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Tu1775 Diminished Esophageal Peristaltic Vigor Is Associated With Poor Bolus Clearance in Patients With Chronic Cough
Among 159 patients with codes for GC, 109 (68.6%) had a verified GC, 2 (1.3%) had EC, 17 (10.7%) had neoplasms in the proximal small bowel and 31 (19.5%) had no GI neoplasia. Similarly, among 561 patients with codes for EC, 393 (70%) had verified EC, 2 (0.4%) had GC while 166 (29.6%) had no evidence of neoplasia. Considering the 720 patients with either GC or EC, 506 (70.3%) had verified gastric or esophageal neoplasms, while for the 86 patients with codes for both gastric and esophageal neoplasms the PPV was 99% for either GC or EC. The yield of GE neoplasms among Veterans with GERD undergoing screening EGD is 8.1 per 1000. Given that close to 30% of these neoplasms are misclassified by using site-specific codes, we recommend chart based verification or predictive algorithms to improve the accuracy of the diagnostic codes. Tu1774 Does Chronic Cough Provoke Increased Gastro-Esophageal Reflux? Jafar Jafari, Leila Mebarek, Robert M. Allen, Priyanka Yerragorla, Daniel Sifrim Background Chronic cough and GERD are very common and prevalent diseases. It is known that GERD is one of the three most common causes of chronic cough. During the last years, new methods have been introduced to study the temporal and causal association between reflux and cough. pH-impedance monitoring has been proposed as the most sensitive method for detection of acid and non acid reflux whereas either manometric or acoustic methods have been used for objective detection of cough. During these studies, a sequence of association of "reflux-cough" has been used to establish a positive diagnosis. The sequence cough-reflux has also been described but controversy still exist about its prevalence and clinical relevance. One potential factor for such controversy could be due to different methodology for cough detection. The aim of this study was to assess the contribution of cough to pathologic GER in patients with chronic cough and increased esophageal acid exposure. Methods Simultaneous 24h ambulatory reflux and cough monitoring was performed in 17 patients with suspected reflux-related chronic cough. Reflux episodes were detected by pH-impedance monitoring and coughs by a) manometric detection and b) acoustic detection (independent listening of complete 24hs sound recordings). Manometric cough detection was performed with a two-channel pressure catheter with sensors in the esophagus and stomach. Cough was manually declared when simultaneous abdominothoracic pressure bursts occurred of at least 2 peaks within 3 seconds. Acoustic detection was performed using 3 sound surface sensors. Cough events were identified and inserted into the reflux tracing. We measured total esophageal acid exposure and bolus exposure (by impedance). We calculated the time of acid exposure and bolus exposure after manometrically and acoustic detected cough events. Results 6/17 patients had pathological esophageal acid exposure. In these patients the total number of reflux events/24hs was 38 (29-70). From that total number, 7.4% (0-25) reflux episodes occurred within 2 minutes after a cough episodes. Total acid exposure was 9.7% ± 4.7. From the acid exposure, 3.5% (08)% occurred after cough detected by manometry or audio. The median total bolus exposure was 2.1± 0.6%. From total bolus exposure, 6.3% (0-20) occurred after manometric cough detection and 6.8% (0-50) after acoustic detected cough. Only 1/6 patients had a significant increase in acid and bolus exposure after cough. Conclusion In patients with chronic cough and pathological acid GER, cough was followed by reflux in a minority of cases regardless of the method for cough detection. In only 1/6 patients the sequence cough-reflux could be considered as causal of pathological GER.
AET=acid exposure time; BAs=bile acids; BAL=broncho-alveolar lavage Tu1772 Comparison of Proximal and Distal Impedance Episodes in Patients With Classic Versus Extra-Esophageal Symptoms of GERD Ryan Kwok, Corinne L. Maydonovitch, Yen-Ju Chen, Lavern Belle, FongKuei Cheng, Fouad J. Moawad Background: Patients are frequently referred for evaluation of extraesophageal (EXT) symptoms (cough, hoarseness, globus sensation) presumably related to gastroesophageal reflux disease (GERD). 24 hour pH/impedance is the most sensitive test for the diagnosis of GERD, however limited data exist in examining the relationship between distal and proximal impedance episodes in patients with EXT symptoms versus classic reflux symptoms. Aim: To compare the number and percentage of proximal impedance episodes in patients with EXT symptoms to those with classic GERD symptoms undergoing 24 hour pH/impedance testing. Patients & Methods: A retrospective review of adult patients undergoing esophageal manometry and 24 hour pH/impedance studies off acid suppressing therapy between 20062011 was performed. Indications for these studies included typical GERD symptoms (heartburn and regurgitation) or atypical symptoms (cough, asthma, hoarseness or globus sensation). GERD was defined using the validated Johnson-DeMeester (JD) score. The results of the esophageal manometry and 24 hour pH/impedance studies between the classic GERD and EXT groups were compared using Chi squared test and students independent t-test. Continuous data is expressed as means (sd). Results: A total of 220 patients were included in the analysis [172 GERD vs. 48 EXT]. GERD and EXT groups were similar in race and gender, however GERD patients were younger than EXT patients [46 (13) years vs. 50 (8) years, p = 0.048]. There was no significant difference between GERD and EXT in the mean number of proximal impedance episodes [33 (22) vs. 28 (22), p = 0.188], the percentage of proximal impedance episodes migrating from the distal esophagus [55 (20) % vs. 50 (17) %, p=0.178), or the mean number of distal impedance episodes [57 (33) vs. 49 (34), p = 0.157]. There was no significant difference between GERD and EXT with regards to mean lower esophageal sphincter pressures [13.3 (11) mmHg vs. 15.3 (7.8) mmHg, p = 0.251] or mean esophageal amplitude [95.4 (44.6) mmHg vs. 84.9 (41.0) mmHg, p=0.146]. Based on 24 hour pH monitoring there was no significant difference between the classic GERD and EXT groups in the JD scores [22.6 (33) vs 17.8 (22), p = 0.358] or percent total time pH ,4 [4.6 (5.3) vs. 4.2 (5.3), p = 0.642]. There was a significant correlation between the number of proximal and distal episodes between the two groups (R2 = 0.724, p , 0.001). Conclusion: Patients with EXT symptoms are similar to classic GERD patients in the number proximal impedance reflux episodes and percentage of distal episodes migrating to the proximal esophagus. Furthermore, both groups have a similar degree of acid reflux.
Tu1775 Diminished Esophageal Peristaltic Vigor Is Associated With Poor Bolus Clearance in Patients With Chronic Cough Cristina Almansa, Jaclyn A. Smith, Michael D. Crowell, Dimitra Valdramidou, Augustine Lee, Kenneth R. DeVault, Lesley A. Houghton Gastroesophageal reflux disease is considered a cause of chronic cough (CC) either singly or in association with nasal disease and/or asthma. However, this does not appear to be due to micro-aspiration or to the number or acidity of reflux events, but rather to a sensitized bronchial-esophageal (B-E) reflex, not active under normal physiological conditions. Studies assessing motility using High Resolution Esophageal Manometry (HREM) in CC are limited, but traditional techniques report the presence of ineffective motility. We hypothesized that poor bolus transit or delayed reflux clearance due to weak esophageal peristalsis contributes to B-E reflex sensitization. Aim: To assess esophageal motor function in patients with CC, and to evaluate the association with bolus transit and reflux clearance. Methods: HREM was completed in 44 CC patients and 33 randomly selected gastrointestinal (GI) patient controls. Esophageal pressure plots were evaluated using the Chicago classification criteria. Primary outcome measures included weak peristalsis with large breaks (WPLB), weak peristalsis with small breaks (WPSB), the location of peristaltic breaks, and the Distal Contractile Integral (DCI). In addition, 27 of the CC patients completed simultaneous HREM and stationary impedance monitoring to assess bolus transit. Ambulatory 24-h pH-impedance was also recorded in patients. Group differences were evaluated using the Mann Whitney U test at the 0.05 significance level. Results: WPLB were found in 16 (36%) patients with CC and 7 (21%) of controls (P=0.209). WPSB were identified in 11 (21%) CC patients and 6 (18%) of controls (P=0.583). WPLB was significantly associated with incomplete bolus transit (P= 0.001), but WPSB was not (P=0.713). As shown in the table, the overall DCI was not significantly different between groups. However, the DCI was significantly lower in CC patients with than without WPLB [802 (531, 1350), median (IQR) vs 2354 (956, 3998) mmHg-s-cm, P , 0.001], but not in controls [820 (367, 2628) vs 2419 (1371, 3640) mmHg-s-cm, P = 0.109]. The DCI was not significantly different between CC and controls with WPSB. In the CC patients that completed stationary impedance testing, large breaks were associated with lower complete bolus clearance (29% vs 89%, P =0.011). Mean (95% CI) total number of reflux events (67 (53, 81)) and proximal events (27(18, 36)) during 24hr pH impedance testing was within normal limits; and this did not significantly change with the presence of breaks. Conclusion: Chronic cough patients with diagnosis of WPLB appear to have lower peristaltic contraction vigor (i.e. DCI) compared with the average GI patient with similar diagnosis. In CC this appears to be associated with poor bolus clearance but normal reflux, suggesting poor swallow clearance could contribute to sensitization of the bronchial-esophageal reflex.
Tu1773 Gastroesophageal Malignancies in GERD Patients Undergoing Screening Endoscopy Using Automated Data: What Is the Yield and Can We Trust the Diagnostic Codes? Mohammad H. Shakhatreh, Jennifer R. Kramer, Marilyn Hinojosa-Lindsey, Zhigang Duan, Ashley Helm, Nathaniel Avila, John M. Hollier, Hashem El-Serag Introduction It is difficult to examine the yield of gastroesophageal (GE) neoplasia detected by screening endoscopy (EGD) among patients with GERD due to the relative infrequency of these neoplasms. With the availability of automated data in large healthcare systems, it is possible to conduct sufficiently powered studies of GE neoplastic yield of screening EGD. However, the reliance on diagnostic codes used for healthcare claims and other administrative purposes is a potential serious limitation of automated datasets. We therefore examined the neoplastic yield of EGD in the national VA Healthcare System, and combined the use of automated datasets with that of structured reviews of electronic medical records (EMR). Methods We identified patients with GERD first recorded in national VA outpatient administrative datasets during 2004-2009, and ascertained the performance of an EGD within the first year post- GERD index date. We calculated the proportions of patients with esophageal cancer (ICD-9 codes 150.0-150.5, 150.8-150.9, 230.1) or gastric cancer (codes 151.0-151.6, 151.8-151.9, 209.23, 230.2) among those who underwent "screening" EGD. We excluded patients with conditions prompting a surveillance or diagnostic EGD including Barrett's esophagus, upper GI neoplasms, abdominal surgery, decompensated liver disease, GI bleeding, anemia, celiac disease or metastatic cancer within 5 years preceding the GERD index date. Structured EMR reviews were then used to verify all GE neoplasms and classify them as Esophageal Cancer (EC), Gastric Cancer (GC), or other neoplasia in the upper GI tract. We calculated the true yield of GE neoplasia and examined the validity of the diagnostic codes. Results We identified 499,073 patients with GERD, 77,090 had a screening EGD and of whom 823 patients had codes for esophageal or gastric neoplasia and 625 (8.1/1000) had one or more of these neoplasms verified by chart validation. The codes for either EC or GC had a modest positive predictive value for the presence of these respective cancers.
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AGA Abstracts
better with impedance-detected reflux episodes than with esophageal acid exposure time. Thus, impedance-pH should be considered as a more accurate tool to define the relationship between gastric aspiration and GER in this particular cohort of patients. Table. Correlation between AET, impedance-detected reflux episodes, presence and concentration of pepsin and BAs in saliva and BAL
AGA Abstracts
the PpH thresholds among patients with normal vs. abnormal total DAE (Table). There were also no differences in PR events when comparing DAE in the upright or supine positions. (Table) In the analysis of individual PR events, patients with normal total DAE had a lower frequency of PR with corresponding esophageal reflux (PR+ER+) (31% vs. 57.3% p=0.002) and a higher frequency of isolated PR events (PR+ER-) (69% vs. 42.7%, p= 0.002) compared to the abnormal total DAE group (Figure 1). Conclusions: DAE does not predict the presence of PR in 40% of patients with suspected extra-esophageal GERD largely due to PR episodes that occur in the absence of corresponding measurable ER events. Further studies are required to determine if these isolated PR events represent artifacts of PpH testing (i.e. pseudo-reflux) or true PR episodes of aerosolized reflux that cannot be detected using traditional EpH testing. (Table) Pharyngeal Reflux Episodes Based Upon Distal Esophageal Acid Parameters
Data median (IQR) other than when indicated Tu1776 The Risk of Dental Erosion in GERD Patients As Measured by the Basic Erosive Wear Examination Kristi Erickson, Nicholas J. Shaheen, Terry Donovan, Evan S. Dellon, Ryan D. Madanick Background and aims: While symptoms and complications from gastroesophageal reflux disease (GERD) such as heartburn, esophageal stricture, bleeding, and Barrett's esophagus are commonly known, dental complications of GERD may go unrecognized. The prevalence of dental erosion in subjects with GERD is poorly described. The aim of this study was to determine the risk of dental erosion in a population diagnosed with GERD. The association between dental erosion and salivary flow, salivary buffering capacity and dietary acidic challenges was also assessed. Methods: Subjects were recruited from The University of North Carolina's Center for Esophageal Disease and Swallowing with a physician diagnosis of GERD, and typical symptoms of heartburn and regurgitation. Subjects received a basic dental exam using the Basic Erosive Wear Exam (BEWE, table); the general population has about a 10% prevalence of erosive wear. Subjects provided a stimulated salivary sample which was used to determine their stimulated salivary flow rate and salivary buffering capacity. A diet diary was given to the subjects to complete for 4 days which was used to calculate daily average acidic challenges. Xerostomia was defined as a flow rate less than 0.1mL/minute. Salivary flow was considered low risk if flow rate was between 0.7-0.1 mL/ minute. Salivary buffering was considered high risk if pH was below 4.0. while the risk was considered moderate if pH was between 4.0-4.9. Simple percentages are reported. Results: To date, 22 GERD subjects (13 female, 9 male) have been enrolled. Of these, 41% have moderate erosive wear (BEWE cumulative score 9-13), 50% have low erosive wear (BEWE score 3-8), and 9% show no erosive wear (BEWE score 0-2) Stimulated salivary flow rate was normal for 77% of the subjects, low for 18.5% and 4.5% of the subjects had xerostomia. Salivary buffering capacity was normal for 46% of the subjects while, 36% were at high risk and 18% of the subjects were at moderate risk. Dietary acidic challenges were low for 50% of the subjects, moderate for 35.7% and high for 14.3%. Conclusion: A high proportion of subjects with GERD show erosive wear of their teeth. Inadequate salivary flow or buffering capacity may in part explain this defect. BEWE Criteria for Grading Erosive Wear
Fig 1: Types of Pharyngeal Reflux (PR) events (with and without preceding Esophageal Reflux) in patients with normal and abnormal Distal Acid Exposure (DAE) Tu1778
Tu1777
Impedance Baseline Measurement Enhances the Sensitivity of Impedance-pH Monitoring in Patients With Suspected GERD-Related Chronic Cough Mentore Ribolsi, Paola Balestrieri, Antonio Fiacco, Sara Emerenziani, Michele Cicala
Impact of pH Testing in Patients With Extra-Esophageal GERD Symptoms: Does Distal Esophageal Acid Exposure Predict Pharyngeal Reflux? Swapna B. Reddy, M. Mazen Jamal, Robert H. Lee
Background and Aim: Although gastro-esophageal reflux disease (GERD) is thought to be a common cause of chronic cough (CC), upper endoscopy and pH monitoring are often in the normal range in CC patients. In these patients, it has been demonstrated that an empiric PPI trial is more cost-effective than pH-monitoring in diagnosing GERD but few data are available concerning the diagnostic yield of impedance-pH (MI-pH) variables and pattern of reflux when compared to those in patients with typical symptoms (TS). Impedance baseline (IB) could be related to epithelial integrity, is strictly correlated to the acid exposure time (AET) and may increase the sensitivity of MI-pH monitoring. Methods: Of consecutive non-smokers CC patients not showing erosive esophagitis, 34 (F 16; mean age 41 yrs) underwent, following a 3-weeks pharmacological washout, ambulatory MI-pH. Subsequently, all patients received a double dose of PPI treatment for at least 4 weeks. Patients filled out a structurized questionnaire (Fisman Cough Severity - Frequency Scores) before and following PPI treatment and were defined as non-responder if showing ,50% of symptom improvement from treatment. In addition to classical parameters, impedance baseline (IB) at 5cm above LES was also calculated, in a time-window of 1h, and was defined pathological if ,1944 V, according to previously published data. MI-pH findings were compared to those obtained in 55 non erosive reflux disease patients with TS responding to PPIs (F 31; mean age 44 yrs). Data are expressed as median and 25th-75th percentile values. Results: MI-pH findings are shown in Table. CC patients showed a higher frequency of reflux episodes and a higher proportion of mixed refluxes compared to TS patients (p ,0.05). Among CC patients, 16 (47%) were non-responders and 18 (53%) responders to PPIs. 16/34 (47%) CC patients and 24/55 (44%) patients with TS presented a pathological AET. IB was pathological in 10/ 16 non responder and in 10/18 responder CC patients. Of the 16 CC patients with a pathological AET, 9 (56%) also presented a pathological IB. When considering IB values in
Background/Aims: A common dilemma in the evaluation of extra-esophageal GERD is the choice between Esophageal pH (EpH) testing that measures Distal Acid Exposure (DAE) or Pharyngeal pH testing (PpH) that tracks Pharyngeal Reflux (PR) events. The aims of this prospective cross sectional study were: 1) To determine the prevalence of abnormal EpH and PpH studies in patients with high Reflux Symptom Index (RSI) scores 2) To determine if parameters on EpH predict the degree of PR on PpH 3) To compare the correlation between individual PR and Esophageal Reflux (ER) events among patients with normal vs. abnormal DAE. Methods: Patients with suspected Extra-Esophageal GERD (40% cough, 24% sore throat, 20% dysphonia, 12% throat-clearing, 4% globus) and RSI scores of . 7 underwent simultaneous 48-hour EpH (BRAVO, Given Imaging) and PpH (Dx-pH, Restech) while off of PPI. A positive EpH test was defined as a DAE . 5.5% at pH , 4. A positive PpH test was defined using the traditional criteria of ≥ 1 PR event (pH,4) occurring within 24-hrs. The number of PR events at the traditional PpH threshold of , 4 along with pH 5.0 and 5.5 were compared based upon Total, Upright and Supine DAE using the Wilcoxon Rank Sum test. Individual PR events were also analyzed for temporal correlation with ER events. PR that occurred within 5 minutes of a preceding ER event was considered to be a PR episode with corresponding esophageal reflux (PR+ER+) whereas PR occurring in the absence of ER in that time window was considered to be an isolated PR event (PR+ER-). The frequencies of PR+ER+ and PR+ER- episodes were compared in patients with normal vs. abnormal total DAE using chi-square. Results: A total of 25 patients (age 53.8, 88% male, BMI 27.8, 40% with Hiatal Hernia, RSI 26.5) were studied. 32% were EpH and PpH positive, 20% EpH positive/PpH negative, 40% EpH negative/PpH positive, and 25% EpH negative/PpH negative. There was no difference in the number of PR events using any of
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AET=acid exposure time; BAs=bile acids; BAL=broncho-alveolar lavage Tu1772 Comparison of Proximal and Distal Impedance Episodes in Patients With Classic Versus Extra-Esophageal Symptoms of GERD Ryan Kwok, Corinne L. Maydonovitch, Yen-Ju Chen, Lavern Belle, FongKuei Cheng, Fouad J. Moawad Background: Patients are frequently referred for evaluation of extraesophageal (EXT) symptoms (cough, hoarseness, globus sensation) presumably related to gastroesophageal reflux disease (GERD). 24 hour pH/impedance is the most sensitive test for the diagnosis of GERD, however limited data exist in examining the relationship between distal and proximal impedance episodes in patients with EXT symptoms versus classic reflux symptoms. Aim: To compare the number and percentage of proximal impedance episodes in patients with EXT symptoms to those with classic GERD symptoms undergoing 24 hour pH/impedance testing. Patients & Methods: A retrospective review of adult patients undergoing esophageal manometry and 24 hour pH/impedance studies off acid suppressing therapy between 20062011 was performed. Indications for these studies included typical GERD symptoms (heartburn and regurgitation) or atypical symptoms (cough, asthma, hoarseness or globus sensation). GERD was defined using the validated Johnson-DeMeester (JD) score. The results of the esophageal manometry and 24 hour pH/impedance studies between the classic GERD and EXT groups were compared using Chi squared test and students independent t-test. Continuous data is expressed as means (sd). Results: A total of 220 patients were included in the analysis [172 GERD vs. 48 EXT]. GERD and EXT groups were similar in race and gender, however GERD patients were younger than EXT patients [46 (13) years vs. 50 (8) years, p = 0.048]. There was no significant difference between GERD and EXT in the mean number of proximal impedance episodes [33 (22) vs. 28 (22), p = 0.188], the percentage of proximal impedance episodes migrating from the distal esophagus [55 (20) % vs. 50 (17) %, p=0.178), or the mean number of distal impedance episodes [57 (33) vs. 49 (34), p = 0.157]. There was no significant difference between GERD and EXT with regards to mean lower esophageal sphincter pressures [13.3 (11) mmHg vs. 15.3 (7.8) mmHg, p = 0.251] or mean esophageal amplitude [95.4 (44.6) mmHg vs. 84.9 (41.0) mmHg, p=0.146]. Based on 24 hour pH monitoring there was no significant difference between the classic GERD and EXT groups in the JD scores [22.6 (33) vs 17.8 (22), p = 0.358] or percent total time pH ,4 [4.6 (5.3) vs. 4.2 (5.3), p = 0.642]. There was a significant correlation between the number of proximal and distal episodes between the two groups (R2 = 0.724, p , 0.001). Conclusion: Patients with EXT symptoms are similar to classic GERD patients in the number proximal impedance reflux episodes and percentage of distal episodes migrating to the proximal esophagus. Furthermore, both groups have a similar degree of acid reflux.
Tu1775 Diminished Esophageal Peristaltic Vigor Is Associated With Poor Bolus Clearance in Patients With Chronic Cough Cristina Almansa, Jaclyn A. Smith, Michael D. Crowell, Dimitra Valdramidou, Augustine Lee, Kenneth R. DeVault, Lesley A. Houghton Gastroesophageal reflux disease is considered a cause of chronic cough (CC) either singly or in association with nasal disease and/or asthma. However, this does not appear to be due to micro-aspiration or to the number or acidity of reflux events, but rather to a sensitized bronchial-esophageal (B-E) reflex, not active under normal physiological conditions. Studies assessing motility using High Resolution Esophageal Manometry (HREM) in CC are limited, but traditional techniques report the presence of ineffective motility. We hypothesized that poor bolus transit or delayed reflux clearance due to weak esophageal peristalsis contributes to B-E reflex sensitization. Aim: To assess esophageal motor function in patients with CC, and to evaluate the association with bolus transit and reflux clearance. Methods: HREM was completed in 44 CC patients and 33 randomly selected gastrointestinal (GI) patient controls. Esophageal pressure plots were evaluated using the Chicago classification criteria. Primary outcome measures included weak peristalsis with large breaks (WPLB), weak peristalsis with small breaks (WPSB), the location of peristaltic breaks, and the Distal Contractile Integral (DCI). In addition, 27 of the CC patients completed simultaneous HREM and stationary impedance monitoring to assess bolus transit. Ambulatory 24-h pH-impedance was also recorded in patients. Group differences were evaluated using the Mann Whitney U test at the 0.05 significance level. Results: WPLB were found in 16 (36%) patients with CC and 7 (21%) of controls (P=0.209). WPSB were identified in 11 (21%) CC patients and 6 (18%) of controls (P=0.583). WPLB was significantly associated with incomplete bolus transit (P= 0.001), but WPSB was not (P=0.713). As shown in the table, the overall DCI was not significantly different between groups. However, the DCI was significantly lower in CC patients with than without WPLB [802 (531, 1350), median (IQR) vs 2354 (956, 3998) mmHg-s-cm, P , 0.001], but not in controls [820 (367, 2628) vs 2419 (1371, 3640) mmHg-s-cm, P = 0.109]. The DCI was not significantly different between CC and controls with WPSB. In the CC patients that completed stationary impedance testing, large breaks were associated with lower complete bolus clearance (29% vs 89%, P =0.011). Mean (95% CI) total number of reflux events (67 (53, 81)) and proximal events (27(18, 36)) during 24hr pH impedance testing was within normal limits; and this did not significantly change with the presence of breaks. Conclusion: Chronic cough patients with diagnosis of WPLB appear to have lower peristaltic contraction vigor (i.e. DCI) compared with the average GI patient with similar diagnosis. In CC this appears to be associated with poor bolus clearance but normal reflux, suggesting poor swallow clearance could contribute to sensitization of the bronchial-esophageal reflex.
Tu1773 Gastroesophageal Malignancies in GERD Patients Undergoing Screening Endoscopy Using Automated Data: What Is the Yield and Can We Trust the Diagnostic Codes? Mohammad H. Shakhatreh, Jennifer R. Kramer, Marilyn Hinojosa-Lindsey, Zhigang Duan, Ashley Helm, Nathaniel Avila, John M. Hollier, Hashem El-Serag Introduction It is difficult to examine the yield of gastroesophageal (GE) neoplasia detected by screening endoscopy (EGD) among patients with GERD due to the relative infrequency of these neoplasms. With the availability of automated data in large healthcare systems, it is possible to conduct sufficiently powered studies of GE neoplastic yield of screening EGD. However, the reliance on diagnostic codes used for healthcare claims and other administrative purposes is a potential serious limitation of automated datasets. We therefore examined the neoplastic yield of EGD in the national VA Healthcare System, and combined the use of automated datasets with that of structured reviews of electronic medical records (EMR). Methods We identified patients with GERD first recorded in national VA outpatient administrative datasets during 2004-2009, and ascertained the performance of an EGD within the first year post- GERD index date. We calculated the proportions of patients with esophageal cancer (ICD-9 codes 150.0-150.5, 150.8-150.9, 230.1) or gastric cancer (codes 151.0-151.6, 151.8-151.9, 209.23, 230.2) among those who underwent "screening" EGD. We excluded patients with conditions prompting a surveillance or diagnostic EGD including Barrett's esophagus, upper GI neoplasms, abdominal surgery, decompensated liver disease, GI bleeding, anemia, celiac disease or metastatic cancer within 5 years preceding the GERD index date. Structured EMR reviews were then used to verify all GE neoplasms and classify them as Esophageal Cancer (EC), Gastric Cancer (GC), or other neoplasia in the upper GI tract. We calculated the true yield of GE neoplasia and examined the validity of the diagnostic codes. Results We identified 499,073 patients with GERD, 77,090 had a screening EGD and of whom 823 patients had codes for esophageal or gastric neoplasia and 625 (8.1/1000) had one or more of these neoplasms verified by chart validation. The codes for either EC or GC had a modest positive predictive value for the presence of these respective cancers.
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AGA Abstracts
AGA Abstracts
better with impedance-detected reflux episodes than with esophageal acid exposure time. Thus, impedance-pH should be considered as a more accurate tool to define the relationship between gastric aspiration and GER in this particular cohort of patients. Table. Correlation between AET, impedance-detected reflux episodes, presence and concentration of pepsin and BAs in saliva and BAL
AGA Abstracts
the PpH thresholds among patients with normal vs. abnormal total DAE (Table). There were also no differences in PR events when comparing DAE in the upright or supine positions. (Table) In the analysis of individual PR events, patients with normal total DAE had a lower frequency of PR with corresponding esophageal reflux (PR+ER+) (31% vs. 57.3% p=0.002) and a higher frequency of isolated PR events (PR+ER-) (69% vs. 42.7%, p= 0.002) compared to the abnormal total DAE group (Figure 1). Conclusions: DAE does not predict the presence of PR in 40% of patients with suspected extra-esophageal GERD largely due to PR episodes that occur in the absence of corresponding measurable ER events. Further studies are required to determine if these isolated PR events represent artifacts of PpH testing (i.e. pseudo-reflux) or true PR episodes of aerosolized reflux that cannot be detected using traditional EpH testing. (Table) Pharyngeal Reflux Episodes Based Upon Distal Esophageal Acid Parameters
Data median (IQR) other than when indicated Tu1776 The Risk of Dental Erosion in GERD Patients As Measured by the Basic Erosive Wear Examination Kristi Erickson, Nicholas J. Shaheen, Terry Donovan, Evan S. Dellon, Ryan D. Madanick Background and aims: While symptoms and complications from gastroesophageal reflux disease (GERD) such as heartburn, esophageal stricture, bleeding, and Barrett's esophagus are commonly known, dental complications of GERD may go unrecognized. The prevalence of dental erosion in subjects with GERD is poorly described. The aim of this study was to determine the risk of dental erosion in a population diagnosed with GERD. The association between dental erosion and salivary flow, salivary buffering capacity and dietary acidic challenges was also assessed. Methods: Subjects were recruited from The University of North Carolina's Center for Esophageal Disease and Swallowing with a physician diagnosis of GERD, and typical symptoms of heartburn and regurgitation. Subjects received a basic dental exam using the Basic Erosive Wear Exam (BEWE, table); the general population has about a 10% prevalence of erosive wear. Subjects provided a stimulated salivary sample which was used to determine their stimulated salivary flow rate and salivary buffering capacity. A diet diary was given to the subjects to complete for 4 days which was used to calculate daily average acidic challenges. Xerostomia was defined as a flow rate less than 0.1mL/minute. Salivary flow was considered low risk if flow rate was between 0.7-0.1 mL/ minute. Salivary buffering was considered high risk if pH was below 4.0. while the risk was considered moderate if pH was between 4.0-4.9. Simple percentages are reported. Results: To date, 22 GERD subjects (13 female, 9 male) have been enrolled. Of these, 41% have moderate erosive wear (BEWE cumulative score 9-13), 50% have low erosive wear (BEWE score 3-8), and 9% show no erosive wear (BEWE score 0-2) Stimulated salivary flow rate was normal for 77% of the subjects, low for 18.5% and 4.5% of the subjects had xerostomia. Salivary buffering capacity was normal for 46% of the subjects while, 36% were at high risk and 18% of the subjects were at moderate risk. Dietary acidic challenges were low for 50% of the subjects, moderate for 35.7% and high for 14.3%. Conclusion: A high proportion of subjects with GERD show erosive wear of their teeth. Inadequate salivary flow or buffering capacity may in part explain this defect. BEWE Criteria for Grading Erosive Wear
Fig 1: Types of Pharyngeal Reflux (PR) events (with and without preceding Esophageal Reflux) in patients with normal and abnormal Distal Acid Exposure (DAE) Tu1778
Tu1777
Impedance Baseline Measurement Enhances the Sensitivity of Impedance-pH Monitoring in Patients With Suspected GERD-Related Chronic Cough Mentore Ribolsi, Paola Balestrieri, Antonio Fiacco, Sara Emerenziani, Michele Cicala
Impact of pH Testing in Patients With Extra-Esophageal GERD Symptoms: Does Distal Esophageal Acid Exposure Predict Pharyngeal Reflux? Swapna B. Reddy, M. Mazen Jamal, Robert H. Lee
Background and Aim: Although gastro-esophageal reflux disease (GERD) is thought to be a common cause of chronic cough (CC), upper endoscopy and pH monitoring are often in the normal range in CC patients. In these patients, it has been demonstrated that an empiric PPI trial is more cost-effective than pH-monitoring in diagnosing GERD but few data are available concerning the diagnostic yield of impedance-pH (MI-pH) variables and pattern of reflux when compared to those in patients with typical symptoms (TS). Impedance baseline (IB) could be related to epithelial integrity, is strictly correlated to the acid exposure time (AET) and may increase the sensitivity of MI-pH monitoring. Methods: Of consecutive non-smokers CC patients not showing erosive esophagitis, 34 (F 16; mean age 41 yrs) underwent, following a 3-weeks pharmacological washout, ambulatory MI-pH. Subsequently, all patients received a double dose of PPI treatment for at least 4 weeks. Patients filled out a structurized questionnaire (Fisman Cough Severity - Frequency Scores) before and following PPI treatment and were defined as non-responder if showing ,50% of symptom improvement from treatment. In addition to classical parameters, impedance baseline (IB) at 5cm above LES was also calculated, in a time-window of 1h, and was defined pathological if ,1944 V, according to previously published data. MI-pH findings were compared to those obtained in 55 non erosive reflux disease patients with TS responding to PPIs (F 31; mean age 44 yrs). Data are expressed as median and 25th-75th percentile values. Results: MI-pH findings are shown in Table. CC patients showed a higher frequency of reflux episodes and a higher proportion of mixed refluxes compared to TS patients (p ,0.05). Among CC patients, 16 (47%) were non-responders and 18 (53%) responders to PPIs. 16/34 (47%) CC patients and 24/55 (44%) patients with TS presented a pathological AET. IB was pathological in 10/ 16 non responder and in 10/18 responder CC patients. Of the 16 CC patients with a pathological AET, 9 (56%) also presented a pathological IB. When considering IB values in
Background/Aims: A common dilemma in the evaluation of extra-esophageal GERD is the choice between Esophageal pH (EpH) testing that measures Distal Acid Exposure (DAE) or Pharyngeal pH testing (PpH) that tracks Pharyngeal Reflux (PR) events. The aims of this prospective cross sectional study were: 1) To determine the prevalence of abnormal EpH and PpH studies in patients with high Reflux Symptom Index (RSI) scores 2) To determine if parameters on EpH predict the degree of PR on PpH 3) To compare the correlation between individual PR and Esophageal Reflux (ER) events among patients with normal vs. abnormal DAE. Methods: Patients with suspected Extra-Esophageal GERD (40% cough, 24% sore throat, 20% dysphonia, 12% throat-clearing, 4% globus) and RSI scores of . 7 underwent simultaneous 48-hour EpH (BRAVO, Given Imaging) and PpH (Dx-pH, Restech) while off of PPI. A positive EpH test was defined as a DAE . 5.5% at pH , 4. A positive PpH test was defined using the traditional criteria of ≥ 1 PR event (pH,4) occurring within 24-hrs. The number of PR events at the traditional PpH threshold of , 4 along with pH 5.0 and 5.5 were compared based upon Total, Upright and Supine DAE using the Wilcoxon Rank Sum test. Individual PR events were also analyzed for temporal correlation with ER events. PR that occurred within 5 minutes of a preceding ER event was considered to be a PR episode with corresponding esophageal reflux (PR+ER+) whereas PR occurring in the absence of ER in that time window was considered to be an isolated PR event (PR+ER-). The frequencies of PR+ER+ and PR+ER- episodes were compared in patients with normal vs. abnormal total DAE using chi-square. Results: A total of 25 patients (age 53.8, 88% male, BMI 27.8, 40% with Hiatal Hernia, RSI 26.5) were studied. 32% were EpH and PpH positive, 20% EpH positive/PpH negative, 40% EpH negative/PpH positive, and 25% EpH negative/PpH negative. There was no difference in the number of PR events using any of
AGA Abstracts
S-842