What Is the Profiles for Predicting Treatment Responsiveness in Gastroesophageal Reflux Disease? (Gut 2012;61:501-506)

Abstract

Gastroesophageal reflux disease (GERD) has a high prevalence and an increasing incidence. Traditionally, 24-hour ambulatory pH monitoring has been recognized as a standard diagnostic test for GERD. However, compared with pH-alone monitoring, combined esophageal pH-impedance monitoring allows detection and characterization of all types of reflux episodes as well as their extent to the proximal esophagus.1 Previous studies with 24-hour ambulatory pH monitoring have demonstrated that patients with normal acid exposure have the lowest rate of response to proton pump inhibitors (PPIs) and patients with a positive symptom-reflux association have a better response to PPIs.2 This study was performed in 100 patients with typical GERD symptoms (heartburn and/or regurgitation) from 3 university hospitals.3 Among these patients, 48 patients had functional dyspepsia and 36 had irritable bowel syndrome. Patients were considered as responders to PPI therapy if they had fewer than 2 days of mild symptoms per week while receiving a standard or double dose of PPI treatment for at least 4 weeks. Patients were considered to be non-responders if they had more than 2 days of mild symptoms per week while receiving a standard or double dose of PPI treatment for at least 4 weeks. Forty-three patients were considered as PPI responders and 57 as non-responders. All responders and non-responders were referred for 24 hour pH-impedance monitoring in order to demonstrate the presence of pathologic GER. Esophageal impedance-pH monitoring was performed using a Sleuth Multi-channel Intraluminal Impedance ambulatory system (Sandhill Scientific, Highland Ranch, CO, USA). Both clinical and reflux parameters were taken into account for analysis. The authors demonstrated that the factors associated with the absence of response were absence of esophagitis (P = 0.050), body mass index (BMI) of ≤ 25 kg/m2 (P = 0.004) and functional dyspepsia (FD) (P = 0.001). However, no reflux pattern associated with PPI failure was demonstrated by 24 hour pH-impedance monitoring. They performed analysis in different subgroups of patients. In patients who reported symptoms during the recording (n = 85), the factors associated with PPI failure were BMI ≤ 25 kg/m2 (P =0.004), FD (P = 0.009) and irritable bowel syndrome (IBS) (P = 0.045). In patients who documented GERD (n = 67), the factors associated with PPI failure were absence of esophagitis (P = 0.040), FD (P = 0.003), IBS (P = 0.012) and BMI ≤ 25 kg/m2 (P = 0.029). Therefore, they concluded that absence of esophagitis, presence of functional digestive disorders and BMI ≤ 25 kg/m2 were strongly associated with PPI failure. And no reflux pattern demonstrated by 24 hour pH-impedance monitoring is associated with response to PPIs in patients with GERD symptoms.