A Retrospective Chart Review on Outcomes after Impedance-pH Monitoring (MII-pH) in Patients with Non-acid Reflux Disease

Abstract

Purpose: Proton pump inhibitors (PPIs) are known to be effective treatment for gastro-esophageal reflux disease (GERD). There are a number of patients, however, who continue to have symptoms despite the use of PPI therapy. Impedance-pH monitoring (MII-pH) can be performed to rule in or out non-acid reflux (NAR) as the etiology of these symptoms. There is limited data available on the management of these cases. The objective of this study was to evaluate patient characteristics and management outcomes in those patients diagnosed with NAR and positive symptom association. Methods: This was a retrospective chart review of patients who underwent M II- pH testing for symptoms refractory to PPI therapy at our institution. Patient characteristics and treatment outcomes were evaluated for those specifically associated with a positive Symptom Index (SI) for non-acid reflux events (SI score ≥ 50%). Results: Of 140 MII-pH studies reviewed, 23 patients were found to have + SI score for NAR with an abnormal total number of reflux episodes (15%). All patients were considered to have “refractory GERD,” and had been treated with PPI therapy (10 QD dosing and 13 BID dosing). Two patients had previous Nissen fundoplications and were being evaluated for increasing symptoms. There were 15 female and eight male patients, with a mean age of 60 years and mean BMI of 27. Primary symptoms for which the studies were done included: heartburn, cough, and regurgitation. High-resolution manometry revealed decreased distal esophageal amplitude peristalsis in eight patients. Hiatal hernias were noted in 13 patients, and no patients had esophagitis on endoscopy. Two patients were treated with visceral pain modulators, with improvement in symptoms. Five patients were referred for surgical fundoplication and two for surgical revision with reported improvement in their symptoms noted 6-12 months post-operatively. Fifteen patients remained on PPI, six in conjunction with antidepressants. A third of these patients were able to be contacted on a follow-up phone interview, and all of them reported that their symptoms continued. One patient was placed on baclofen, but ultimately underwent surgical fundoplication. Conclusion: Treatment of patients with symptomatic reflux symptoms associated with NAR remains limited. Most patients in this study were kept on PPIs with no resolution of symptoms. Continuing the PPI appeared insufficient for these patients. Anti-reflux surgery may be an option in well selected patients. MII-pH testing will help determine the best strategy of treatment in these patients.