD), there are a substantial number of patients who do not respond to PPI and seek further medical care. Esophageal reflux monitoring can be used to establish whether an abnormal amount of reflux is present and to identify patients who need more aggressive anti-reflux therapy. However, it is impractical to perform esophageal reflux monitoring for every refractory GERD patient in daily clinical practice. The aim of this study was to determine predictors for persistent gastroesophageal reflux (GER) as measured by impedance-pH monitoring in PPI refractory GERD patients. Methods: Forty-eight patients (Age 70±11 years, 48% female) with refractory GERD despite a minimum of 8-week standard-dose PPI therapy were investigated. Symptom severity by Gastrointestinal Symptom Rating Scale, the presence of erosive esophagitis (EE), large hiatal hernia (HH > 3cm) and columnar lined esophagus (CLE > 1cm) by endoscopy, and the amount of GER utilizing ambulatory 24-hour impedance-pH monitoring on PPI therapy were assessed. Persistent GER was confirmed by abnormal esophageal acid exposure (EAE ‡ 4%) or abnormal number of total reflux events (TRE ‡ 48). Results: 1) Twenty-six (54%) patients exhibited persistent GER (abnormal EAE 10 (21%), abnormal TRE 25 (52%)) detected by impedance-pH monitoring. The presence of concomitant EE was associated with EAE (EE 2.3%, no EE 0.7%; p=0.003), but not with TRE (60, 46; p=0.93). 2) In patients with persistent GER, male gender (73%, 27%; p<0.01), large HH (54%, 18%; p= 0.01), EE (23%, 5%; p=0.08), and CLE (54%, 9%; p<0.01) were more prevalent than those with normal GER, but there were no differences in age (73, 71; p=0.78), BMI>25 (23%, 27%; p=0.73), or reflux symptom score (2.8, 3.0; p=0.52). 3) Multivariate logistic regression analysis revealed male gender (OR 7.0, p=0.02), EE (OR 15.2, p=0.06), CLE (OR 8.5, p= 0.048) were independent predictors for persistent GER. Prediction model incorporating these factors had an AUC of 0.85 (95%CI: 0.73-0.96) with a sensitivity of 89% and specificity of 64%. Conclusions: Approximately half of PPI refractory GERD patients exhibit persistent GER and may require more aggressive anti-reflux therapy. Male gender, the presence of concomitant erosive esophagitis and columnar lined esophagus are predictors for persistent GER.
Sa1320 SI or SAP? A Closer Look at Symptom Association in Suspected GERD Patients Crystal L. Zhang, Mustafa Abdul-Hussein, Donald O. Castell Background Symptom index (SI) and symptom association probability (SAP) are popular methods currently used to measure symptom association in patients with gastro-esophageal reflux disease (GERD). Hypothesis To investigate whether these two methods yield similar results in analysis of both typical and atypical GERD symptoms. Methods Combined impedance-pH reflux studies of 1471 patients tested for possible GERD symptoms from January 2010- May 2015 were reviewed. SI and SAP were analyzed for typical and atypical GERD symptoms including heartburn, regurgitation, indigestion, chest pain, cough and throat clearing (TC). Patients who reported less than 3 symptom events /24 hours were excluded. On and Off PPI groups were reviewed. Kappa coefficient ( k) rather than simple percentage was used to measure the agreement rate. Results On PPI therapy, there was a good k between SI and SAP for regurgitation (0.68) and indigestion (0.64), moderate for heartburn (0.48) and chest pain (0.51), and poor for cough (0.33) and TC (0.29). There was a lower k OFF PPI therapy for heartburn (0.36), regurgitation (0.44), and indigestion (0.50). But there was no difference in k for chest pain (0.61), cough (0.29) and TC (0.33). Simple percentage agreement is a less reliable method compared to k. Results are shown in table 1 below. Conclusion SI and SAP showed better agreement for patients with typical GERD symptoms and even better when tested ON PPI. A better symptom association method is needed for patients with atypical GERD symptoms.
Sa1319 Reduced Lower Esophageal Sphincter Pressure Predicts Increased Reflux But Is Still Uncommon In Supine-Only Disease Inki Hong, Sanjana Luther, Henry P. Parkman, Michael S. Smith Background: The lower esophageal sphincter (LES) provides a barrier to gastroesophageal reflux (GER) at the esophago-gastric junction. Defects in function, such as diminished LES resting pressure (LESRP), are thought to facilitate GER by compromising the efficacy of this structure in preventing retrograde flow of gastric contents. It is hypothesized that decreased LES tone is most deleterious in the supine position, when gravity is less able to keep potential refluxate in the stomach. Our aims were to confirm that patients with decreased LESRP have more supine reflux, and to evaluate whether abnormal supine reflux on quantitative reflux testing predicts abnormally low LESRP. Methods: A retrospective analysis was performed on all patients undergoing both 48 hour wireless capsule pH-metry (BRAVO®, Medtronic) and high resolution esophageal manometry between January 2012 and October 2015 at a single high volume center. Patients were excluded if less than 36 hours of pHmetry data were collected. De-identified demographic data and results were aggregated for analysis. Statistical analysis was performed using t-tests. Results: A total of 234 patients were included, with a mean age of 48.5 years (71% female). Most patients (206) had a normal LESRP, while 28 had an abnormally low value defined as <13 mmHg on manometry. Abnormal GER was defined as having a distal esophageal pH less than 4 >= 8.4% of upright time, >= 3.5% of supine time or >= 4.5% of total time. Patients with abnormally low LESRP had statistically significantly more reflux episodes (109 vs 79, p=0.043) and percent supine time with pH<4 (6.3% vs 2.9%, p=0.0018) when compared to patients with normal LESRP. Patients with supine-only GER were more likely to have a low LESRP (24%) compared to patients with upright-only GER (9%) and both supine and upright GER (17%). However, 76% of patients with supine-only GER were found to have normal LESRP. Conclusion: Reduced LESRP predicts a statistically significant increase in both the number of reflux episodes and the amount of time a patient has supine acidic GER during wireless capsule pH-metry, when compared to patients with normal LES tone. However, while patients with supine-only GER are more likely to have reduced LESRP, three quarters of patients still had normal LESRP. Therefore, results of pH-metry testing cannot reliably be used to predict
Sa1321 The Esophagogastric Junction Contractile Integral (EGJ-CI) is the Parameter of High Resolution Manometry Predicting GERD in the Impedance pH testing and Erosive Esophagitis Yu Kyung Cho, Chul-Hyun Lim, Jin Su Kim, Jae Myung Park, Inseok Lee, Young-Seok Cho, Myung-Gyu Choi, Myung-Ki Baek, Bo-In Lee Background: The clinical role of esophagogastric junction contractile integral (EGJ-CI) measured by high-resolution manometry (HRM) in assessing GERD is unclear. Aims: We aimed to correlate EGJ-CI with impedance pH parameters and endoscopic findings in patients with suspected GERD. Methods: Consecutive patients with typical and atypical suspected GERD symptoms were enrolled. All patients underwent upper endoscopy, HRM, and impedance-pH testing. The EGJ-CI was calculated using the distal contractile integral tool box during three consecutive respiratory cycles. The value was then divided by the duration of these cycles. We assessed EGJ morphology, reflux esophagitis, hiatal hernia, abnormal esophageal acid exposure, pathologic bolus exposure and symptom association analysis (SAA). Results: Among 103 patients (42 males, 51+15years) we enrolled, 17 had erosive esophagitis (EE) and 10 had hiatal hernia. By the results of impedance pH, 22 was positive
S-281
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AGA Abstracts