Wireless oesophageal pH monitoring: establishing values in a multiracial cohort of asymptomatic Asian subjects.

BACKGROUND: Wireless oesophageal (Bravo) readings in healthy European and American subjects show varied results. Values in Asians remain unstudied. AIMS: We performed Bravo studies in healthy Asians to determine if values differed from previously published and identified reflux parameters to differentiate healthy volunteers from patients. METHODS: Fifty healthy volunteers were recruited between August 2009 and August 2011 to undergo 48 h wireless pH monitoring. Bravo capsule was introduced transorally and placed 6 cm above the squamocolumnar junction. Acid reflux parameters were compared against 41 patients previously evaluated for non-erosive reflux disease. RESULTS: Five volunteers were excluded. Capsule dislodgement occurred in four and three volunteers on study days 1 and 2 respectively. Forty and 37 volunteers (73% male, mean age 33.0 ± 7.6 years) had interpretable readings at 24 and 48 h, respectively. Percentage of time oesophageal pH<4 in 37 volunteers who completed 48 h recordings was 1.6% (7.5%), 1.5% (6.3%) and 1.9% (5.8%) on days 1, 2 and overall study duration, respectively. CONCLUSION: Bravo readings in Asians differed from previously published. Percentage of time oesophageal pH<4 on day 2 and DeMeester score on day 2 (95th percentile 22.9) best discriminated healthy volunteers from patients.

The diagnostic utility of narrow band imaging magnifying endoscopy in clinical practice in a population with intermediate gastric cancer risk.

OBJECTIVE: Narrow band imaging (NBI) and NBI-magnifying endoscopy (ME) have been reported to facilitate the diagnosis of intestinal metaplasia (IM) and early gastric cancer (EGC) in high-risk populations. This study aimed at comparing the detection rate of focal gastric lesions by NBI against white light endoscopy (WLE), and examined the utility of NBI-ME in differentiating gastric mucosal pathology in a population with intermediate gastric cancer risk. METHODS: Chinese patients aged 35-70 years undergoing diagnostic gastroscopy (GIF FQ260Z) by six experienced endoscopists were enrolled prospectively. The sequence of endoscopic evaluation was WLE followed by NBI. Focal lesions were re-examined by NBI-ME. The incremental diagnostic yield of NBI over WLE and ability of NBI-ME to differentiate gastric mucosal pathology were analyzed. RESULTS: Over a 30-month period, 458 patients (mean age: 52 years; men: 53.7%; Helicobacter pylori positive: 20.1%) were recruited. WLE detected a focal gastric lesion in 43.7% (200/458). WLE made a definitive diagnosis in 148 out of 200 patients (147 benign lesions and one gastric cancer), whereas NBI-ME correctly clarified the nature of the remaining 52 lesions (benign: 51; EGC: one). NBI detected an additional 69 out of 458 lesions (type 0_IIa: 91.3%; type 0_IIb: 8.7%) missed by WLE; the diagnoses based on NBI-ME were IM (67/69), EGC (1/69), and benign lesion (1/69). Interobserver agreement study revealed a κ statistic of 0.71. CONCLUSION: NBI detected IM missed by WLE. NBI-ME was useful in differentiating the pathology of focal gastric mucosal lesions.

Is impedance pH monitoring superior to the conventional 24-h pH meter in the evaluation of patients with laryngorespiratory symptoms suspected to be due to gastroesophageal reflux disease?

OBJECTIVE: Cough and laryngo-pharyngeal symptoms (LPS) are associated with gastroesophageal reflux disease (GERD). The role of acid reflux (AR) and non-acid reflux (NAR) in atypical GERD pathogenesis is controversial. The aims of the study were to determine the prevalence of high esophageal acid exposure time (AET) in patients presenting with cough or LPS and determine the incremental yield of multichannel intraluminal impedance-pH (MII-pH) monitoring. METHODS: We undertook a prospective study of patients with cough or LPS referred for GERD evaluation between January 2009 and May 2011. All patients underwent esophageal manometry, gastroscopy and MII-pH. Patients' characteristics, gastroscopy findings, distal esophageal AET, bolus exposure (BE) time and numbers of AR and NAR episodes in the proximal and distal esophagus were studied. RESULTS: Overall 50 patients (22 male, mean age 47.5 ± 14.2 years) were evaluated for unexplained chronic cough (n = 23, 46.0%), and LPS symptoms including globus (n = 10, 20.0%), sore throat (n = 12, 24.0%) and hoarse voice (n = 5, 10.0%). A normal gastroscopy, Los Angeles grade A and B esophagitis occurred in 44 (88.0%), 5 (10.0%) and 1 (2.0%) patient, respectively. Seven (14.0%) recorded elevated AET (chronic cough, 4; sore throat, 2; and hoarse voice, 1). Nine patients recorded abnormal impedance characteristics (raised BE time and/or increased reflux numbers) despite a normal AET leading to an incremental diagnostic yield of 18%. CONCLUSION: An isolated high AET is uncommon in patients with cough or LPS. Combined MII-pH improves the diagnostic yield in patients with atypical GERD manifestations.

Conscious awakenings are commonly associated with Acid reflux events in patients with gastroesophageal reflux disease.

BACKGROUND & AIMS: More than half of patients with gastroesophageal reflux disease (GERD) report heartburn that awakens them from sleep. We aimed to determine the frequency of conscious awakenings associated with acid reflux events during sleep and their relationship with symptoms in patients with GERD compared with normal subjects. METHODS: The study included 39 patients with heartburn and/or regurgitation at least 3 times each week and 9 healthy individuals as controls. Subjects underwent pH testing concomitantly with actigraphy. Novel software simultaneously integrated raw actigraphy and pH data matched by time to determine patients' conscious awakenings during sleep and their temporal relationship with acid reflux events and GERD-related symptoms. RESULTS: A total of 104 and 11 conscious awakenings were recorded in 89.7% of patients and 77.8% of normal controls, respectively. The mean number of conscious awakenings was significantly higher in the group with GERD compared with controls (3.0 ± 0.3 vs 1.8 ± 0.4, P < .05). Of the conscious awakenings, 51.9% (51/104) were associated with an acid reflux event in GERD patients and 0 in controls (P < .01). Only 16.3% of total conscious awakenings were symptomatic. In most of the conscious awakenings that were associated with an acid reflux event (85.6%), the awakening preceded the reflux event. CONCLUSIONS: Acid reflux events occur primarily after an awakening episode. Conscious awakenings from sleep are common among patients with GERD and are frequently associated with acid reflux events. However, conscious awakenings associated with reflux events are seldom symptomatic.

Review: treatment of gastroesophageal reflux disease in the elderly.

The prevalence of gastroesophageal reflux disease (GERD) increases with age; older patients are more likely to develop severe disease. Common symptoms of GERD in the elderly include dysphagia, vomiting, and respiratory problems. Older patients are more likely to require aggressive therapy, and usually their management is compounded by the presence of comorbidities and consumption of various medications. Proton pump inhibitors are the mainstay of GERD treatment in the elderly because of their profound and consistent acid suppressive effect. Overall, proton pump inhibitors seem to be safe for both short- and long-term therapy in elderly patients with GERD. Antireflux surgery may be safe and effective in a subset of elderly patients with GERD.

Gastroesophageal reflux disease.

GERD is a common chronic gastrointestinal disorder, and its prevalence in Asia is increasing. Classical symptoms of heartburn and regurgitation are common presentations. There is no standard criterion for the diagnosis of GERD, and 24-h pH monitoring lacks sensitivity in NERD. Furthermore, diagnostic studies for gastroesophageal reflux disease have several limitations. A short course of PPI is often used in clinical practice as a diagnostic test for gastroesophageal reflux disease. Elderly patients with GERD usually present with atypical manifestations, and they tend to develop more severe disease. PPI remains the mainstay of treatment for GERD. In a subset of patients who wish to discontinue maintenance treatment, anti-reflux surgery is a therapeutic option.

To Bravo or not? A comparison of wireless esophageal pH monitoring and conventional pH catheter to evaluate non-erosive gastroesophageal reflux disease in a multiracial Asian cohort.

OBJECTIVE: Non-erosive reflux disease (NERD) constitutes the majority of patients with gastroesophageal reflux disease (GERD). Esophageal pH monitoring is useful in distinguishing patients with NERD from functional heartburn. The gastroenterologist often faces the dilemma of choosing the most appropriate investigative modality. The wireless Bravo capsule allows prolonged 48 hour monitoring with improved patient tolerance, but concerns regarding its reduced sensitivity compared to conventional pH catheter have been raised. We compared the prevalence of high esophageal acid exposure and positive symptom correlation profiles (using the symptom index [SI] and symptom association probability [SAP]) in patients who underwent Bravo compared to patients who underwent conventional pH catheter, and evaluated the efficacy of Bravo monitoring in a multiracial Asian cohort. METHODS: Retrospective analysis of all pH studies performed between January 2004 and February 2009 for patients with persistent reflux symptoms and a normal gastroscopy. RESULTS: 66 (27 Male, 42.4 +/- 13.4 years) and 55 (24 Male, 47.1 +/- 13.3 years) patients underwent wireless and pH catheter evaluation respectively. "True NERD" (abnormal acid exposure) was diagnosed in 26 (39.4%) and 20 (36.4%) patients (pNS) while "acid-sensitive esophagus" (SI > or = 50% and/or SAP > or = 95%) occurred in 14 (21.2%) and 12 (21.8%) patients (pNS) using the wireless and pH catheter respectively. Extended recording time with Bravo led to an incremental diagnostic yield of 30%. CONCLUSION: The wireless capsule was well tolerated. The diagnostic yield was similar using both modalities. With the increasing availability of impedance-pH technology, it is uncertain if devices that detect only acid-reflux events will be surpassed.

Reassessment of the principal characteristics of gastroesophageal reflux during the recumbent period using integrated actigraphy-acquired information.

OBJECTIVES: Characterization of gastroesophageal reflux (GERD) events during the sleep period has been hampered by lack of any patient-friendly technique that allows accurate assessment of sleep duration and awakening time, without confining patients to a sleep laboratory. Our aim was to compare principal reflux characteristics during the upright, recumbent-awake, and recumbent-asleep periods as well as to determine the effect of sleep awakenings on the principal reflux characteristics of the recumbent-asleep period using novel technology that allows integration of recorded actigraphy data into collected pH information. METHODS: Patients with heartburn at least three times a week for the previous 3 months were invited to participate in this study. All participants were evaluated by the demographics and the GERD Symptom Checklist questionnaires. Thereafter, patients underwent ambulatory 24-h esophageal pH monitoring concomitantly with actigraphy. A novel technique was used to superimpose simultaneously recorded raw actigraphy data over pH data, resulting in more accurate information about reflux events during upright, recumbent-awake, recumbent-asleep, and conscious awakening periods as well as the relationship between symptoms and acid reflux events in the aforementioned periods. RESULTS: Thirty-nine subjects (M/F: 26/13, mean age 56.6+/-14 years) with an abnormal pH test were enrolled into the study. The recumbent period appeared heterogeneous and was clearly divided into recumbent-awake (123.0+/-20.2 min) and recumbent-asleep (485.6+/-23.6 min) periods. The percent total time pH<4, the mean number of acid reflux events, and the number of symptoms associated with reflux events were significantly greater in the recumbent-awake as compared with the recumbent-asleep period. The mean duration of an acid reflux event was not different among upright, recumbent-awake, and recumbent-asleep periods. However, short-duration reflux events during the sleep period were associated with conscious awakenings as compared with those during sleep (0.74+/-0.11 min vs. 1.64+/-0.3 min, P=0.01). CONCLUSIONS: The recumbent period is divided into recumbent-awake and recumbent-asleep periods. The recumbent-awake period has significantly different principal reflux characteristics than the recumbent-asleep period. Duration of an acid reflux event during the recumbent-asleep period is not uniformly prolonged. Short-duration acid reflux events during the sleep period are likely due to conscious awakenings.

Upper GI tract findings in patients with heartburn in whom proton pump inhibitor treatment failed versus those not receiving antireflux treatment.

BACKGROUND: Failure of proton pump inhibitor (PPI) treatment in patients with heartburn is very common. Because endoscopy is easily accessible, it is commonly used as the first evaluative tool in these patients. OBJECTIVE: To compare GERD-related endoscopic and histologic findings in patients with heartburn in whom once-daily PPI therapy failed versus those not receiving antireflux treatment. DESIGN: Cross-sectional study. SETTING: A Veterans Affairs hospital. PATIENTS: Heartburn patients from the GI outpatient clinic. INTERVENTION: Recording of endoscopic results. MAIN OUTCOME MEASUREMENTS: Endoscopic findings and association between PPI treatment failure and esophageal mucosal injury by using logistic regression models. RESULTS: A total of 105 subjects (mean age 54.7 +/- 15.7 years; 71 men, 34 women) were enrolled in the PPI treatment failure group and 91 (mean age 53.4 +/- 15.8 years; 68 men, 23 women) were enrolled in the no-treatment group (P = not significant). Anatomic findings during upper endoscopy were significantly more common in the no-treatment group compared with the PPI treatment failure group (55.2% vs 40.7%, respectively; P = .04). GERD-related findings were significantly more common in the no-treatment group compared with the PPI treatment failure group (erosive esophagitis: 30.8% vs 6.7%, respectively; P < .05). Eosinophilic esophagitis was found in only 0.9% of PPI treatment failure patients. PPI treatment failure was associated with a significantly decreased odds ratio of erosive esophagitis compared with no treatment, adjusted for age, sex, and body mass index (adjusted odds ratio 0.11; 95% CI, 0.04-0.30). CONCLUSIONS: Heartburn patients in whom once-daily PPI treatment failed demonstrated a paucity of GERD-related findings compared with those receiving no treatment. Eosinophilic esophagitis was uncommon in PPI therapy failure patients. Upper endoscopy seems to have a very low diagnostic yield in this patient population.

Gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS)--is it one disease or an overlap of two disorders?

Up to 79% of IBS patients report gastroesophageal reflux disease (GERD) symptoms, and up to 71% of GERD patients report irritable bowel syndrome (IBS) symptoms. There are two principal hypotheses for the common presence of IBS symptoms in GERD patients. The first theory suggests that GERD and IBS overlap in a significant number of patients. The second theory suggests that IBS-like symptoms are part of the spectrum of GERD manifestation. The first theory is supported by genetic studies and similarities in gastrointestinal sensory-motor abnormalities potentially due to general gastrointestinal disorder of smooth muscle or sensory afferents. The other theory is primarily supported by studies demonstrating improvement of IBS-like symptoms in GERD patients receiving anti-reflux treatment. The close relationship between GERD and IBS could be explained by either GERD affecting different levels of the GI tract or a high overlap rate between GERD and IBS due to similar underlying GI dysfunction.