Ambulatory pH Research Articles

Construction of a Wireless-Enabled Endoscopically Implantable Sensor for pH Monitoring with Zero-Bias Schottky Diode-based Receiver.

Ambulatory pH monitoring of pathological reflux is an opportunity to observe the relationship between symptoms and exposure of the esophagus to acidic or non-acidic refluxate. This paper describes a method for the development, manufacturing, and implantation of a miniature wireless-enabled pH sensor. The sensor is designed to be implanted endoscopically with a single hemostatic clip. A fully passive rectenna-based receiver based on a zero-bias Schottky diode is also constructed and tested. To construct the device, a two-layer printed circuit board and off-the-shelf components were used. A miniature microcontroller with integrated analog peripherals is used as an analog front end for the ion-sensitive field-effect transistor (ISFET) sensor and to generate a digital signal which is transmitted with an amplitude shift keying transmitter chip. The device is powered by two primary alkaline cells. The implantable device has a total volume of 0.6 cm3 and a weight of 1.2 grams, and its performance was verified in an ex vivo model (porcine esophagus and stomach). Next, a small footprint passive rectenna-based receiver which can be easily integrated either into an external receiver or the implantable neurostimulator, was constructed and proven to receive the RF signal from the implant when in proximity (20 cm) to it. The small size of the sensor provides continuous pH monitoring with minimal obstruction of the esophagus. The sensor could be used in routine clinical practice for 24/96 h esophageal pH monitoring without the need to insert a nasal catheter. The "zero-power" nature of the receiver also enables the use of the sensor for automatic in-vivo calibration of miniature lower esophageal sphincter neurostimulation devices. An active sensor-based control enables the development of advanced algorithms to minimize the used energy to achieve a desirable clinical outcome. One of the examples of such an algorithm would be a closed-loop system for on-demand neurostimulation therapy of gastroesophageal reflux disease (GERD).

Do Preoperative Esophageal pH Monitoring and High-Resolution Manometry Predict Symptoms of GERD After Sleeve Gastrectomy?

Predictive factors of evolution or appearance of gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) have not been identified to date. We aimed to assess the evolution of GERD symptoms 1 year after SG and to determine preoperative predictive factors using high-resolution manometry (HRM) and ambulatory 24-h esophageal pH monitoring (APM). We included 160 patients who underwent SG between 2013 and 2017 and performed preoperative APM and HRM. Positive APM was defined according to the Lyon consensus. Symptoms of GERD, proton pump inhibitors (PPI) use, weight loss (WL), and diet were recorded in all patients before and 1 year after surgery. One year after surgery, 58 patients (36.3%) complained of GERD symptoms compared to 52 patients (32.5%) preoperatively (p=0.48). Among patients with preoperative GERD symptoms, only 26/52 patients (50%) still had symptoms, whereas 32/108 (29.6%) asymptomatic patients developed de novo GERD symptoms after surgery. PPI use increased after surgery reaching 36.9% of patients against 15.0% before (p<0.0001). Only preoperative symptoms of GERD were predictive of postoperative symptoms (OR= 2.47 [1.14-5.45]; p=0.023) in multivariate analysis. Preoperative manometric parameters, postoperative diet, and WL were not related to postoperative symptoms. In asymptomatic patients before surgery, silent GERD (positive APM without symptom) was predictive of postoperative GERD symptoms (OR=2.69 [1.00-7.25]; p=0.049). Evolution of GERD symptoms after SG reveals improvement for half of the patients and de novo GERD symptoms in one-third of patients. Predictive factors of postoperative symptoms are preoperative symptoms and positive preoperative APM in asymptomatic patients.

Safety and efficacy of an implantable device for management of gastroesophageal reflux in lung transplant recipients.

BackgroundMagnetic sphincter augmentation (MSA) is a promising minimally invasive surgical technique for management of gastroesophageal reflux disease (GERD); however, device implantation after transplantation has not been studied and may be concerning in these immunosuppressed patients. We explored the safety of the LINX Reflux Management System (MSA device) for management of GERD following lung transplantation (LTx).MethodsLung transplant recipients who underwent LINX implantation at our institution between 2017 and 2019 were followed prospectively in the Reflux Following Lung Transplantation and Associated Treatment Registry. Ambulatory pH testing and acid-suppressing medication use were compared before and after LINX implantation. One-year outcomes and change in pulmonary function were compared between matched LINX and fundoplication groups.ResultsOf 17 patients who underwent post-lung transplant LINX implantation, 8 (47.1%) agreed to undergo post-LINX pH testing. Three/eight (37.5%) patients achieved normal esophageal acid exposure time; 14 (82.4%) remained on acid-suppressing medication at one-year under the direction of their transplant teams. One-year patient survival and change in pulmonary function were similar between groups. LINX patients experienced more early side effects.ConclusionsUse of the LINX MSA device in a cohort of lung transplant recipients at our institution was associated with similar short-term safety compared to traditional fundoplication, however assessment of efficacy was limited. Further investigation is needed to characterize the long-term efficacy of LINX implantation after LTx.

To Compare and Evaluate Laryngeal Changes in Patients with Dysphonia in Laryngopharyngeal Reflux (LPR) before and after Treatment with Proton Pump Inhibitors (PPI) and Prokinetic Drugs.

To evaluate and compare pre and post treatment results using the following parameters by (a) Dual probe pH monitoring. (b) Laryngeal mucosal changes as assessed by direct video laryngoscopy/stroboscopy using Belafsky scores. (c) Voice changes by using GRBAS and Dr Speech software for speech analysis. In our study we have evaluated and compared voice and laryngeal changes in patients with dysphonia and RSI > 10 (which is suggestive of LPR) before treatment and after 6months of treatment with Tab. Pantoprazole and Tab. Mosapride. This prospective study was carried out on 50 patients attending the ENT OPD of a tertiary care referral centre over a period of 18months i.e. from Nov 2008 to Apr 2010. The study showed that prolonged therapy (> 6months) is required to treat LPR effectively and 24h ambulatory dual probe pH metry and videolaryngoscopy to assess RFS are the most preferred diagnostic tools in LPR. Dr Speech software for voice analysis can give an objective assessment of voice changes in LPR before and after treatment. The treatment consisting of PPI and prokinetic drugs proved to be effective in laryngopharyngeal reflux disease as improvement was seen in all the parameters including reflux findings score, subjective and objective voice assessment. According to results of our study, 24h ambulatory dual probe pH metry, Reflux Finding Score (RFS), subjective and objective acoustic parameters can be used as indicators of efficacy of treatment.

Advances in the diagnosis of GERD.

Gastroesophageal reflux disease (GERD) is considered one of the most frequent chronic gastrointestinal diseases globally with high costs due to treatment and investigations.First line therapy is with proton pump inhibitors, those who do not respond to initial treatment usually require further investigations such as upper gastrointestinal endoscopy or ambulatory 24-hours esophageal pH monitoring. The total time of exposure to acid and the DeMeester score represent the most useful parameters associated with conventional pH-metry, because they can identify gastroesophageal reflux disease.Although pH-metry is considered the gold standard for the evaluation of gastroesophageal reflux disease, new impedance-based parameters have been introduced in recent years with the role of increasing the accuracy of diagnosing gastroesophageal reflux disease and characterizing the type of reflux. The development of multichannel intraluminal pH-impedance has improved the ability to detect and quantify gastroesophageal reflux. New parameters such as post-reflux swallowing peristaltic wave (PSPW) index and the mean nocturnal basal impedance (MNBI) have recently been introduced to assess GERD phenotypes more accurately. This review evaluates current GERD diagnotic tools while also taking a brief look at newer diagnostic parameters like PSPW and MNBI.

Validation of the Lyon classification for GORD diagnosis: acid exposure time assessed by prolonged wireless pH monitoring in healthy controls and patients with erosive oesophagitis

ObjectiveAcid exposure time (AET) from ambulatory pH studies and reflux oesophagitis are independent measurements used by the Lyon classification to diagnose GORD. This study aimed to validate AET reference ranges...

Diagnostic Criteria for Gastro-esophageal Reflux Following Sleeve Gastrectomy

BackgroundGastro-esophageal reflux disease (GERD) post-sleeve gastrectomy (SG) is a controversial issue and diagnostic dilemma. Strong heterogeneity exists in the assessment of reflux post-SG, and better diagnostic tools are needed to characterize symptomatic reflux. We aimed to determine the discriminant factors of symptomatic reflux and establish diagnostic thresholds for GERD following SG.Materials and MethodsPatients post-SG were categorized into asymptomatic and symptomatic cohorts and completed validated symptom questionnaires. All patients underwent stationary esophageal manometry and 24-h ambulatory pH monitoring. Univariate and multivariate analyses were conducted to determine the strongest discriminant factors for GERD.ResultsBaseline characteristics of the asymptomatic cohort (n = 48) and symptomatic cohort (n = 76) were comparable. The median post-operative duration was 7.3 (14.1) vs 7.5 (10.7) months (p = 0.825). The symptomatic cohort was more female predominant (90.8 vs 72.9%, p = 0.008). Reflux scores were significantly higher in the symptomatic group (36.0 vs 10.5, p = 0.003). Stationary manometry parameters were similar, including hiatus hernia prevalence and impaired esophageal motility. The symptomatic cohort had significantly higher total acid exposure, especially while supine (11.3% vs 0.6%, p < 0.001). Univariate and multivariate regressions delineated reflux score and supine acid exposure as discriminant factors for symptomatic reflux. The thresholds for distinguishing symptomatic reflux are as follows: reflux score of 11.5 (sensitivity 84.0%, specificity 68.2%) and supine acid exposure of 2.65% (sensitivity 67.1%, specificity 70.8%).ConclusionA reflux score of 11.5 or more or supine acid exposure of 2.65% or more should be considered diagnostic in defining symptomatic reflux following SG.

Clinical spectrum and presentation of patients with absent contractility

BackgroundPrimary absent contractility is an uncommon finding on high-resolution manometry (HRM). The goal of this study was to describe the clinical spectrum and presentation of patients with primary absent contractility.MethodsWe queried a prospectively maintained esophageal testing registry to identify patients with absent contractility who presented between August 2016 and September 2018. Patients with poor quality studies and patients with insufficient clinical records as well as those with a history of previous foregut surgery or esophagram consistent with achalasia were excluded.ResultsA total of 2068 patients underwent HRM during the study period. Of these, 66 patients (3.2%) met the inclusion criteria and formed the study cohort; 52 patients in the cohort had an upper gastrointestinal contrast study, 50 had endoscopy, and 51 completed a foregut symptom questionnaire. Thirty-eight patients (57.6%) were women. The mean age was 56.6±13.86 years, and the mean body mass index was 26.37±5.7 kg/m2. Almost half of the patients (29/66, 43.9%) were undergoing lung transplant evaluation, and 22 patients (37.3%) had a history of autoimmune immune-mediated or myopathic diseases. On the symptom questionnaire, 42 of 51 patients (82.3%) reported heartburn, 24 of 51 (47.1%) reported dysphagia, and 23 of 51 patients (45.1%) reported both. On ambulatory pH monitoring, 23 of 37 patients (62.2%) had pathological esophageal acid exposure (acid exposure time >6%).ConclusionsAbsent contractility on HRM is uncommon and is frequently associated with connective tissue, myopathic or autoimmune disorders. The usual clinical presentation is reflux, dysphagia or both.

The concatenation of association between gastroesophageal reflux and obstructive adenotonsillar hypertrophy

ObjectivesGastroesophageal reflux (GER) is frequently seen in patients with adenotonsillar hypertrophy. However, the sequential association between GER and adenotonsillar hypertrophy is unknown. This leads to unpredictable outcomes while treating patients of adenotonsillar hypertrophy with GER. The objective of this study is to evaluate the prevalence of GER and gastroesophageal reflux disease (GERD) in paediatric patients with obstructive adenotonsillar hypertrophy (OATH), and to assess the effect of adenotonsillectomy (AT) on GER as well as GERD. MethodsIn this prospective cohort study, consecutive pediatric patients with grade III/IV hypertrophy of adenoid or/and tonsillar tissue who were planned for AT were recruited after excluding comorbidities predisposing to GER. Symptoms of GERD using Gastro Esophageal Reflux Questionnaire for Young Children (GERQ-YC) and Reflux Indices (RI) obtained from 24-h ambulatory esophageal pH monitoring were evaluated in all patients pre-operatively and 12 weeks following AT. ResultsA total of 49 patients with OATH with average age of 6 years were included in this study. With a RI of >4.3% as the threshold for making the diagnosis of GER on esophageal pH monitoring, the prevalence of GER was 20.4%. The average RI preoperatively was 15.7% which reduced to 1.7% following AT (p = 0.004). Among the 10 patients with preoperative GER, 80% of the patients had no evidence of GER after surgery. New incidences of GER was not observed post operatively in this cohort. As per the GER symptom scoring system, 31% of the parents reported GERD pre-operatively which resolved completely in all patients following surgery. Conclusions– In this study, the prevalence of GER proven by 24 h ambulatory esophageal pH monitoring is 20% in pediatric patients with OATH. Following AT, GER resolved in 80% of cases and was reduced substantially in the remaining cases in the subset of patients with pre-operative GER. The symptoms of GERD based on parents' recall of child's previous symptoms may not accurately represent presence of GER. Our results suggest that OATH can result in GER due to increased negative intra-thoracic pressure as a result of breathing against an obstructed upper airway and hence, GER subsides following surgical removal of the obstructive pathology. To establish this concatenational association of OATH and GER, larger studies are mandated.

S0351 Characterizing Reflux on High Resolution Esophageal Manometry With Impedance

INTRODUCTION: In some patients, reflux at esophagogastric junction (EGJ) can be seen on the impedance portion of the high-resolution esophageal manometry with impedance (HREMI) studies. How this might correlate with reflux seen on conventional esophageal reflux monitoring studies is unknown. We aimed to: 1) Determine prevalence of reflux seen on HREMI, and 2) Correlate reflux during HREMI studies with reflux on esophageal reflux monitoring studies. METHODS: Patients undergoing HREMI from 7/2019 to 2/2020 were studied. Results of ambulatory reflux monitoring were obtained if undergone. Patients rated the severity of symptoms. RESULTS: Of 354 patients (mean age 56.0 ± 1.0, 68% females) undergoing HREMI, 99 (28%) had reflux at EGJ on HREMI on 3.9 ± 0.3 swallows. Patients with reflux on HREMI had lower Distal Contractile Integral/DCI (1414 ± 137 vs 2049 ± 159), lower esophageal sphincter (LES) basal pressure (19.2 ± 1.3 vs. 32.4 ± 1.1), integrated relaxation pressure/IRP (7.2 ± 0.7 vs 13.8 ± 0.6), less likely to have EGJ outflow disorders (8.1% vs 29.4%) and major disorders of peristalsis (7.1% vs 21.2%), and more likely to have hiatal hernia/HH (71.7% vs 31.4%) than patients without reflux on HREMI (all P < 0.01, Table 1). Patients with reflux on HREMI had lower severities of regurgitation, dysphagia, and vomiting than patients without reflux (all P ≤ 0.01), likely due to lower prevalence of major esophageal motility disorders. Of the 273 patients with ambulatory pH monitoring (multichannel intraluminal impedance-pH = 257, Bravo = 16), 135 (49.5%) had GERD (Table 2). Patients with reflux on HREMI were more likely to have GERD on ambulatory pH monitoring (60.5%) than patients without reflux on HREMI (44.8%, P = 0.02). Patients with reflux on HREMI had a higher number of reflux events detected on MII-pH than patients without reflux on HREMI (56.0 ± 4.7 vs 42.6 ± 2.5, P = 0.01). Reflux on ≥1 swallow on HREMI had a specificity of 76.8% and sensitivity of 36.3% for GERD (Table 3). Reflux on ≥4 swallows on HREMI improved specificity to 90.6%, with sensitivity of 14.8% for GERD. CONCLUSION: Amongst patients undergoing HREMI, 28% had reflux at EGJ on HREMI. These patients had lower DCI, LES basal pressure, IRP and more frequent HH on HREMI than patients without reflux on HREMI. Patients with reflux on HREMI were more likely to meet criteria for GERD on ambulatory pH monitoring. Reflux on HREMI had good specificity but low sensitivity for GERD. Reflux seen on HREMI may be supportive evidence for GERD.Table 1Table 2Table 3

Sa1238 MUCOSAL INTEGRITY TESTING CAN RULE OUT REFLUX IN REFRACTORY GERD

Ambulatory reflux monitoring is considered the gold standard for diagnosis of GERD but only provides a “snap shot” of a disease process that by definition is chronic in nature and can have false negative results in up to 30% of patients. Mucosal integrity (MI) testing is a minimally invasive, innovative test that can detect changes in esophageal mucosa instantly during endoscopy. The aim of this prospective blinded study was to assess the predictive value of MI as a diagnostic modality for the evaluation of suspected GERD refractory to therapy at index endoscopy without the need for ambulatory pH monitoring. Patients with suspected GERD-related symptoms with partial or incomplete response to acid suppressive therapy undergoing endoscopy and 48-hour wireless pH monitoring one week OFF treatment were enrolled in this study. During the endoscopy, MI values (Ω) were collected at 2, 5, and 10 cm above the squamocolumnar junction (SCJ). GERD was predicted (pre-wireless pH monitoring) based on low MI values distally and axial pattern of MI along the esophageal axis. A member of the research team (TH), blinded to the endoscopy images during the procedure and pH monitoring data, predicted GERD or non-GERD based on the MI pattern alone. Predictions were later compared to data from the ambulatory 48-hour wireless pH monitoring. 34 patients constituted the study population [70% female, median age 48]. Clinical symptoms were similar between the groups (heartburn, regurgitation). 24/34 patients were predicted to have GERD based on MI pattern during endoscopy [median MI at 2 cm of 1811 (1499-2676), at 5 cm of 2790 (2162-3508), and at 10 cm of 3823 (2724-4922)] and 10/34 were predicted to be normal [median MI at 2 cm of 3126 (2357-4042), at 5 cm of 5674 (5179-6267), and at 10 cm of 5403 (4339-5936)]. Median total % time pH <4 was 5.9 (4.8-10.2) in the predicted GERD group and 4.4 (2.5-6.9) in the non-GERD group (Table 1). 7/34 patients had erosive esophagitis (3 LA grade A, 4 LA grade B), which were all predicted to have GERD based on MI pattern. MI testing had a sensitivity of 83% with negative predictive value of 90% for AET of >12% (moderate to severe GERD). MI testing during endoscopy has high negative predictive value (90%) for moderate to severe reflux during endoscopy. In patients with incomplete or partial response to PPI negative MI testing would obviate the need for ambulatory pH monitoring.

Sa1252 PROSPECTIVE EVALUATION OF SYMPTOM CORRELATION FOR GASTROESOPHAGEAL REFLUX DISEASE BY AMBULATORY WIRELESS PH MONITORING AFTER PER-ORAL ENDOSCOPIC MYOTOMY

Ambulatory pH monitoring following POEM is reportedly abnormal in up to 60% of patients. There are limited data regarding correlation of patient reported symptoms with reflux episodes during these studies after POEM. To evaluate the relationship of patient reported typical and atypical GERD symptoms to objective reflux episodes by ambulatory pH monitoring after POEM. From a prospective database, consecutive patients who underwent POEM for esophageal motility disorders at our hospital were identified. High resolution impedance manometry (HRM) and Eckardt scores (ES) were recorded at baseline. At 6 months after POEM, HRM, ES and 48-hour ambulatory wireless pH testing (Bravo, Medtronic, Minneapolis, MN) off antisecretory therapy were obtained. Symptoms experienced during pH testing were recorded. A positive pH study was defined as pH <4 in >5.3% of time on day 1 alone, day 2 alone or total test duration. A symptom index (SI) score (percentage of a GERD-related symptom that correlates with a pH event <4) and symptom sensitivity index (SSI) (percentage of test duration events with pH <4 that are associated with symptoms) were calculated. Symptom-reflux correlation was defined as SI ≥50% or SSI ≥ 10%. 208 consecutive patients underwent POEM between 2015 and 10/2019. The study population included 93 patients (52 ± 17 yrs.; 53M) who underwent follow-up testing 6 months after POEM. The most common indication for POEM was type 1 (18%), type 2 achalasia (58%) and EGJOO (13%). At 6 month follow-up, there were significant decreases in mean ES (1.3 ± 1.9 vs. 7.7 ± 1.9) and mean IRP (8.7 ± 6.4 mmHg vs. 29.6 ± 15.3 mmHg, both p<0.001). A positive pH test was present in 70/93 (75%). The frequency of reported symptoms and their correlation with events during pH testing are recorded in Table 1. At least one symptom was reported by 58/93 (62%), the most frequent of which were cough (29%), heartburn (27%), and chest pain (27%). All reported symptoms had an SI <50% and SSI<10%. For all 3096 reported symptoms, SSI was 9.9%. There was no difference in the frequency of any reported symptom in patients with and without a positive pH study (Table 2). In this series, 75% of post-POEM patients evaluated had abnormal wireless pH testing. Both typical and atypical symptoms of GERD after POEM showed poor correlation with abnormal acid exposure and occurred with equal frequency among those with and without abnormal pH testing. Objective testing rather than patient reported symptoms are required to diagnose, treat and prevent potential complications from post–POEM GERDView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Diagnosis of gastroesophageal reflux: an update on current and emerging modalities.

Gastroesophageal reflux disease (GERD) is a common condition characterized by troublesome symptoms or esophageal mucosal lesions attributed to excessive esophageal acid exposure. Various pathophysiological mechanisms account for GERD, including impaired esophageal peristalsis and anatomical or physiological defects at the esophagogastric junction (EGJ). Endoscopy identifies GERD complications and detects potential alternative diagnoses. However, if symptoms persist despite proton pump inhibitor therapy, functional esophageal tests are useful to characterize reflux burden and define the symptom association profile. Ambulatory pH or pH-impedance monitoring measures the 24-h acid exposure time, which remains the most reproducible reflux metric and predicts response to antireflux therapy. Apart from identifying peristaltic dysfunction, esophageal high-resolution manometry defines the morphology and contractile vigor (EGJ-CI) of the EGJ. Novel metrics obtained from pH-impedance monitoring include the postreflux swallow-induced peristaltic wave index and mean nocturnal baseline impedance, which augment the diagnostic value of pH-impedance testing. Mucosal impedance can also be recorded using a probe inserted through a gastroscope, or a novel balloon catheter with arrays of impedance electrodes inserted following sedated endoscopy. The latest developments in functional esophageal tests define the GERD phenotype based on pathogenesis, reflux exposure, structural or motility disorders, and symptom burden, facilitating appropriate treatment.

Gastroesophageal Reflux Disease Is Not Associated With Jackhammer Esophagus: A Case-control Study.

Background/AimsThe pathophysiology of jackhammer esophagus (JE) remains unknown but may be related to gastroesophageal reflux disease or medication use. We aim to determine if pathologic acid exposure or the use of specific classes of medications (based on the mechanism of action) is associated with JE.MethodsHigh-resolution manometry (HRM) studies from November 2013 to March 2019 with a diagnosis of JE were identified and compared to symptomatic control patients with normal HRM. Esophageal acid exposure and medication use were compared between groups. Multivariate regression analysis was performed to look for predictors of mean distal contractile integral.ResultsForty-two JE and 127 control patients were included in the study. Twenty-two (52%) JE and 82 (65%) control patients underwent both HRM and ambulatory pH monitoring. Two (9%) JE patients and 14 (17%) of controls had evidence of abnormal acid exposure (DeMeester score > 14.7); this difference was not significant (P = 0.290). Thirty-six (86%) JE and 127 (100%) control patients had complete medication lists. Significantly more JE patients were on long-acting beta agonists (LABA) (JE = 5, control = 4; P = 0.026) and calcium channel blockers (CCB) (JE = 5, control = 3; P = 0.014). Regular opioids (β = 0.298, P = 0.042), CCB (β = 0.308, P = 0.035), and inhaled anticholinergics (β = 0.361, P = 0.049) predicted mean distal contractile integral (R2 = 0.082, F = 4.8; P = 0.003).ConclusionsPathologic acid exposure does not appear to be associated with JE. JE patients had increased CCB and LABA use. The unexpected finding of increased LABA use warrants more investigation and may provide support for a cholinergic etiology of JE.

Clinical Symptom Presentation of Hypercontractile Peristalsis in the Era of High-Resolution Manometry: A Single-Center Experience

Background: Hypercontractile motility of the esophagus is occasionally noted on high-resolution manometry (HRM), but its clinical correlations are unclear. We compared symptom severity and clinical presentation of patients with hypercontractile motility of the esophagus. Methods: This was a retrospective cohort study. We queried a prospectively maintained database for patients who underwent esophageal function testing from October 1, 2016, to October 30, 2018. We included patients with jackhammer esophagus (JE; ≥2 swallows with distal contractile integral [DCI] ≥8,000 mm Hg∙cm∙s), nutcracker esophagus (NE; mean DCI 5,000–8,000 mm Hg∙cm∙s without meeting JE criteria), or esophagogastric junction outflow obstruction ([EGJOO]: abnormal median integrated relaxation pressure (>15 mm Hg) without meeting achalasia criteria, with JE [EGJOO-h], or normal motility [EGJOO-n]). HRM, endoscopy, barium esophagram, ambulatory pH studies, and symptom questionnaires were reevaluated for further analysis. Clinical parameters were analyzed using Spearman Rho correlation. Categorical variables were assessed with Fisher exact or chi-square test. Results: Altogether, 85 patients met inclusion criteria. They were divided into 4 subgroups: 28 with JE, 18 with NE, 15 with EGJOO-h, and 24 with EGJOO-n. Patients with EGJOO-h were the most symptomatic overall. No correlation was seen between symptoms and mean DCI (p ≥ 0.05 all groups) or number of hypercontractile swallows (≥8,000 mm Hg∙cm∙s, p ≥ 0.05). A significant correlation was noted between dysphagia and lower esophageal sphincter pressure (LESP) and LESP integral (p ≤ 0.05). Conclusion: The number of hypercontractile swallows and mean DCI were not associated with patient-reported symptoms. Elevated LESP may be a more relevant contributor to dysphagia.

Magnetic sphincter augmentation is an effective treatment for atypical symptoms caused by gastroesophageal reflux disease.

The purpose of this study was to determine whether magnetic sphincter augmentation (MSA) could effectively treat patients with gastroesophageal reflux disease (GERD) who suffer primarily from atypical symptoms due to laryngopharyngeal reflux (LPR). MSA has been shown to treat typical symptoms of GERD with good success, but its effect on atypical symptoms is unknown. A retrospective review of a prospectively maintained institutional review board-approved database was conducted for all patients who underwent MSA between January 2015 and December 2018. All patients had objective confirmation of GERD from ambulatory pH monitoring off anti-reflux medications (DeMeester score > 14.7). Symptoms were assessed preoperatively and at 1 year postoperatively using GERD Health-Related Quality of Life (GERD-HRQL) and Reflux Symptom Index (RSI) questionnaires. There were 86 patients (38 males; 48 females) with a median age of 51.5years. Total GERD HRQL scores improved from a mean of 38.79 to 6.53 (p < 0.01) and RSI scores improved from a mean of 20.9 to 8.1 (p < 0.01). Atypical symptoms evaluated from the RSI questionnaire include hoarseness, throat clearing, postnasal drip, breathing difficulties, and cough. All atypical symptoms were significantly improved at 1year following MSA (p < 0.01). All three typical symptoms of heartburn, dysphagia, and regurgitation were significantly improved based on pre and postoperative GERD HRQL questionnaires (p < 0.02). Ninety-one percent of patients were off their PPI and dissatisfaction with their current therapy decreased from 95% preoperatively to 13% postoperatively. MSA is an effective treatment for typical and atypical GERD symptoms.

Endoscopic measurement of gastric pH associates with persistent acid reflux in patients treated with proton-pump inhibitors for gastroesophageal reflux disease.

Proton-pump inhibitors (PPIs) are the mainstay of gastroesophageal reflux disease (GERD) treatment, however, up to 30% of patients have a poor symptomatic response. PH-impedance is the gold standard to assess whether this is due to persistent acid reflux. We aimed to characterize clinical predictors of persistent esophageal acid reflux on PPIs including gastric pH measured during endoscopy. We prospectively recruited patients with GERD and/or Barrett's esophagus (BE) on PPIs. All patients completed a symptom questionnaire (RDQ) and underwent gastroscopy with gastric pH analysis, immediately followed by ambulatory 24-hour pH-impedance. We used a modified cut-off of 1.3% for pathological esophageal acid exposure time (AET). Multiple linear regression model was used to analyze the correlation between AET and predictive variables. We recruited 122 patients, of which 92 (75.4%) were included in the final analysis [44 male (47.8%), median age 53 years (IQR: 43-66)]. Forty-four patients (47.8%) had persistent acid reflux with a median total AET of 2.2 (IQR1.2-5.0), as compared to 0.1 (IQR 0.0-0.2) in patients without persistent reflux (n=48; P<.001). There was no difference in age, gender, BMI, PPI-regimen, diagnosis of hiatus hernia or BE, and severity of symptoms between patients with normal and abnormal AET. Median gastric pH was significantly lower in patients with abnormal AET (5.8 vs 6.6, P=0.032) and it correlated with the total AET (P=.045; R2=12.0%). With a pH cut-off of 5.05, single point endoscopic gastric pH analysis had an area under the ROC curve (AUC) of 63.0% (95%CI 51.3-74.7) for prediction of pathological esophageal AET. Symptoms and clinical characteristics are not useful to predict persistent acid reflux in patients on PPIs. One-point gastric pH correlates with 24-hour esophageal AET and could guide clinicians to assess response to PPIs, however, its utility needs validation in larger studies.

O15 ESOPHAGEAL MOTILITY OF LUNG TRANSPLANT RECIPIENTS DIAGNOSED WITH SYSTEMIC CONNECTIVE TISSUE DISORDER: A SINGLE-CENTER EXPERIENCE

Abstract Aim To examine the esophageal motility of lung transplant recipients diagnosed with systemic connective tissue disorder, and to evaluate the changes Backgrounds The decision to offer lung transplantation to patients diagnosed with a systemic connective tissue disorder (CTD) is frequently complicated by associated esophageal dysmotility. Absent or ineffective esophageal motility and associated gastroesophageal reflux disease are serious risk factors of posttransplant bronchiolitis obliterans syndrome and subsequent allograft dysfunction. The aim of our study was to evaluate esophageal motility of lung transplant recipients with systemic CTDs, focusing on 1-year survival. Methods After IRB approval of this retrospective cohort study, we reviewed patients who underwent lung transplant at our institution between January 2012 and December 2017. Patients with systemic CTDs such as scleroderma, rheumatoid arthritis, systemic lupus erythematosus, polymyositis, dermatomyositis, mixed connective tissue disorder, and Sjögren syndrome were included. Endoscopy studies, high-resolution manometry (HRM), and ambulatory pH studies were re-evaluated. Results A total of 545 patients underwent lung transplant during study period; of these, 34 met study criteria. Detailed demographic characteristics of the study cohort are shown in Table 1. The overall 1-year survival was 85.3%. Of the 34 patients diagnosed with a systemic CTD (mean age: 59.24 ± 10.44 years; 24/34 women [70.6%]), 27 had both pre- and posttransplant esophageal function testing data available. 7 patients were diagnosed with complete aperistalsis, 5 patients had ineffective esophageal motility, and the remaining 15 patients had normal or hypercontractile esophageal motility (Figure 1). Pathologic distal acid exposure in each of these groups was 57.1%, 40.0%, and 26.7%, respectively. Seven patients with aperistalsis (5 with scleroderma, 1 with polymyositis, and 1 with dermatomyositis) showed no improvement in esophageal body motility, regardless of underlying CTD. 1-year survival in these patients was 55.5%. Five patients with ineffective esophageal motility (3 with rheumatoid arthritis, 1 with scleroderma, 1 with mixed connective tissue disorder) showed significant peristaltic improvement (mean positive change in distal contractile integral: 1288 ± 391.3 mmHg*cm*s and in the number of normal swallows 6.4 ± 1.4 out of 10). All 5 patients with ineffective esophageal motility were alive 1 year posttransplant. Conclusion In our experience, preexisting absent esophageal body motility (i.e., peristalsis) is unlikely to improve after transplantation in patients with systemic CTDs. This cohort of patients appeared to have a significantly decreased 1-year survival. In contrast, ineffective esophageal body motility improved significantly after transplant and was associated with excellent 1-year survival. Detailed esophageal evaluation is necessary in patients with a systemic connective tissue disorder to minimize the risk of future allograft injury.

Effects of slough clearance rates post adult tonsillectomy in patients with laryngopharyngeal reflux disease

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Laryngopharyngeal reflux is known to be associated with multiple disease of the upper aero digestive tract and can cause serious injury to the mucosa long term.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Patients diagnosed with chronic tonsillitis and indicated for surgery were evaluated for laryngopharyngeal reflux using reflux symptom index score. When score greater than 13 was suggestive of laryngopharyngeal reflux (LPR) and counselled for 24 hours ambulatory dual probe pH monitoring. When the reflux event was 7 or more were diagnosed having LPR. Patients were divided into two groups Group A patients with chronic tonsillitis and without LPR and Group B patients with chronic tonsillitis and LPR. Postoperatively there slough percentage was calculated as 25%, 50%, 75%, 100% on the postoperative day (POD) 7, 14 and 21. Slough clearance rates were calculated as 100- slough percentage. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; There were 40 patients in Group A and 40 patients in Group B. The slough clearance rates of Group A were 46.3, 73.8 and 96.9 on post-operative days 7, 14, 21 respectively. The slough clearance rates of Group B were 30.1, 57.6, 90.1 on POD 7, 14, 21 respectively. The p values comparing slough clearance rates showed 0.00, 0.002, 0.013 on POD 7, 14, 21 which was statistically significant. Group B with laryngopharyngeal reflux had delayed healing than Group A.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Laryngopharyngeal reflux seems to adversely affect healing and complication following tonsillectomy due to lowering of slough clearance rates. Hence we recommend the need for assessment and treatment pre/post operatively of laryngopharyngeal reflux disease in adult patients undergoing tonsillectomy.&lt;/p&gt;

Post-POEM reflux: who's at risk?

Per-Oral Endoscopic Myotomy (POEM) is a less invasive alternative to laparoscopic Heller myotomy for patients with achalasia. While a partial fundoplication is often performed concurrently with laparoscopic myotomy, an endoscopic approach does not offer this and leaves patients prone to post-operative reflux. The objectives of this study were to (1) identify patients with post-POEM reflux using BRAVO pH and endoscopic evaluations, and (2) investigate risk factors associated with post-POEM reflux and esophagitis to optimize patient selection for POEM and identify those who will benefit from a proactive approach to post-operative reflux management. A retrospective review of a prospectively collected database of patients who underwent POEM between January 2011 and July 2017 at a single institution was performed. Demographics along with pre-POEM and post-POEM variables were obtained. Univariate and multivariate analyses were performed, using p values ≤ 0.05 for statistical significance. Forty-six patients were included, with a mean follow-up of 358days. Mean age was 58 (19.2); 61% were female. Thirty-six patients underwent 48-h BRAVO pH testing after POEM, which revealed abnormal esophageal acid exposure in 15 patients (41.7%). There was a correlation between positive BRAVO results and presence of preoperative esophagitis (p = 0.02). Only 13% of patients had symptom-related reflux episodes based on the Symptom Associated Probability of the BRAVO study. Post-operative endoscopy revealed 6 patients with esophagitis, compared to 4 patients who had esophagitis on preoperative endoscopy. Only higher preoperative Eckardt score was significantly associated with endoscopic evidence of esophagitis post-POEM. Reflux is common after POEM. A majority of patients with a positive BRAVO study are asymptomatic, which is concerning. Objective follow-up is of paramount importance with upper endoscopy and ambulatory pH monitoring being the gold standard. Elevated preoperative Eckardt score and esophagitis are associated with post-POEM reflux. This population warrants close surveillance.