Endoscopic Removal of Bravo® pH Probe: Report of Two Cases

Abstract

Introduction: The Bravo pH monitoring system is widely used to further investigate the patients with refractory or atypical GERD. The pH probe is attached by deploying a locking pin that is passed through the esophageal mucosa and pulled by appropriate suction into a small cup in the side of the probe. Subsequently, the probe sloughs spontaneously from the mucosa within 1-2 weeks and passes uneventfully through the GI tract. Most patients have no or mild symptoms while the probe is attached, but more severe chest pain, odynophagia, or dysphagia occurs in about 10% of patients. We report two rare cases of patients requiring endoscopic removal of Bravo pH probe. Case 1: 34 year-old female who presented with persistent heartburn despite maximal acid-suppressive therapy underwent endoscopic placement of Bravo pH probe at 6 cm proximal to GEJ. One hour after the procedure, the patient complained of significant chest pain at the site of Bravo pH monitoring probe and after 3 hours, the pain was persistent with no change in severity. Repeat endoscopy was performed. The Bravo pH probe was identified. A cold snare was placed around Bravo pH probe but was unsuccessful at removal. A hot snare was used and Bravo capsule probe was dislodged and advanced to stomach. Probe was snared and removed with endoscope via mouth. Patient's pain resolved immediately. Case 2: 37 year-old male who had persistent chronic mild-to-moderate heartburn even after treatment with maximal proton-pump inhibitor for appropriate duration underwent endoscopic placement of Bravo pH probe at 6 cm proximal to GEJ. However, due to technical difficulties, the probe did not register with the monitor. Subsequently, another EGD was performed and the Bravo pH probe was removed via hot snare, after cold snare was again unsuccessful, and removed via mouth. A second Bravo pH probe was placed successfully and was working properly. Discussion: Bravo pH probes may require removal in certain situations. These cases show that both cold and hot snare techniques are safe and simple endoscopic procedures for the removal of the Bravo pH probe. We recommend the cold snare method as a first option with the hot snare method in cases the former fails.