Reclassifying Functional Heartburn Using Impedance pH in Refractory GERD Patients

Abstract

Introduction: Background: Functional heartburn as a term has changed in meaning over the years. The most recent definition was introduced based upon Rome IV criteria, as typical heartburn symptoms in the presence of normal upper endoscopy findings (including normal biopsies), normal esophageal pH testing, and a negative association between symptoms and reflux events. Functional heartburn is very common, affecting women more than men. The majority of GERD patients respond to 4-8 weeks of proton-pump inhibitors therapy but up to 40% will demonstrate partial or complete lack of response. This defines the refractory group. 24 hr-impedance pH is the current gold standard for diagnosing all GERD types including acid and non-acid reflux. Symptom index is used as an adjunctive diagnostic tool to link symptoms to specific reflex events. Aim: The aim of the study is to review and reclassify functional heartburn patients using impedance pH.2767 Figure 1 No Caption available.Methods: Retrospective chart review of patient who continued to have GERD symptoms despite being on antisecretory therapy. We reviewed impedance pH studies for adult patients (>18 years old) between 2012-2018. Only patients with refractory symptoms were included. Data including esophageal acid exposure, number of reflux episodes (acids and non-acid), symptoms index and upper endoscopy findings (including esophageal biopsies) were collected. The data was reviewed and classified based on reflux events and symptom index. Cut off for abnormal of reflux episodes was 48, counting both acid and nonacid episodes. All patients were studied while on PPI therapy, once or twice a day. Results:Results 166 patients were included, 68% were females, mean age was 51±19 years, and 62% were on once daily PPI dosing.73% had positive symptom index (see figure). Conclusion: Patients with persistent GERD symptoms on PPI therapy represent a heterogenous group. Exclusively using pH esophageal monitoring, such as in the current functional heartburn classification, risks missing patients who's persistent symptoms are due to non-acid reflux.