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Tu1803 Dysphagia Post-Fundoplication Evaluated With High-Resolution Manometry (HRM). The Relevance of a Dual High-Pressure Zone
AGA Abstracts
Forty-six subjects had biopsy to "rule out EoE"; 29 (63%) of these had normal WEPM. The maximum eos/hpf ranged between 1 and 75 with 19 patients having between 1-15 eos/hpf (mean ± sd: 4.5 ± 4.5) and 6 having .15 eos/hpf (mean ± sd: 41.3 ± 21.3). Of these, 2 patients, 4.3% (95% CI: 0.5, 14.8%) proved to have EoE and one had eosinophilic gastroenteritis with eosinophilic esophagitis. These 46 patients were significantly younger, more commonly female, more likely to have dysphagia, less likely to have abnormal EGD, BE, subepithelial tissue and lamina propia fibrosis than patients who had EB done for other reasons. Patients with abnormal WEPM were significantly more likely to have basal cell hyperplasia (57% vs. 23%; p=0.004). Abnormal histology was significantly more common in patients with abnormal WEPM than in those with normal WEPM (73% vs. 44%; p=0.011). Patients with abnormal histology were more likely to have heartburn and/or regurgitation than those with normal histology (p=0.019). CONCLUSION: Nearly 45% of patients with normal pH study have histologic findings that may affect patient management. EoE is an uncommon finding in patients undergoing WEPM for evaluation of atypical or refractory gastroesophageal reflux symptoms.
Tu1804 Postprandial Reflux Patterns Are Helpful in Categorizing NERD Patients and Can Be Used to Distinguish Them Patients From Those With Functional Heartburn and Healthy Volunteers Manuele Furnari, Alessandro Moscatelli, Elisa Marabotto, Nicola de Bortoli, Luca Bruzzone, Lorenzo Gemignani, Patrizia Zentilin, Vincenzo Savarino, Edoardo Savarino Background and aim : Esophageal 24h impedance-pH (Imp-pH) is the current gold standard to diagnose gastroesophageal reflux disease (GERD) and to characterize the different subgroups included in the definition of non-erosive reflux disease (NERD), patients with abnormal acid exposure time (AET) defined as TRUE NERD and those with normal AET and positive symptom association probability (SAP) or symptom index (SI) defined as hypersensitive esophagus (HE), as well as to exclude subjects with functional heartburn (FH) characterized by a normal AET and negative SAP/SI. Previous studies highlighted the role of impedance-pH over the 24-hour period, while no data exist on the differences between HVs, FH and NERD patients in the postprandial period. We aimed to assess whether post-prandial refluxate may be helpful in further categorizing subjects suffering from NERD. Material and methods : We analyzed data from 52 patients with FH [35F; median age 50 yrs (range 18-74)], 112 [74F; 45.5 yrs (25-77)] with HE, 86 with TRUE NERD [28F; 49.5 yrs (25-70)] patients. Moreover, we enrolled 30 HVs [8F; 25 yrs (22-69)] for comparison. All patients underwent upper endoscopy, esophageal manometry and Imp-pH study offtherapy. During the 24-hour study, patients and HVs ate three standard meals as already reported. We measured total % time ,pH4, median bolus clearance time (MBCT), mean acid clearance time (MACT), median number of acid and non-acid refluxes during the first post-prandial hour for each meal. Results : Overall our patients had a similar frequency (p= ns) of hiatal hernia (16%, 25%, 24% and 27%, respectively). During the postprandial period, subjects with abnormal AET had higher values of all the parameters evaluated compared to the other study groups (p,0.001). Moreover, AET, MACT, number of total and acid refluxes were higher in subjects with HE compared to those with FH (p ,0.05). Although FH showed higher number of total refluxes than HVs (p ,0.5), all the other parameters were similar. Conclusions : The analysis of the three postprandial hours using Imp-pH seems to be helpful in categorizing patients with NERD and distinguishing those with GERD from those with FH and HVs.
Tu1803 Dysphagia Post-Fundoplication Evaluated With High-Resolution Manometry (HRM). The Relevance of a Dual High-Pressure Zone Etsuro Yazaki, Yu Tien Wang, Jafar Jafari, Asma Fikree, Nora Schaub, Rami Sweis, Emily Tucker, Kevin R. Knowles, Jeff Wright, Katharine Hamlett, Ian Beckingham, Mark R. Fox, Daniel Sifrim
Values are expressed as median and 25th - 75th percentiles.
Background Recent studies using HRM have reported that a dual high-pressure zone (HPZ) at the esophago-gastric junction (EGJ) is a sign of failed fundoplication. It is proposed that the dual HPZ is due to either slipped wrap or intra-thoracic fundoplication. Post-operative patients with a dual HPZ can present with recurrent reflux symptoms or dysphagia. Integrated relaxation pressure (IRP) is the currently accepted parameter that best describes EGJ relaxation during wet-swallows. The IRP was not specifically designed to assess dysphagia after antireflux surgery. The aim of this retrospective analysis was to assess pressure patterns that can underlie dysphagia in post-fundoplication patients with a dual HPZ using HRM. Methods: Six patients with dysphagia and double HPZ, who had laparoscopic fundoplication at least 6 months before investigations, were included. Patients underwent HRM and 24h MII-pH. At HRM, standard 10 wet-swallows (WS) of 5ml water were performed followed by multiple rapid 3ml swallows (MRS), 200ml rapid swallows (200RS) and solid swallowing (SS). IRP was calculated after single WS, MRS, 200RS and SS. The intrabolus pressure within the 2 pressure bands of the dual HPZ was measured from the deceleration point for 10 seconds. Results: In these patients with postoperative dysphagia and dual HPZ, the IRP was not higher than 15 mm Hg (considered as cut off value for wet swallows by the Chicago classification). IRP was 8.65±6.17 mmHg after single wet swallows, 5.75±5.15 mmHg during 3ml multiple rapid swallows, 4.62±4.56 mm Hg during the 200mL and 10.12±2.92, mmHg during solid swallows. Similarly, the intrabolus pressure within the 2 pressure bands was low for WS (7.01±4.42 mmHg), during 3 ml MRS (7.12±5.96mmHg) and 200 ml MRS (6.17±7.75 mmHg). However, this pressure was significantly higher during solid swallows 25.41±17.87 (p= 0.03). Furthermore, solid swallows with high intrabolus pressure within the dual HPZ were more often symptomatic compared to WS or 200RS Conclusion: In GERD patients with dysphagia after fundoplication surgery, a distal outflow obstruction might not be evident as an alteration in IRP measurements during liquid single or multiple swallows. However, a solid swallow-induced increase in pressure within a dual HPZ can objectively demonstrate the mechanical obstruction and the cause of symptoms.
AGA Abstracts
Tu1805 Different Accuracy of Various Impedance-pH Normal Values in Diagnosing GERD in Patients With Proven Reflux Disease Edoardo Savarino, Nicola de Bortoli, Manuele Furnari, Daniel Pohl, Patrizia Zentilin, Elisa Marabotto, Francesca Galeazzi, Giacomo C. Sturniolo, Santino Marchi, Radu Tutuian, Vincenzo Savarino Introduction: Since the introduction of impedance-pH monitoring in clinical practice different normal values have been proposed in order to diagnose gastro-esophageal reflux disease (GERD). The most common used [i.e. the United States (US), Belgian-French (BF) and Italian (ITA) normal values] have different upper limit of normal for esophageal acid exposure time (AET) and number of reflux episodes (NRE), the two main parameters used to distinguish normal from abnormal GER. Aim: To evaluate if using different normal values influences the final impedance-pH diagnosis of GERD in a multicenter setting. Methods: In this multicenter study, 40 consecutive patients reporting heartburn and regurgitation with proven reflux disease (i.e. n=20 with erosive esophagitis) or strong evidence of GERD [n=20 with positive proton pump inhibitor (PPI) test] underwent 24-h impedance-pH testing off-therapy (PPI stopped .14 days before). Twenty patients ate a standardized Mediterranean diet, while 20 patients were asked to follow a free diet. We evaluated distal AET (% time pH ,4), number of total and proximal reflux episodes, symptom association analysis using symptom association probability (SAP + if ≥95%) and symptom index (SI + if ≥50%). GERD was diagnosed in case of abnormal AET or increased total NRE according to the different normal values. Results: Patients undergoing impedance-pH using a Mediterranean diet (7F/13M; mean age 44) had similar reflux features in terms of mean AET [5.1 (3.1-5.2) vs. 4.6 (3.15.3), p=ns], median NRE [60 (39-77) vs. 52 (35-68), p=ns] and proximal reflux events [32 (14-63) vs. 23 (11-58), p=ns] compared to patients with free-diet (12F/8M; mean age 48). Moreover, no differences were found regarding the frequency of patients with abnormal values of AET, NRE, proximal reflux events and positive symptom association analysis (Table). As to the GERD diagnosis, it was diagnosed in 15 (38%) patients using US values, in 17 (43%) patients using BF values and in 30 (75%) patients using ITA values (US vs. ITA p=0.001; US vs. BF p=0.820 and ITA vs. BF p=0.006). Conclusion: The use of a
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Forty-six subjects had biopsy to "rule out EoE"; 29 (63%) of these had normal WEPM. The maximum eos/hpf ranged between 1 and 75 with 19 patients having between 1-15 eos/hpf (mean ± sd: 4.5 ± 4.5) and 6 having .15 eos/hpf (mean ± sd: 41.3 ± 21.3). Of these, 2 patients, 4.3% (95% CI: 0.5, 14.8%) proved to have EoE and one had eosinophilic gastroenteritis with eosinophilic esophagitis. These 46 patients were significantly younger, more commonly female, more likely to have dysphagia, less likely to have abnormal EGD, BE, subepithelial tissue and lamina propia fibrosis than patients who had EB done for other reasons. Patients with abnormal WEPM were significantly more likely to have basal cell hyperplasia (57% vs. 23%; p=0.004). Abnormal histology was significantly more common in patients with abnormal WEPM than in those with normal WEPM (73% vs. 44%; p=0.011). Patients with abnormal histology were more likely to have heartburn and/or regurgitation than those with normal histology (p=0.019). CONCLUSION: Nearly 45% of patients with normal pH study have histologic findings that may affect patient management. EoE is an uncommon finding in patients undergoing WEPM for evaluation of atypical or refractory gastroesophageal reflux symptoms.
Tu1804 Postprandial Reflux Patterns Are Helpful in Categorizing NERD Patients and Can Be Used to Distinguish Them Patients From Those With Functional Heartburn and Healthy Volunteers Manuele Furnari, Alessandro Moscatelli, Elisa Marabotto, Nicola de Bortoli, Luca Bruzzone, Lorenzo Gemignani, Patrizia Zentilin, Vincenzo Savarino, Edoardo Savarino Background and aim : Esophageal 24h impedance-pH (Imp-pH) is the current gold standard to diagnose gastroesophageal reflux disease (GERD) and to characterize the different subgroups included in the definition of non-erosive reflux disease (NERD), patients with abnormal acid exposure time (AET) defined as TRUE NERD and those with normal AET and positive symptom association probability (SAP) or symptom index (SI) defined as hypersensitive esophagus (HE), as well as to exclude subjects with functional heartburn (FH) characterized by a normal AET and negative SAP/SI. Previous studies highlighted the role of impedance-pH over the 24-hour period, while no data exist on the differences between HVs, FH and NERD patients in the postprandial period. We aimed to assess whether post-prandial refluxate may be helpful in further categorizing subjects suffering from NERD. Material and methods : We analyzed data from 52 patients with FH [35F; median age 50 yrs (range 18-74)], 112 [74F; 45.5 yrs (25-77)] with HE, 86 with TRUE NERD [28F; 49.5 yrs (25-70)] patients. Moreover, we enrolled 30 HVs [8F; 25 yrs (22-69)] for comparison. All patients underwent upper endoscopy, esophageal manometry and Imp-pH study offtherapy. During the 24-hour study, patients and HVs ate three standard meals as already reported. We measured total % time ,pH4, median bolus clearance time (MBCT), mean acid clearance time (MACT), median number of acid and non-acid refluxes during the first post-prandial hour for each meal. Results : Overall our patients had a similar frequency (p= ns) of hiatal hernia (16%, 25%, 24% and 27%, respectively). During the postprandial period, subjects with abnormal AET had higher values of all the parameters evaluated compared to the other study groups (p,0.001). Moreover, AET, MACT, number of total and acid refluxes were higher in subjects with HE compared to those with FH (p ,0.05). Although FH showed higher number of total refluxes than HVs (p ,0.5), all the other parameters were similar. Conclusions : The analysis of the three postprandial hours using Imp-pH seems to be helpful in categorizing patients with NERD and distinguishing those with GERD from those with FH and HVs.
Tu1803 Dysphagia Post-Fundoplication Evaluated With High-Resolution Manometry (HRM). The Relevance of a Dual High-Pressure Zone Etsuro Yazaki, Yu Tien Wang, Jafar Jafari, Asma Fikree, Nora Schaub, Rami Sweis, Emily Tucker, Kevin R. Knowles, Jeff Wright, Katharine Hamlett, Ian Beckingham, Mark R. Fox, Daniel Sifrim
Values are expressed as median and 25th - 75th percentiles.
Background Recent studies using HRM have reported that a dual high-pressure zone (HPZ) at the esophago-gastric junction (EGJ) is a sign of failed fundoplication. It is proposed that the dual HPZ is due to either slipped wrap or intra-thoracic fundoplication. Post-operative patients with a dual HPZ can present with recurrent reflux symptoms or dysphagia. Integrated relaxation pressure (IRP) is the currently accepted parameter that best describes EGJ relaxation during wet-swallows. The IRP was not specifically designed to assess dysphagia after antireflux surgery. The aim of this retrospective analysis was to assess pressure patterns that can underlie dysphagia in post-fundoplication patients with a dual HPZ using HRM. Methods: Six patients with dysphagia and double HPZ, who had laparoscopic fundoplication at least 6 months before investigations, were included. Patients underwent HRM and 24h MII-pH. At HRM, standard 10 wet-swallows (WS) of 5ml water were performed followed by multiple rapid 3ml swallows (MRS), 200ml rapid swallows (200RS) and solid swallowing (SS). IRP was calculated after single WS, MRS, 200RS and SS. The intrabolus pressure within the 2 pressure bands of the dual HPZ was measured from the deceleration point for 10 seconds. Results: In these patients with postoperative dysphagia and dual HPZ, the IRP was not higher than 15 mm Hg (considered as cut off value for wet swallows by the Chicago classification). IRP was 8.65±6.17 mmHg after single wet swallows, 5.75±5.15 mmHg during 3ml multiple rapid swallows, 4.62±4.56 mm Hg during the 200mL and 10.12±2.92, mmHg during solid swallows. Similarly, the intrabolus pressure within the 2 pressure bands was low for WS (7.01±4.42 mmHg), during 3 ml MRS (7.12±5.96mmHg) and 200 ml MRS (6.17±7.75 mmHg). However, this pressure was significantly higher during solid swallows 25.41±17.87 (p= 0.03). Furthermore, solid swallows with high intrabolus pressure within the dual HPZ were more often symptomatic compared to WS or 200RS Conclusion: In GERD patients with dysphagia after fundoplication surgery, a distal outflow obstruction might not be evident as an alteration in IRP measurements during liquid single or multiple swallows. However, a solid swallow-induced increase in pressure within a dual HPZ can objectively demonstrate the mechanical obstruction and the cause of symptoms.
AGA Abstracts
Tu1805 Different Accuracy of Various Impedance-pH Normal Values in Diagnosing GERD in Patients With Proven Reflux Disease Edoardo Savarino, Nicola de Bortoli, Manuele Furnari, Daniel Pohl, Patrizia Zentilin, Elisa Marabotto, Francesca Galeazzi, Giacomo C. Sturniolo, Santino Marchi, Radu Tutuian, Vincenzo Savarino Introduction: Since the introduction of impedance-pH monitoring in clinical practice different normal values have been proposed in order to diagnose gastro-esophageal reflux disease (GERD). The most common used [i.e. the United States (US), Belgian-French (BF) and Italian (ITA) normal values] have different upper limit of normal for esophageal acid exposure time (AET) and number of reflux episodes (NRE), the two main parameters used to distinguish normal from abnormal GER. Aim: To evaluate if using different normal values influences the final impedance-pH diagnosis of GERD in a multicenter setting. Methods: In this multicenter study, 40 consecutive patients reporting heartburn and regurgitation with proven reflux disease (i.e. n=20 with erosive esophagitis) or strong evidence of GERD [n=20 with positive proton pump inhibitor (PPI) test] underwent 24-h impedance-pH testing off-therapy (PPI stopped .14 days before). Twenty patients ate a standardized Mediterranean diet, while 20 patients were asked to follow a free diet. We evaluated distal AET (% time pH ,4), number of total and proximal reflux episodes, symptom association analysis using symptom association probability (SAP + if ≥95%) and symptom index (SI + if ≥50%). GERD was diagnosed in case of abnormal AET or increased total NRE according to the different normal values. Results: Patients undergoing impedance-pH using a Mediterranean diet (7F/13M; mean age 44) had similar reflux features in terms of mean AET [5.1 (3.1-5.2) vs. 4.6 (3.15.3), p=ns], median NRE [60 (39-77) vs. 52 (35-68), p=ns] and proximal reflux events [32 (14-63) vs. 23 (11-58), p=ns] compared to patients with free-diet (12F/8M; mean age 48). Moreover, no differences were found regarding the frequency of patients with abnormal values of AET, NRE, proximal reflux events and positive symptom association analysis (Table). As to the GERD diagnosis, it was diagnosed in 15 (38%) patients using US values, in 17 (43%) patients using BF values and in 30 (75%) patients using ITA values (US vs. ITA p=0.001; US vs. BF p=0.820 and ITA vs. BF p=0.006). Conclusion: The use of a
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