Atypical GERD Research Articles

Tu1134: ATYPICAL GERD SYMPTOMS MAY BE ASSOCIATED WITH DIAPHRAGM STRENGTH IN LEAN AND OLDER SUBJECTS

Tu1134: ATYPICAL GERD SYMPTOMS MAY BE ASSOCIATED WITH DIAPHRAGM STRENGTH IN LEAN AND OLDER SUBJECTS

Prevalence of reflux-related symptoms in South-Hungarian blood donor volunteers.

Background/AimPopulation-based studies on the prevalence of GERD-related symptoms are still missing in Eastern Europe, therefore, we aimed to obtain such data in South-East Hungarian subjects.MethodsA total of 2,002 apparently healthy blood donor volunteers were consecutively enrolled and completed detailed questionnaires related to general factors, demographic data, socioeconomical factors, and the presence and frequency of typical and atypical GERD-related symptoms.ResultsAmong 2,002 study participants, 56.5% were completely asymptomatic. The prevalence of typical GERD symptoms appearing at least monthly or weekly was 16.5% and 6.8%, respectively. Two-thirds (209/330) of the patients experienced at least monthly occurring typical GERD symptoms and also had associated atypical symptoms and this was even more pronounced when comparing subgroups with higher symptom frequencies. Significant correlations were found between monthly GERD-related complaints and height, body mass index (BMI), coffee consumption, and smoking. Positive family history was another significant factor in all the symptom-frequency categories. GERD-related symptom frequency showed a linear association with sex (R2 = 0.75, P = 0.0049). Typical and atypical GERD symptoms were significantly more common in those with chronic diseases than those without. Heartburn was observed in 12.5% and 4.4% (P<0.05) and acid regurgitation was seen in 6.9% and 1.8% (P<0.05), respectively.ConclusionThe prevalence of GERD-related symptoms in South Hungary was significantly lower than that in Western countries and was closer to Eastern values. The presence of mild, non-exclusionary chronic diseases significantly increased the prevalence of GERD-related symptoms, as well as positive family history of GERD, height, BMI, coffee consumption, and smoking.

CHANGES IN SERUM GHRELIN AND ITS RELATIONSHIP WITH OF BODY MASS INDEX IN PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE AND SPONDYLOARTHRITIS.

The aim: To determine the features of changes in serum ghrelin levels and its relationship with the body mass index in patients with GERD and spondyloarthritis (SpA) with lesions of the cervical and thoracic spine. Materials and methods: The examined patients included 80 patients with SpA with cervical and thoracic spine lesions in combination with GERD. The examined patients with SpA with predominant cervical and thoracic spine lesions were divided into two groups depending on the clinical course of GERD, namely: group I included 33 (41.2%) patients with typical esophageal manifestations of GERD (13 males (39.4%), 20 females (60.6%)), and group II consisted of 47 (58.8%) patients with atypical extraesophageal manifestations of GERD (among them were 17 (36.2%) males and 30 (63.2%) females). Results: All patients were tested for serum ghrelin by enzyme-linked immunosorbent assay. Analysis of clinical manifestations of atypical GERD (group II patients) revealed that most often patients with SpA of the cervical and thoracic spine were diagnosed with dental and otolaryngological masks of reflux disease (40.4 % and 25.5 % of patients, respectively). Maximum serum ghrelin levels were detected in patients with SpA with cardiac GERD (355.02 ± 4.75 ng/ml), while minimum values were found in patients with dental signs of reflux disease (298.17 ± 5.16 ng/ml - p <0.05). Conclusions: 1. In patients with SpA with cervical and thoracic spine lesions, GERD often has atypical symptoms (mostly dental and otolaryngological forms in 40.4% and 25.5% of patients). 2. In patients with SpA with esophageal clinical signs of GERD, normal weight or underweight is more common, while in patients with extraesophageal forms of GERD overweight or obesity of varying severity prevails. 3. In patients with SpA and GERD, an increase in serum ghrelin levels was found in patients with cardiac manifestations of reflux disease (355.02 ± 4.75 ng/ml). 4. The relationship between BMI changes in patients with SpA and GERD and increased serum ghrelin levels was found, namely: in group II patients with overweight and obesity a direct correlation was found, and in group I patients with underweight an inverse correlation was fund.

CHANGES IN SERUM GHRELIN AND ITS RELATIONSHIP WITH OF BODY MASS INDEX IN PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE AND SPONDYLOARTHRITIS

The aim: To determine the features of changes in serum ghrelin levels and its relationship with the body mass index in patients with GERD and spondyloarthritis (SpA) with lesions of the cervical and thoracic spine. Materials and methods: The examined patients included 80 patients with SpA with cervical and thoracic spine lesions in combination with GERD. The examined patients with SpA with predominant cervical and thoracic spine lesions were divided into two groups depending on the clinical course of GERD, namely: group I included 33 (41.2%) patients with typical esophageal manifestations of GERD (13 males (39.4%), 20 females (60.6%)), and group II consisted of 47 (58.8%) patients with atypical extraesophageal manifestations of GERD (among them were 17 (36.2%) males and 30 (63.2%) females). Results: All patients were tested for serum ghrelin by enzyme-linked immunosorbent assay. Analysis of clinical manifestations of atypical GERD (group II patients) revealed that most often patients with SpA of the cervical and thoracic spine were diagnosed with dental and otolaryngological masks of reflux disease (40.4 % and 25.5 % of patients, respectively). Maximum serum ghrelin levels were detected in patients with SpA with cardiac GERD (355.02 ± 4.75 ng/ml), while minimum values were found in patients with dental signs of reflux disease (298.17 ± 5.16 ng/ml – p &lt;0.05). Conclusions: 1. In patients with SpA with cervical and thoracic spine lesions, GERD often has atypical symptoms (mostly dental and otolaryngological forms in 40.4% and 25.5% of patients). 2. In patients with SpA with esophageal clinical signs of GERD, normal weight or underweight is more common, while in patients with extraesophageal forms of GERD overweight or obesity of varying severity prevails. 3. In patients with SpA and GERD, an increase in serum ghrelin levels was found in patients with cardiac manifestations of reflux disease (355.02 ± 4.75 ng/ml). 4. The relationship between BMI changes in patients with SpA and GERD and increased serum ghrelin levels was found, namely: in group II patients with overweight and obesity a direct correlation was found, and in group I patients with underweight an inverse correlation was fund.

Atypical and typical manifestations of the hiatal hernia

: Hiatal hernias may present in variety of ways, both typical and atypical. Manifestations are dependent on the type and size of the hernia. Gastrointestinal manifestations are the most common, predominately with GERD and associated syndromes. Typical GERD presents with heartburn and regurgitation as part of a reflux syndrome. Additionally, GERD may manifest as a typical chest pain syndrome unrelated to a cardiac etiology. Hiatal hernia associated GERD may present with esophageal mucosal injury in the form of reflux esophagitis, stricture, Barrett’s esophagus, and progress to esophageal malignancy. Atypical GERD symptoms like cough, laryngitis, asthma, and dental erosions may be may exist with hiatal hernias. GERD symptoms are more often associated with type 1 hiatal hernias. Typical gastrointestinal obstructive symptoms of hiatal hernia manifest as nausea, bloating, emesis, dysphagia, early satiety, and postprandial fullness and pain in the epigastrium and chest. Less common, atypical presentations include gastric outlet obstruction, secondary gastric volvulus, intestinal obstruction and ischemia, and bleeding. These manifestations occur more frequently with paraesophageal hernias. Bleeding, ulcerations in the form of Cameron lesions, and iron deficiency anemia are additional atypical manifestations of hiatal hernia. As hiatal hernias enlarge and move more into the thorax, non-gastrointestinal symptoms become more frequent. Typical pulmonary presentations consist of dyspnea, dyspnea on exertion, and atelectasis as a result of pulmonary compression. Similarly, compression on the left atrium may explain the higher prevalence of atrial fibrillation in patients with hiatal hernia. Pulmonary fibrosis remains an atypical presentation of hiatal hernia, likely associated with the increased prevalence of GERD in hiatal hernia.

789 HIGH RESOLUTION ESOPHAGEAL MOTILITY: VARIABLE GEOGRAPHIC DISTRIBUTION IN A LARGE MEXICAN COHORT

Abstract High resolution esophageal manometry (HREM) has been in use for about a decade. However, there is no available information regarding geographical or regional differences in diagnostic outcome. Aim Characterize the indications, demographics and diagnostic outcome of HREM in a diverse population of Mexico. Methods Data was collected from four major referral centers representing diverse geographical areas of Mexico: central—Mexico City (two centers, years 2016-2020), south (Veracruz, years 2015-2020) and north (Monterrey, years 2013—2020). All consecutive cases referred for HREM were entered into a data base and analyzed using Chicago 3 classification. Data was evaluated using chi-square to compare frequencies among groups. Results 2,932 patients included: Central n = 877(29.9), North n = 1003(34.2), South n = 1052(35.9). Mean age 47.9(11-93), women 1,795(61.2), men 1,137(38.8). Nationwide, the most common indications for testing were: GERD n = 1677(57.2), followed by dysphagia 587(20), atypical GERD 244(8.3), post-operative GERD 230(7.9), chest pain 114(3.9), and post-operative dysphagia 78(2.8). HREM was normal in 1,468(49.9) patients. Table shows the diagnostic distribution among centers: Central-Mexico had more abnormal cases 531(60.5) (p &amp;lt; 0.0.001) vs 407(40.6) North and 532(50.6) South. Achalasia was more commonly diagnosed in the South n = 104(19.5) whereas outlet obstruction 39(967) p &amp;lt; 0.001 and spastic disorders were more common in the North 47(11.8) p = 0.002. Weak peristaltic disorders were more common in Central-Mexico 369(78.8) p &amp;lt; 0.001. Conclusion This study represents the first large comparative multicenter HREM data base project in Mexico. In this cohort, most patients receiving HREM are women and those whose indication was GERD. These findings indicate variable regional geographical distribution of HERM diagnosis. Our study suggests that further investigation into the causes and epidemiological distribution of motility disorders is warranted.

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)

P33 UPPER ESOPHAGEAL SPHINCTER (UES) ABNORMALITIES ARE SIGNIFICANT DIAGNOSTIC FINDINGS IN PATIENTS WITH ATYPICAL GERD UNDERWENT PH-IMPEDANCE AND HIGH RESOLUTION MANOMETRY (HRM)

Abstract Aim To investigate UES function in patients underwent esophageal testing with pH-impedance and HRM for suspected GERD Background &amp; Methods GERD is a complex condition with a typical: heartburn, regurgitation or epigastric pain and an atypical presentation with symptoms such as chronic cough, hoarseness, globus, dysphagia or throat clearing caused by the retrograde movement of gastric contents above the UES into the laryngopharynx. The association between GERD and abnormalities of UES and esophageal motility is not clearly known. HRM has allowed accurate measurement and evaluation of UES and esophageal function. We evaluate the UES function of the HRM exams in patients underwent pH-impedance for suspected GERD with typical or atypical symptoms. Results HRM tracings of 60 patients (35F, median age 53,08 R23-74), 35 with typical (20F, m.a 51,42 R24-74) and 25 with atypical (15F, m.a 51,73 R29-74) symptoms who underwent Ph-impedance for suspected typical and atypical GERD were evaluated. 40% of those with typical presentation had a positive pH-impedance for GERD versus 8% of those with atypical symptoms. Patients with typical symptoms presented in 42,85% UES abnormalities versus 60% of the patients with atypical presentation. From those patients with typical GERD symptoms that had a positive pH-impedance the 40% had a concomitant UES abnormality versus 100% of the patients with atypical presentation and a confirmed GERD diagnosis. Statistical analysis revealed a significant association between positive pH-impedance result and LES residual pressure in patients with typical (p=0,045) and atypical (p=0,038) symptoms. Conclusion UES abnormalities is the prevalent diagnostic finding in patients with atypical GERD underwent pH-impedance. UES dysfunction characterize all patients diagnosticated with atypical GERD by Ph-impedance.

O32 LYON CONSENSUS CRITERIA SIGNIFICANTLY CHANGES THE PH IMPEDANCE DIAGNOSIS OF GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Abstract Aim To investigate the Lyon Consensus Criteria impact on Ph-Impedance diagnosis of GERD and their relation to high resolution manometric tracing results. Background &amp; Methods GERD is a complex disease with a heterogeneous symptom profile and a multifaceted pathogenic basis that defies a simple diagnostic algorithm or categorical classification. The Lyon Consensus defines parameters on esophageal testing that conclusively establish the presence of GERD and characteristics that rule out GERD. We retrospectively evaluated according the new criteria our patients underwent pH-Impedance one year before the publication of Lyon Consensus Criteria and analyzed the differences in relation to the older diagnostic criteria. Results 130 patients (56 M, median age 52,03 R18-77) Ph-impedance exams for suspected typical and atypical GERD were re-evaluated. According to Lyon criteria for conclusive evidence of GERD 15,38% of them were over-diagnosticated and 1,53% had inconclusive evidence of the disease using the past criteria. In the evaluation of 94 patients with typical symptoms 23,4% were over-diagnosticated in according to the past diagnostic criteria. Statistical analysis of manometric values of the patients highlight that LES basal pressure (median 108.95, R38.7-283.4) (p=0,049) and UES residual pressure (median 7.8 R0.6-63.5) (p=0,003) significantly predict the Lyon criteria pH-impedance outcome. Analysis of manometric values of the patients with typical symptoms revealed that LES residual pressure (median 5,21 R0,1-20,7) (p=0,007) and Total Number of refluxes (median 28,03 R1-122) (p=0,013) significantly predict the Lyon criteria pH-impedance outcome. Conclusion Lyon Consensus Criteria significantly changes the pH-impedance diagnosis in patients undergoing testing for suspected GERD. In patients with typical symptoms new criteria allow not to overdiagnose 25% of GERD patient. Manometric values analysis significantly correlates and predict the Lyon criteria pH-impedance outcome.

370 Can Subjective GERD Questionnaires Predict Abnormal Findings in pH Impedance Testing?

INTRODUCTION: Subjective and objective tools are used to diagnose GERD, including questionnaires and 24 hour pH impedance. We examined correlations between the GERD questionnaire (GERDQ) and Reflux Symptom Index (RSI) questionnaires against component metrics of 24-hour pH impedance testing (number of reflux events, esophageal acid exposure, and symptom association). METHODS: 117 consecutive adult patients referred for PPI refractory GERD symptoms were included. All patients completed GERDQ and RSI, which are validated questionnaires for predicting GERD based on typical and atypical reflux symptoms, respectively. Patients then underwent 24 hour pH impedance testing. RSI score, GERDQ grade, pH impedance results (positive, negative), esophageal acid exposure (EAE), number of reflux events, and symptom association were variables of interest analyzed using Chi-square tests. RESULTS: A positive GERDQ result (grade C or D) was not significantly associated with abnormal pH impedance (P = 0.08). There was no correlation between positive GERDQ and abnormal EAE (P = 0.79) or number of reflux events (P = 0.26). However, positive symptom association was associated with an abnormal GERDQ (P = 0.01). Similarly, there was no significant correlation between positive RSI and abnormal pH-Imp (P = 0.06), abnormal EAE (P = 0.19), or number of reflux events (P = 0.09). Positive RSI was significantly associated with positive symptom association (P = 0.04). 58% (52/90) of patients with positive GERDQ also had positive RSI (P = 0.001). CONCLUSION: Our data suggest that positive subjective GERD assessment tools (GERDQ and RSI) are associated with positive symptom association component of pH impedance testing. However abnormal acid exposure or number of reflux episodes are more difficult to predict. Many patients report typical and atypical GERD symptoms, suggesting an overlap of symptoms. This may be exaggerated by self-report bias, and is not predictive of pH-impedance result.

Gastroesophageal reflux symptoms and microscopic esophagitis in a cohort of consecutive patients affected by atrophic body gastritis: a pilot study

Aim: In patients affected by atrophic body gastritis (ABG) gastro-oesophageal reflux (GER) related symptoms have been reported, despite the presence of hypochlorhydria.Objective: Objectives of this single-centre study was to assess in ABG the occurrence of GER-related symptoms and their relationship with histopathologic oesophageal findings.Materials and methods: Fifty-four consecutive patients (20.4%male, 57.6 ± 14 years) undergoing to follow-up for ABG, underwent assessment of GER-related symptoms and gastroscopy with multiple gastric and oesophageal biopsies to investigate the presence of microscopic esophagitis (ME).Results: At least one typical GER symptoms were reported in 24.1% with 9.2% of patients complaining of heartburn and 18.5% regurgitation. One or more atypical GERD symptoms were reported in 44.4% of patients. Two symptomatic ABG patients presented oesophageal lesions at endoscopy (one with erosive esophagitis (LA-C) and one with Barrett’s oesophagus (C2M2)), 49% reported a mild ME and 24.5% a severe ME. No significant differences regarding GERD prevalence were found among patients with or without ME, but cough was the only symptom significantly more frequent in patients with ME (38.95% vs. 7.7%, p = .042).Conclusions: These data showed that GERD is present in a quarter of ABG patients, suggesting that hypochlorhydria not exclude per se arising of oesophageal symptoms. In ABG we found that ME is a frequent finding but its clinical relevance remains to be investigated with further studies.

PS01.056: ELECTRICAL STIMULATION OF THE LOWER ESOPHAGEAL SPHINCTER IN PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE AND IMPAIRED ESOPHAGEAL MOTILITY

Abstract Background Laparoscopic fundoplication (LF) is considered as standard surgical antireflux therapy. However, even if performed in specialized centers, the procedure can be followed by long-term side effects dysphagia, gas bloating or inability to belch. Especially patients with motility disorders (IEM) and concurrent GERD are prone to postoperative dysphagia after LF. The aim of this study is the evaluation of electrical stimulation (EST) of the lower esophageal sphincter (LES) in patients with IEM and GERD and its impact on procedure-related gastrointestinal side effects such as dysphagia. Methods This is a prospective, open-label, non-randomized single-center study. All variables are depicted as median and interquartile range (IQR) or 95% confidence intervals (CIs) or mean with standard deviation (SD). Ineffective esophageal motility (IEM) was defined as a Distal Contractile Integral (DCI) below 450 mmHg-s-cm in ≥ 5 of out 10 swallows. Differences in GERD health-related quality of life (HRQL) scores before and after treatment were compared with paired t-test due to a normal distribution. P-values &lt; 0.05 were considered significant. Results Between 05/2015 and 10/2017 twenty patients were treated with LES-stimulation for GERD. Thirteen patients (61.9%) presented with IEM in esophageal manometry before surgery and were included in this analysis. DCI was 91 (IQR 30.5–331.5) mmHg-s-cm. Median 24-hours esophageal pH at baseline was 10.2% (IQR 4.4–21.5). Fifty-seven percent of patients were treated with PPI at time of surgery. Nine patients (69.2%) presented with typical GERD symptoms whereas 6 patients (46.2%) also presented with atypical GERD symptoms. BMI was 26.1 (SD 4.9). Eight patients (61.5%) showed a hiatal hernia at the time of surgery and underwent also hiatal repair. Operating time was 59 minutes (IQR 34.5–70.25). HRQL for heartburn at baseline was 21.1 (SD 5.4) and improved to 7.3 after surgery (SD 6.7) at follow up of one month (mean difference 13.8 (CI 12.5–15.1) P &lt; 0.001). HRQL for regurgitation at baseline was 18.69 (SD 6.9) and improved to 3.84 (SD 2.4) (mean difference 14.9 (CI 13.95–15.76) P &lt; 0.001). No patients showed any clinical signs of dysphagia nor impaired findings in postoperative contrast swallow. Gastrointestinal side effects such as the inability to belch or bloating were not seen in any patients. There were no severe adverse events related to the procedure, but one patient need re-do surgery and re-implantation of the LES-stimulation due to a breaking of the lead close to the implanted pulse generator after one year. Conclusion LES-EST was introduced as a potential alternative technique to avoid side effects of LF. It was demonstrated that LES-EST significantly raises the LES pressure and improved GERD symptoms such as heartburn and regurgitation. The advantage of this procedure is that the anatomy of the esophageal-gastric junction is not altered dramatically. Disclosure All authors have declared no conflicts of interest.

The Pressure Inversion Point (PIP): Passeʼ or Paramount

PIP is produced by diaphragmatic moverment during respiration. In conventional manometry, it was used as a landmark to locate the approximate location of the LES. However, using this landmark in small hiatal hernia (HH) can give inaccurate LES location. The role of PIP in the era of high resolution manometry (HRM) has diminished. This is especially due to the easy recognition of HH using its colored pressure topography. HH is identified by 2 distal high pressure zones with the peristaltic sequence ending at the level of the LES, distinguishing it from the diaphragmatic pressure zone. Here we present a case of 72 year old female, referred to our motility laboratory by her primary care physician. Her main complain is recurrent episodes of epigastric pain, associated with nausea, dizziness and shortness of breath. Her past medical history includes hypertension and GERD. She denied dysphagia, weight loss and any atypical GERD symptoms. The patient states she had similar attacks throughout the last 8 years. Her work up included HRM and stress perfusion cardiac MRI. The HRM showed normal peristalsis with normal LES metrics (resting pressure and integrated relaxation pressure were 19 and 14 mm/Hg respectively). The only interesting finding was the absence of detectable PIP (figure 1). The stress perfusion MRI showed no cardiac perfusion and left ventricular function pararmeters. Incidentally, the MRI showed complete intrathoracic positioning of the stomach. CT abdomin was performed and it confirmed the finding (figure 2).Figure: HRM of the case. There was absence of detectable PIP with same respiratory cyclic color fluctuation above and below the LES.Figure: A: MRI showing the presence of intrathoracic stomach, B: CT abdomen confirming the same finding.Figure: An example of normal manometry with detectable PIP at the level of the LES. The respiratory cyclic color fluctuation is inverted in the region below the LES.Discussion: Locating the PIP is relatively easy using HRM. However, one must learn to recognize the color contour appearance of this phenomenon. In addition, its presence /absence can be roughly deetermined by observing the respiratory variations in the HRM color plot. The typical blue of the intraesophageal pressure darkens with inspiration and lightens with expiration. This finding assists in locating the diaphragm and so the PIP, since intraabdominal pressure changes inversely to the intrathoracic pressure with respiration (figure 3). In our case, these respiratory cyclic pressure fluctuations were the same above and below the LES. Lessons learned: Locating the PIP is important, despite not being used in the HRM algorithm of the Chicago classification. As shown in this case, the absence of detectable PIP reflects a significant structural pathology (complete intrathoracic stomach).

P116 A case of difficult-to-treat asthma due to uncontrolled atypical gerd

P116 A case of difficult-to-treat asthma due to uncontrolled atypical gerd

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

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.

Su1756 The Role of Syptom Index (SI) and Symptom Associated Probability (SAP) in the Surgical Treatment of Atypical GERD Symptoms

S A T A b st ra ct s performed or reduce postoperative dysphagia. Methods and Procedures: We performed a retrospective review of all patients undergoing PEH repair between January 2011 and July 2014. Demographic, preoperative, operative, and outcome data were collected prospectively and maintained in an IRB approved database. The primary outcome measures included the type of fundoplication performed and post-operative dysphagia scores. Secondary outcomes included disease specific quality of life scores (GERD-HRQL) and patient satisfaction. Data were analyzed using Stata 12 software (Stata Corporation, College Station, TX) with significance set at p < 0.05. Results: One hundred twenty-five patients underwent laparoscopic PEH repair during the study period. Forty-seven (37%) patients underwent preoperative manometry, and 78 (62%) did not. The mean age was 65.6±14.3 years and 87 (70%) were female with a mean body mass index (BMI) of 29.9±5.8 kg/m2. Patients who did not undergo manometry were older (67.9 vs. 61.7, p=0.02), but the groups did not differ in terms of BMI, gender, Proton Pump Inhibitor (PPI) use, baseline dysphagia score, baseline GERDHRQL score or type of fundoplication performed. At a median follow-up of 16 months (range 4 44 months), the median dysphagia score was 0 for both groups (p=0.41). Five (14%) patients in the no manometry group required endoscopic dilation compared to 3 (17%) in the manometry group (p=0.76). Median GERD-HRQL score improved significantly in both the no manometry and manometry groups (7 vs. 2, p<0.01 and 16 vs. 2, p<0.01 respectively). Overall 96% of patients were satisfied with their operation and 96% would choose to have surgery again given the benefit of hindsight. Conclusions: Laparoscopic paraesophageal hernia repair with complete fundoplication is a safe and effective treatment that improves disease specific quality of life with a low rate of post-operative dysphagia. The use of preoperative manometry does not impact the choice of fundoplication and its omission does not increase the rate of post-operative dysphagia or the need for postoperative dilation. Hence, the routine use of preoperative manometry for patients undergoing paraesophageal hernia repair is not necessary. Further study is needed to define which patients may benefit from selective preoperative manometry.

Tu1877 Different Contractile and Relaxant Effects of Trypsin in Phasic Smooth Muscles of the Esophageal Body and the Tonic Lower Esophageal Sphincter

G A A b st ra ct s significant difference was observed for age (mean age 52 years in both groups, p=0.922), gender (50% men vs 34%, p=0.097) and body mass index (median 25 kg/m2 vs 24.7 kg/ m2, p=0.569). Patients with typical symptoms were non-responders in 86%, those with atypical symptoms alone in 74% and those with atypical symptoms dominant in 92%. The results of pH-impedance tests were not significantly different between PPI-responders and non-responders. The prevalence of PDS was significantly higher in PPI-non responders, while the prevalence of EPS and IBS almost reach statistical significance (Table). Conclusion This study confirms that pH-impedance monitoring does not help to predict clinical response or non-response to PPI treatment. Functional digestive disorders (EBS, PDS or IBS) appear more frequent in PPI-non responders. Visceral hypersensitivity may be a predictive factor of PPI-non-response in patients with typical or atypical GERD symptoms.

Gastroesophageal reflux symptoms in typical and atypical GERD: Roles of gastroesophageal acid refluxes and esophageal motility

To determine the roles of gastroesophageal acid reflux (GER) and esophageal dysmotility on typical and atypical GERD symptoms. Two hundred thirty-six patients (159 females, age 47 ± 14 years) with typical and atypical GERD symptom(s) for > 3 months underwent standard water perfused esophageal manometry (EM) and 24 h esophageal pH studies during off therapy. Eighty seven and 93 patients had positive lower esophageal pH tests and abnormal EM, respectively. Patients with positive lower esophageal pH test were significantly older (50 ± 13 vs 45 ± 13 years, P < 0.005) and had higher prevalence of acid regurgitation symptoms than patients with negative test (56/87 vs 72/149, P < 0.05). Patients with positive upper esophageal pH test (n = 67) also had significantly higher prevalence of acid regurgitation symptoms (43/67 vs 74/152, P < 0.05). Prevalence of other upper gastrointestinal and respiratory symptoms were similar between patients with positive and negative upper and lower pH test. Patients with abnormal EM were significantly older (49 ± 14 vs 45 ± 13 years, P < 0.05) and had higher prevalence of chronic cough than patients with normal EM(30/93 vs 26/143, P < 0.05). In patients with positive pH tests, the prevalence of dysphagia, chronic cough, and hoarseness of voice were significantly higher in patients with abnormal than those with normal EM (18/31 vs 18/56, P < 0.05; 12/31 vs 6/56, P < 0.005 and 19/31 vs 18/56, P < 0.01, respectively). Whereas in patients with negative lower pH tests, only the prevalence of heartburn was significantly lower in patients with normal than those with abnormal EM (26/87 vs 30/62, P < 0.05). Acid regurgitation but not heartburn was associated with GER. Esophageal dysmotility had no significant effect on acid regurgitation symptom but associated with chronic cough, hoarseness of voice, and dysphagia only in patients with abnormal esophageal acid exposure.

Tu1809 Preoperative Esophagogastric Junction (EGJ) Distensibility Predicts Treatment Outcome After Endoscopic Fundoplication in GERD Patients

G A A b st ra ct s reduction of proton pump inhibitors (PPI) therapy after the weight loss. MATERIAL AND METHODS: we enrolled a group of 50 overweight and obese patients with typical and atypical GERD symptoms with previous erosive esophagitis endoscopically proven. These patients were evaluated with two validated questionnaires (QOLRAD and VAS) to detect the prevalence of GERD related symptoms and the ongoing PPI therapy. All patients underwent an anthropometric evaluation (BMI, height, weight, abdominal circumference) and received a personalized hypo-caloric diet with 1200-1500Kcal for women and 1500-1800Kcal for men. The hypocaloric diet was considered effective if at least of 10% weight loss was obtained in each patient. The hypocaloric diet was completed within 6 months. The same anthropometric evaluation and questionnaires were performed at the end of treatment. The results were evaluated with a Student paired t-test and considered statistically significant when p value was , 0.05. RESULTS: Male/female ratio was 0.78 (22/28). Mean age was 49.3(±11,8). Mean BMI decreased from 30.3 (sd ±4,1) to 25.7(±3.1) (p,0.05) and the mean weight loss from 82.1(±16.9) to 69.9 (±14,4) after hypocaloric diet (p,0.05). Symptoms perception decreased both with QUOLRAD and VAS scale (p,0.05). In particular, heartburn decreased from 3.68(±1.9) to 0.28(±0.4) in QUOLRAD scale and from 5.7(±1.8) to 0.6(±0.6) in VAS scale (p,0.05). PPI therapy was completely discontinued in 27/50 (54%) patients, was halved in 16/50 (32%) patients. Only 7/50 (14%) continued the same PPI dosage. CONCLUSION:we can conclude that a 10% of weight loss is recommended in all patients with GERD-related symptoms. This weight reduction could be able to reduce not only symptoms perception but also the dose of PPI therapy.

Tu2094 Atypical GERD Is a Mechanism of Nausea in a Subset of Patients With Gastroparesis

Tu2094 Atypical GERD Is a Mechanism of Nausea in a Subset of Patients With Gastroparesis