Reply

Abstract

We thank Dr Furnari and colleagues for their interest in our paper.1Cheng F.K.F. et al.Clin Gastroenterol Hepatol. 2015; 13: 867-873Google Scholar They raise 2 excellent points for discussion. The first is in regards to categorizing nonerosive reflux disease based on normal endoscopic findings of esophageal mucosa and number of reflux episodes on 24-hour pH and impedance monitoring without taking into account symptom association analysis. We agree that the number of reflux episodes alone may be less than ideal to assess for nonerosive reflux disease. In fact, this is what prompted Johnson and DeMeester2Johnson L.F. et al.Am J Gastroenterol. 1974; 63: 325-332Google Scholar to develop a score that incorporates other parameters besides reflux episodes. Our study classification differs from Savarino et al3Savarino E. et al.Am J Gastroenterol. 2008; 103: 2685-2693Google Scholar in that we used the results of impedance testing early in the categorization of patients with reflux who had a normal 24-hour pH score and a normal endoscopy. This method focuses on the objective role of testing rather than reliance on patient symptoms, in which limitations exist in the accuracy of patient reporting. One study showed that patients do not report most of their symptoms during the 24-hour testing period.4Kavitt R.T. et al.Am J Gastroenterol. 2012; 107: 1826-1832Google Scholar Furthermore, both symptom index and symptom association probability may be overinterpreted in patients with gastroesophageal reflux disease with day to day variability.5Slaughter J.C. et al.Clin Gastroenterol Hepatol. 2011; 9: 868-874Google Scholar, 6Vela M.F. et al.Am J Gastroenol. 2013; 108: 1658-1659Google Scholar These indices are also primarily used to assess patients with gastroesophageal reflux disease, but not in those who fail to respond to proton pump inhibitors7Wiener G.J. et al.Am J Gastroenterol. 1988; 83: 358-361Google Scholar, 8Weusten V.L. et al.Gastroenterology. 1994; 107: 1741-1745Google Scholar and are suboptimal in predicting response to therapy as outcome.9Taghavi S.A. et al.Gut. 2005; 54: 1067-1071Google Scholar Finally, the only data evaluating response to surgery in proton pump inhibitor–nonresponders are uncontrolled,10Frazzoni M. et al.Surg Endosc. 2013; 27: 2940-2946Google Scholar and more high-quality outcome studies are needed. The second point is that an impedance cutoff value of 73 reflux episodes may overestimate the number of patients classified as hypersensitive esophagus or with functional symptoms. The 73 episodes as the cutoff value for reflux episodes is in accordance with the American College of Gastroenterology guidelines.11Hirano I. et al.Am J Gastroenterol. 2007; 102: 668-685Google Scholar In a Belgian-French study, the 95% of reflux episodes is 75, nearly identical to US studies.12Shay S. et al.Am J Gastroenterol. 2004; 99: 1037-1043Google Scholar, 13Tutuian R. et al.Gastroenterology. 2006; 130: A171Google Scholar, 14Moawad F.J. et al.Aliment Pharmacol Ther. 2013; 37: 1011-1018Google Scholar Furnari et al refer to an Italian study that demonstrated the 95% value as 54 reflux episodes in a cohort that may have been influenced by consuming a Mediterranean diet.15Zentilin P. et al.Dig Liver Dis. 2006; 38: 226-232Google Scholar Although we agree that a lower cutoff value may reduce the number of false-positive episodes during testing, further high-quality studies on normal impedance values need to be performed before uniformly standardizing a lower cutoff value. The other implication is patients without acid reflux may be referred for antireflux surgery rather than be treated with a pain modulator. However, data for fundoplication in non–acid reflux, particularly in the absence of reduced lower esophageal sphincter pressure, are scarce and generally we do not advocate this as an initial approach to the management of non–acid reflux. Caution About Overinterpretation of Number of Reflux Episodes in Reflux Monitoring for Refractory Gastroesophageal Reflux DiseaseClinical Gastroenterology and HepatologyVol. 14Issue 7PreviewWe read with great interest the study by Cheng et al,1 who investigated patients with gastroesophageal reflux disease (GERD) refractory to antisecretory therapy by means of endoscopy and impedance-pH monitoring off-therapy and concluded that roughly half of these patients referred for testing actually underwent investigations and received medications with no evidence of GERD; they were affected by functional heartburn, functional disorders other than heartburn, or by undetermined disorders. These data confirm previous studies2,3 on the importance of investigating refractory patients and also emphasize the need of stopping antisecretory therapy to reduce overuse of proton pump inhibitors. Full-Text PDF