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Resumen La enfermedad por reflujo gastroesofágico (ERGE) se define como el tránsito anormal del contenido gástrico hacia el esófago, que se da por una alteración de la barrera antirreflujo, causando síntomas o complicaciones. Para su correcto diagnóstico y abordaje terapéutico, se requiere de la integración de hallazgos clínicos, endoscópicos y monitorización del pH esofágico en 24 horas con o sin impedanciometría, la cual debe ser realizada con especificaciones técnicas, y su interpretación debe basarse en la mejor evidencia clínica disponible, con el objetivo de tener diagnósticos precisos que permitan tomar las mejores decisiones con los pacientes. Recientemente, en el Consenso de Lyon se han incorporado nuevas directrices para el diagnóstico de ERGE por monitorización de pH esofágico, las cuales se revisan en este artículo.
Abstract Gastroesophageal reflux disease (GERD) is defined as the abnormal transit of gastric contents into the esophagus. It is caused by an alteration of the anti-reflux barrier, causing multiple symptoms or complications. In order to achieve accurate diagnosis and proper therapeutic approach, integration of clinical findings, endoscopic findings and 24-hour esophageal pH monitoring, with or without impedancometry, is required. These tests must be performed following technical specifications and their interpretation must be based on the best clinical evidence available to obtain accurate diagnoses that allow making the best decisions to the benefit of patients. Recently, the Lyon Consensus incorporated new guidelines for the diagnosis of GERD by esophageal pH monitoring, which are reviewed in this paper.
Subject(s)
Humans , Male , Female , Therapeutics , Gastroesophageal Reflux , Electric Impedance , Esophageal pH Monitoring , DiseaseABSTRACT
Objective:To analyze the difference and clinical significance of reflux related parameters between patients with reflux asthma (RA) and typical gastroesophageal reflux disease (TGERD).Methods:From June 2017 to June 2020, at PLA Rocket Force Characteristic Medical Center, the clinical data of 120 patients with gastroesophageal reflux disease (GERD) who underwent gastroscopy, high-resolution esophageal manometry (HREM) and 24 h pH-impedance monitoring contemporaneously were retrospectively analyzed. The GERD patients were divided into RA group and TGERD group according to the symptom correlated indexes, 60 cases in each group. The reflux related indexes of two groups were compared, which included reflux esophagitis (RE) score, esophageal hiatal hernia, Hill grade score of gastroesophageal flap valve, upper esophageal sphincter (UES) pressure, DeMeester score, and reflux episodes. Mann-Whitney U test and chi-square test were used for statistical analysis. Results:There were no significant differences in RE score and Hill grade score between TGERD group and RA group (0.0, 0.0 to 1.0 vs. 0.0, 0.0 to 1.8; 3.0, 2.0 to 3.0 vs. 3.0, 2.0 to 3.0) (both P>0.05). The detection rate of UES pressure less than 34 mmHg (1 mmHg=0.133 kPa) of RA group was higher than that of TGERD group (41.7%, 25/60 vs. 23.3%, 14/60), and the difference was statistically significant ( χ2=4.596, P=0.032). The UES pressure of RA group was lower than that of TGERD group (51.7 mmHg, 23.6 mmHg to 70.1 mmHg vs. 62.0 mmHg, 37.4 mmHg to 77.4 mmHg), and the difference was statistically significant ( Z=-2.105, P=0.035). There were no significant differences in other parameters of HREM between TGERD group and RA group (all P>0.05). The detection rates of DeMeester score more than 14.7, acid exposure time more than 4.5% and total reflux episodes more than 73 episodes of RA group were all higher than those of TGERD group (41.7%, 25/60 vs. 23.3%, 14/60; 40.0%, 24/60 vs. 21.7%, 13/60; 38.3%, 23/60 vs. 20.0%, 12/60, respectively), and the differences were all statistically significant ( χ2=5.546, 4.728 and 4.881, all P<0.05). The total reflux episodes and weak acid gas reflux episodes of RA group were both higher than those of TGERD group (60 episodes, 43 episodes to 98 episodes vs. 52 episodes, 34 episodes to 69 episodes; 12 episodes, 6 episodes to 21 episodes vs. 9 episodes, 3 episodes to 14 episodes), and the differences were statistically significant ( Z=-2.323 and -2.053, both P<0.05). There were no significant differences in other parameters of 24 h pH-impedance monitoring between TGERD group and RA group (all P>0.05). Conclusion:Low UES pressure, abnormal esophageal acid exposure and increased reflux episodes, especially weak acid gas reflux episodes, may be more likely to induce RA.
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OBJECTIVE@#To analyze the differences in reflux patterns in 24-hour esophageal pH-impedance monitoring in patients with non-erosive reflux disease (NERD), reflux hypersensitivity (RH) and functional heartburn (FH) and explore the possible mechanism of symptoms in patients with heartburn and negative endoscopic findings.@*METHODS@#Seventy-nine patients with heartburn as the main symptoms but negative endoscopic findings, including 35 with NERD, 16 with RH and 28 with FH, were enrolled in this study.All the patients underwent 24-h esophageal pH-impedance monitoring and esophagogastroscopy, and the results were compared among the 3 groups.@*RESULTS@#Acid reflux episode was significantly increased and weakly alkaline reflux episode was significantly decreased in NERD group in comparison with RH group and FH group (@*CONCLUSIONS@#Patients with NERD, RH and FH had different reflux patterns.Acid reflux is predominant in the NERD, while weakly alkaline reflux is significantly increased RH and FH.In patients with normal esophageal acid exposure but without symptoms or without recorded symptoms during esophageal pH-impedance monitoring, analysis of the total reflux episode, mixed reflux episode, proximal acid reflux episode and percentage can help in the differential diagnosis between RH and FH.
Subject(s)
Humans , Electric Impedance , Esophageal pH Monitoring , Gastroesophageal Reflux/diagnosis , Heartburn/etiology , Hydrogen-Ion ConcentrationABSTRACT
Resumen Introducción y objetivos: el análisis de la impedancia basal nocturna media (IBNM) se ha propuesto para incrementar la precisión diagnóstica de enfermedad por reflujo erosiva (ERGE). Nuestro objetivo fue evaluar el rendimiento diagnóstico de esta prueba en un grupo de pacientes con ERGE conocida. Materiales y métodos: incluimos 123 individuos (58 con ERGE y 65 controles sanos) a quienes se les realizó pH-impedanciometría (pH-IMM) consecutiva entre enero de 2015 y junio de 2017. Todos los pacientes tenían endoscopia tomada en los 6 meses previos. El tiempo de exposición ácida (TEA) anormal (>4,2%) y la presencia de pirosis y/o regurgitación en los 6 meses previos fueron los criterios para el diagnóstico de ERGE. Se encontraron 58 pacientes con ERGE, 24 con enfermedad por reflujo erosiva (ERE) y 34 con enfermedad por reflujo no erosiva (ERNE). Los 65 restantes fueron controles sanos (CS) asintomáticos con EGD y pH-IMM normales. Todos los trazos de pH-IMM se reanalizaron para medir la IBNM por un segundo observador que desconocía los datos previos. El análisis estadístico incluyó pruebas múltiples de Bonferroni para comparar los grupos; regresión lineal para variables continuas; y análisis de curva ROC para buscar valor IBNM con mayor rendimiento. Para los diferentes parámetros de precisión diagnóstica se utilizó el punto de corte de la IBNM. Se usó significancia estadística con valor de p <0,01 e intervalos de confianza de 95% (IC 95%) para todos los cálculos. Resultados: los pacientes con ERE y ERNE presentaron valores de IBNM significativamente más bajos que el grupo control (p <0,01). Se observó una correlación negativa entre los valores de la IBNM y TEA (r = 0,59; p = <0,001), y también entre la IBNM y número de eventos de reflujo (r = 0,37; p = <0,001). En el análisis de curva ROC, el área bajo la curva de la IBNM fue de 0,941 (IC 95%: 0,894-0,987) y el punto de corte con mayor eficiencia 1102 ohms (sensibilidad 98,5%; especificidad 84,5%). Usando este valor (<1,102), la IBNM tuvo una sensibilidad para detectar ERGE de 91% (ERNE 86% y ERE 100%) y una especificidad de 98%. Conclusión: la IBNM tiene alta sensibilidad y especificidad para el diagnóstico de la ERGE. Adicionar esta prueba al análisis convencional de la pH-impedancia y a los métodos actuales de estudio de la ERGE puede mejorar significativamente nuestra capacidad para diagnosticar la enfermedad.
Abstract Introduction and Objectives: Analysis of nocturnal basal impedance (IBNM) has been proposed as a way to increase accuracy of GERD diagnosis. Our objective was to evaluate the diagnostic performance of this test in a group of patients known to have GERD. Materials and methods: We included 123 individuals: 58 with GERD and 65 healthy controls. They underwent consecutive pH-impedance monitoring between January 2015 and June 2017. All had undergone endoscopy in the 6 months prior to testing. Criteria used for diagnosis of GERD were abnormal acid exposure time (AET > 4.2%), pyrosis and/or regurgitation in the previous 6 months. We found 58 patients with GERD of whom 24 had erosive reflux disease (ERE) and 34 had non-erosive reflux disease (NERD). The remaining 65 were asymptomatic healthy controls with normal endoscopic results and pH impedance monitoring. A second observer who did not know the previous data measurements analyzed all pH impedance monitoring traces for IBMN. Statistical analysis included multiple Bonferroni tests for comparison between groups, linear regression for continuous variables, and receiver operating characteristic (ROC) curve analysis to find high performance IBNM values. The IBNM cutoff point was used for diagnostic precision parameters. Statistical significance was set at p <0.01, and 95% confidence intervals were used for all calculations. Results: IBNM measures were significantly lower for patients with ERE and NERD than for the control group (p <0.01). A negative correlation was observed between IBNM and acid exposure time values (r = 0.59, p = <0.001) and also between IBNM and number of reflux events (r = 0.37, p = <0.001). ROC curve analysis found that the area under the curve for IBNM was 0.941 (95% CI: 0.894-0.987), and the cutoff point with the highest efficiency was 1,102 ohms (sensitivity 98.5%, specificity 84.5%). Using this value (<1.102), the IBNM had a sensitivity for detecting GERD of 91% (NERD 86% and ERE 100%) and a specificity of 98%. Conclusion: IBNM has high sensitivity and specificity for diagnosis of GERD. Addition of this test to conventional pH-impedance analysis and current methods for studying GERD can significantly improve our ability to diagnose this disease.