Extraesophageal Manifestations Of Gastroesophageal Reflux Disease Research Articles

Заболевания верхних дыхательных путей как внепищеводные проявления гастроэзофагеальной рефлюксной болезни: современное состояние проблемы

Bronchial asthma, chronic cough, laryngitis, erosion of tooth enamel are attributed to extra esophageal manifestations of gastroesophageal reflux disease (GERD). This form of GERD is characterized by the difficulty of establishing the diagnosis and high frequency of ineffective therapy. The article describes the main endoscopic signs of damage to the esophagus and larynx, presents normal pH-impedance reflux monitoring and criteria for pathological reflux into the esophagus and the lower third of the pharynx, as well as the possibilities of additional diagnostic methods – esophageal manometry and pepsin test. Treatment of patients with extra esophageal manifestations of GERD is a difficult task; the results of randomized placebo-controlled studies are contradictory. At the same time, empirical therapy is most effective in patients whose extra esophageal symptoms are combined with typical ones

Гастроэзофагеальная рефлюксная болезнь и коррекция ее проявлений у пациентов перед офтальмохирургическими вмешательствами

Purpose. Evaluation of the frequency of extraesophageal manifestations in the structure of gastroesophageal reflux disease (GERD) in patients admitted for ophthalmic surgery. Material and methods. The preoperative state of 76 patients with extraesophageal manifestations of GERD was analyzed. The assessment of the adequacy and effectiveness of drug therapy, algorithms for diagnosing extraesophageal manifestations of GERD is given, our own clinical case is presented to illustrate the complexity of diagnosing extraesophageal manifestations of GERD. Results. A group of 76 people with extraesophageal manifestations of GERD (21 %) out of 363 patients with GERD admitted for treatment in 2019 was studied. In 25 people (33 %), the extraesophageal form of GERD was not diagnosed before admission to the hospital. Of these, in 17 people GERD proceeded under the guise of cardiological pathology, in 8 people - under the guise of bronchopulmonary pathology. Conclusion. GERD occupies a leading position among diseases of the upper gastrointestinal tract (more than 30 %). About 21 % are atypical manifestations of GERD. Modern etiopathogenetic treatment of GERD makes it possible to effectively stop the symptoms of the disease, avoid polypharmacy, undesirable drug interactions and unreasonable refusal of planned surgical treatment for patients with ophthalmic diseases. Keywords: gastroesophageal reflux disease, extraesophageal manifestations, cardiological and bronchopulmonary “masks”, ophthalmic surgery.

Роль біологічно активних речовин у формуванні гастроезофагеальної рефлюксної хвороби у хворих на цукровий діабет 2 типу

Актуальність. У наш час недостатньо вивчені фактори, що впливають на перебіг і клінічні прояви гастроезофагеальної рефлюксної хвороби (ГЕРХ) у хворих на цукровий діабет (ЦД) 2 типу. Мета. Дослідження особливостей зміни рівнів простагландинів (Pg) І2 та F2α у сироватці крові залежно від клінічного перебігу ГЕРХ у хворих на ЦД 2 типу. Матеріали та методи. Обстежено 82 хворих на ГЕРХ і ЦД 2 типу (основна — 1 група) і групу порівняння (85 хворих на ГЕРХ — 2 група). Обстеженим пацієнтам у сироватці крові проводили визначення PgF2α та 6-кето-простагландину F1α (простациклін крові — PgI2). Результати. Скарги щодо органів травлення, характерні для ГЕРХ, установлено у 61,0 % пацієнтів 1 групи; у 22,0 % хворих із поєднаною патологією виявлено отоларингологічну; у 17,1 % обстежених — кардіальну форму ГЕРХ. У хворих на поєднану патологію більш виражене підвищення концентрації PgI2 із позастравохідними проявами ГЕРХ, особливо при його отоларингологічній формі (в 4,1 раза порівняно з показниками контрольної групи), тоді як у хворих при кардіальній масці ГЕРХ його концентрація підвищена у 3,5 раза, а у хворих зі стравохідними проявами ГЕРХ і ЦД 2 типу — у 3,0 раза. У хворих на ГЕРХ аналогічні зміни встановлено у 2,4 раза (отоларингологічні прояви), у 2,2 раза (кардіологічні прояви) та у 1,6 раза (типові прояви ГЕРХ) частіше. Висновки. ГЕРХ при ЦД 2 типу часто проявляється позастравохідною симптоматикою (отоларингологічна, кардіологічна форми). Максимальне підвищення рівня простацикліну у сироватці крові встановлено у хворих із позастравохідними проявами ГЕРХ у поєднанні з ЦД 2 типу, особливо його отоларингологічної форми.

Baseline impedance via manometry and ambulatory reflux testing are not equivalent when utilized in the evaluation of potential extra-esophageal gastroesophageal reflux disease.

BackgroundEsophageal baseline impedance (BI) shows promise for the diagnosis of gastroesophageal reflux disease (GERD), but means of acquisition and relevance to extra-esophageal manifestations of GERD (EE-GERD) remain unclear. In this study we aim to (I) evaluate concordance between BI as measured by 24-hour pH-impedance (pH-MII) and high-resolution impedance manometry (HRIM), and (II) assess relationship to potential EE-GERD symptoms.MethodsIn this prospective open cohort study, patients presenting for outpatient HRIM and pH-MII studies were prospectively enrolled. All patients completed the GERD-HRQL, NOSE, and respiratory symptom index questionnaire (RSI), plus questions regarding wheezing and dental procedures. HRIM and pH-MII were evaluated with calculation of BI. Correlations were assessed using either Pearson’s correlation or Spearman’s rank coefficients.Results70 HRIM patients were enrolled, 35 of whom underwent pH-MII. There was no correlation between BI measurements as assessed by HRIM and pH-MII proximally, but there was moderate-weak correlation distally (r=0.34 to 0.5). Distal acid exposure time correlated with distal BI only for measurements by pH-MII (rho= −0.5 to −0.65), and not by HRIM. There was no relationship between proximal acid exposure time and proximal BI. There were no correlations when comparing proximal or distal BI measurements, acid exposure times, and impedance events to symptoms.ConclusionsConcordance between BI as measured by HRIM and pH-MII is poor, especially proximally, suggesting that these two methods are not interchangeable. There is no correlation between BI both distally/proximally and symptoms of either GERD/EE-GERD, suggesting that many symptoms are unrelated to acid or that BI is not an adequate marker to assess EE-GERD symptoms.

Gastroesophageal reflux disease and atrial fibrillation: comorbidity or overlap syndrome? View of gastroenterologist

Аtrial fibrillation (AF) still occupies a special place in the structure of cardiovascular diseases, both due to its high prevalence, close association with socially significant diseases, and due to the high risks of death, stroke, and other thromboembolic complications. In turn, a patient with AF is always a comorbid patient, and among extracardiac pathology, the prevalence of diseases of the upper gastrointestinal tract, especially gastroesophageal reflux disease (GERD), pay attention. Recently more and more data have appeared that indicate the non-randomness of this combination. Many authors consider GERD as another independent risk factor for AF, while others propose to consider AF as an extra-esophageal manifestation of GERD, of course, in the absence of other cardiac risk factors. This review discusses the main pathophysiological mechanisms that determine the pathogenetic relationship of AF and GERD, known to date.

Laryngopharyngeal reflux: clinical significance, modern approaches to diagnosis and treatment

Gastroesophageal reflux disease (GERD) is one of the most common pathologies in modern clinical practice. Laryngopharyngeal reflux (LPR) is considered to be an extraesophageal manifestation of GERD and is characterized by retrograde ingestion of gastric content into the larynx and pharynx, leading to recurrent otolaryngological symptoms. Classical manifestations of LPR are hoarseness, perspiration, dryness and feeling of lump in the throat, coughing. There is no «gold standard» for the diagnosis of LPR. At the same time, several instrumental methods are used in clinical practice to verify the diagnosis: laryngoscopy and EGDS are the most common, and in some cases - 24-hour pH-metry and impedancemetry. In the case of an established diagnosis of LPR, it is recommended to use a standard dosage of PPI twice a day for 3–6 months.

Extraesophageal Manifestations of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common disease, affecting approx 40 million people in the United States alone. In fact, even this huge number is only an estimate, which is based on population surveys of the prevalence of frequent heartburn (the cardinal symptom of GERD) in the population. The GERD population would likely be even larger if the estimate encompassed individuals with extraesophageal manifestations of GERD, as well as heartburn sufferers. Extraesophageal manifestations of GERD, encompassing a spectrum of pulmonary and otolaryngologic disorders, may be the primary (or only) manifestation of GERD in some individuals. The implicated syndromes include posterior laryngitis, asthma, chronic cough, recurrent pneumonitis, chronic hoarseness, chest pain, pharyngitis, sinusitis, and dental disease.

Association Between Response to Acid-Suppression Therapy and Efficacy of Antireflux Surgery in Patients With Extraesophageal Reflux.

The effectiveness of antireflux surgery (ARS) varies among patients with extraesophageal manifestations of gastroesophageal reflux disease (GERD). By studying a cohort of patients with primary extraesophageal symptoms and abnormal physiologic markers for GERD, we aimed to identify factors associated with positive outcomes from surgery, and compare outcomes to those with typical esophageal manifestations of GERD. We performed a retrospective cohort study to compare adult patients with extraesophageal and typical reflux symptoms who underwent de novo ARS from 2004 through 2012 at a tertiary care center. All 115 patients (79 with typical GERD and 36 with extraesophageal manifestations of GERD) had evidence of abnormal distal esophageal acid exposure based on pH testing or endoscopy. The principle outcome was time to primary symptom recurrence after surgery, based on patient reports of partial or total recurrence of symptoms at follow-up visits. Patients were followed up for a median duration of 66 months (interquartile range, 52-77 mo). The median time to recurrence of symptoms in the overall cohort was 68 months (11.5 months in the extraesophageal cohort vs >132 months in the typical cohort). Symptom recurrence after ARS was associated with having primarily extraesophageal symptoms (adjusted hazard ratio, 2.34; 95% confidence interval, 1.31-4.17) and poor preoperative symptom response to acid-suppression therapy (AST) (hazard ratio, 3.85; 95% confidence interval, 2.05-7.22). Patients with primary extraesophageal symptoms who had a full or partial preoperative AST response experienced lower rates of symptom recurrence compared to patients with poor AST response (P < .01). The rate of symptom recurrence was lowest among patients with primary typical reflux symptoms who had a partial or full symptom response to AST (P < .01). The severity of acid reflux on pH testing, symptom indices, severity of esophagitis, and hiatal hernia size were not associated with symptom response. In a retrospective study, we found the effectiveness of ARS to be less predictable in patients with extraesophageal symptoms of GERD than in patients with typical GERD. Response to AST before surgery was associated with ARS effectiveness in patients with extraesophageal reflux symptoms. Caution should be exercised when advocating ARS for patients with extraesophageal symptoms that do not respond to AST.

Oropharyngeal Reflux Monitoring and Atypical Gastroesophageal Reflux Disease.

The prevalence of gastroesophageal reflux disease (GERD) has been increasing since the 1990 s, with up to 27.8 % of people in North America affected by this disorder. The healthcare burden of patients who primarily have extra-esophageal manifestations of GERD (atypical GERD) is estimated to be 5 times that of patients with primarily heartburn and regurgitation due to lack of a gold standard diagnostic test, poor responsiveness to PPI therapy, and delay in recognition. Empiric twice daily PPI therapy for 1-2 months is currently considered the best diagnostic test, but due to poor responsiveness to PPIs in patients with atypical GERD in multiple randomized controlled trials, newer modes of diagnostic procedures such as oropharyngeal pH monitoring have gained significantly more traction. The utility of oropharyngeal pH monitoring systems such as Restech Dx-pH is currently limited due to lack of consensus on normal and abnormal cutoff values. Recent studies suggest its utility as a prognostic tool and its ability to predict responsiveness to medical and surgical therapy. However, routine use of oropharyngeal pH monitoring is still not widespread due to the lack of well-controlled prospective studies.

Сравнение эффективности лапароскопической фундопликации по ниссену и тупе у пациентов с выраженными внепищеводными ларинго-фарингеальными проявлениями гастроэзофагеальной рефлюксной болезни

&lt;p&gt;Близко 10 % пациентов, страдающих гастроэзофагеальной рефлюксной болезнью (ГЭРБ), отмечают наличие внепищеводных проявлений, что является серьёзной клинической проблемой. При неэффективности консервативной терапии у пациентов с внепищеводными проявлениями ГЭРБ альтернативой выступает выполнение операции.&lt;/p&gt;&lt;p&gt; Представлены результати оперативного лечения у 251 пациента с внепищеводными ЛОР-симптомамы ГЭР в период с 2001 по 2011 г. У 221 (88 %) пациента выполнялась фундопликация по Ниссену, у 30 (12 %) – фундопликация по Тупе. У больных с фундопликацией по Ниссену индекс DeMeester был достоверно ниже, нежели у больных, перенесших фундопликации по Тупе, соответственно, 11,6±4,8 и 23,8±4,2 (p&amp;lt;0,05). Средняя оценка индекса симптомов рефлюкса улучшилась в большей степени у пациентов, которым проводили фундопликацию по методике Ниссена, в сравнении с больными после фундопликации по Тупе, соответственно, 10,4±3,4 и 17,8±4,6 (р&amp;lt;0,05).&lt;/p&gt;&lt;p&gt;Лапароскопическая фундопликация – эффективный метод лечения пациентов как с классической формой ГЭРБ, так и пациентов с внепищеводными проявлениями ГЭРБ. При наличии внепищеводных проявлений ГЭРБ целесообразно выполнять фундопликацию по Ниссену.&lt;/p&gt;

The frequency and clinical aspects of extraesophageal syndromes in elderly patients with gastroesophageal reflux disease

To investigate the frequency of extraesophageal syndromes in elderly patients with gastroesophageal reflux disease (GERD). This cross-sectional study was conducted to compare the clinical manifestations of GERD in 1100 patients aged 60 to 75 years and in 453 patients aged 36 to 60 years. A control group consisted of 154 elderly patients without GERD and 178 mature-aged patients without this condition. GERD was diagnosed via analysis of its symptoms, esophagogastroduodenoscopy, and 24-hour pH monitoring on the basis of the Montreal consensus guidelines. Extraesophageal syndromes were detected actively using the current methods accepted to treat lung, heart, and ENT diseases and a simultaneous gastroesophageal examination. Chronic cough, asthma, chronic laryngitis, cardialgias and cardiac arrhythmias were much more common in elderly patients with GERD than in those without this condition and prevalent in patients with erosive esophagitis and Barrett's esophagus as compared with those with non-erosive reflux disease. The mature-aged patients were recorded to have similar but less pronounced trends. The authors proposed an algorithm for the management of patients with extraesophageal manifestations of GERD, the important aspect of which was two-month acid-suppressive therapy used as both diagnostic testing and empirical treatment for this pathology. The extraesophageal manifestations of GERD in elderly patients are a serious clinical problem calling for considerable attention.

Unmet Needs in the Treatment of Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) is a highly prevalent gastrointestinal disorder. Proton pump inhibitors have profoundly revolutionized the treatment of GERD. However, several areas of unmet need persist despite marked improvements in the therapeutic management of GERD. These include the advanced grades of erosive esophagitis, nonerosive reflux disease, maintenance treatment of erosive esophagitis, refractory GERD, postprandial heartburn, atypical and extraesophageal manifestations of GERD, Barrett’s esophagus, chronic protein pump inhibitor treatment, and post-bariatric surgery GERD. Consequently, any future development of novel therapeutic modalities for GERD (medical, endoscopic, or surgical), would likely focus on the aforementioned areas of unmet need.

Gastroesophageal Reflux Disease in Neonates and Infants

Gastroesophageal reflux (GER) is defined as the involuntary retrograde passage of gastric contents into the esophagus with or without regurgitation or vomiting. It is a frequently experienced physiologic condition occurring several times a day, mostly postprandial and causes no symptoms. These infants are also called 'happy spitters'. GER disease (GERD) occurs when reflux of the gastric contents causes symptoms that affect the quality of life or pathologic complications, such as failure to thrive, feeding or sleeping problems, chronic respiratory disorders, esophagitis, hematemesis, apnea, and apparent life-threatening events. About 70-85 % of infants have regurgitation within the first 2 months of life, and this resolves without intervention in 95 % of infants by 1 year of age. The predominant mechanism causing GERD is transient lower esophageal sphincter (LES) relaxation, which is defined as an abrupt decrease in LES pressure to the level of intragastric pressure, unrelated to swallowing and of relatively longer duration than the relaxation triggered by a swallow. Regurgitation and vomiting are the most common symptoms of infant reflux. A thorough history and physical examination with attention to warning signals suggesting other causes is generally sufficient to establish a clinical diagnosis of uncomplicated infant GER. Choking, gagging, coughing with feedings or significant irritability can be warning signs for GERD or other diagnoses. If there is forceful vomiting, laboratory and radiographic investigation (upper gastrointestinal series) are warranted to exclude other causes of vomiting. Irritability coupled with back arching in infants is thought to be a non-verbal equivalent of heartburn in older children. Other causes of irritability, including cow's milk protein allergy, neurologic disorders, constipation and infection, should be ruled out. The presentation of cow's milk protein allergy overlaps with GERD, and both conditions may co-exist in 42-58 % of infants. In these infants, symptoms decrease significantly within 2-4 weeks after elimination of cow's milk protein from the diet. For non-complicated reflux, no intervention is required for most infants. Effective parental reassurance and education regarding regurgitation and lifestyle changes are usually sufficient to manage infant reflux. Sandifer syndrome, apnea and apparent life-threatening events are the extraesophageal manifestations of GERD in infants. Pharmacotherapeutic agents used to treat GERD encompass antisecretory agents, antacids, surface barrier agents and prokinetics. Currently, North American Society for Pediatric Gasroenterology, Hepatology and Nutrition (NASPGHAN) and European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) practice guidelines concluded that there is insufficient evidence to justify the routine use of prokinetic agents. Esomeprazole (Nexium) is now approved in the US for short-term treatment of GERD with erosive esophagitis in infants aged from 1 to 12 months. Although Nissen fundoplication is now well established as a treatment option in selected cases of GERD in children, its role in neonates and young infants is unclear and is only reserved for selective infants who did not respond to medical therapy and have life-threatening complications of GERD.

Nocturnal Gastroesophageal Reflux: Assessment and Clinical Implications

Nocturnal Gastroesophageal Reflux: Assessment and Clinical Implications

Pulmonary manifestations of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) may cause, trigger or exacerbate many pulmonary diseases. The physiological link between GERD and pulmonary disease has been extensively studied in chronic cough and asthma. A primary care physician often encounters patients with extra esophageal manifestations of GERD in the absence of heartburn. Patients may present with symptoms involving the pulmonary system; noncardiac chest pain; and ear, nose and throat disorders. Local irritation in the esophagus can cause symptoms that vary from indigestion, like chest discomfort and abdominal pain, to coughing and wheezing. If the gastric acid reaches the back of the throat, it may cause a bitter taste in the mouth and/or aspiration of the gastric acid into the lungs. The acid can cause throat irritation, postnasal drip and hoarseness, as well as recurrent cough, chest congestion and lung inflammation leading to asthma and/or bronchitis/ pneumonia. This clinical review examines the potential pathophysiological mechanisms of pulmonary manifestations of GERD. It also reviews relevant clinical information concerning GERD-related chronic cough and asthma. Finally, a potential management strategy for GERD in pulmonary patients is discussed.

The Proton Pump Inhibitor (PPI) Test in GERD

The proton pump inhibitor (PPI) test is a short course of high-dose PPI, used to diagnose gastroesophageal reflux disease (GERD). This diagnostic strategy is commonly used globally, primarily because of its availability, simplicity, and high sensitivity. The PPI test has been proven to be a sensitive tool for diagnosing GERD in noncardiac chest pain patients and in preliminary trials in extraesophageal manifestations of GERD. Several recent meta-analyses reevaluated the value of the PPI test in patients with classic GERD-related symptoms and noncardiac chest pain. Although the results were conflicting, the PPI test remains a popular tool for determining the presence of GERD. Attempts to challenge the PPI test without offering attractive alternatives are unlikely to alter clinical practice.

GERD und Komplikationen: Wann ist der Chirurg gefragt?

Esophagitis, ulcer with potential for bleeding and peptic stenosis are typical complications of gastroesophageal reflux disease (GERD). Whereas GERD is frequent with symptom prevalence of 30 % in the normal population, ulcer and peptic stenosis have become very rare. Consequently surgical interventions due to these complications are only necessary in exceptional cases. After successful bougienage and response to adequate medical treatment, surgical indications for peptic stenosis or ulcer are not different to those for other forms of reflux disease. GERD patients with a "short esophagus" and axial hiatal hernia are difficult to treat either by medication or surgery. However, intrathoracic fundoplication may lead to acceptable results. Extraesophageal manifestations of GERD are caused by a severe reflux up to the cervical esophagus. The resulting laryngitis or pulmonary problems require antireflux surgery more often than in the absence of these symptoms. Long-standing reflux can lead to the development of Barrett mucosa, which represents a precancerous for esophageal adenocarcinoma and can be considered as a special complication of GERD. Retrospective data show that progression of Barrett mucosa or its malignant degeneration cannot be prevented by fundoplication. However, in a comparative study concerning low-grade neoplasia fundoplication leads to significantly more cases with regression than medication. High-grade neoplasia has to be removed in all cases. With regard to the prerequisite for correct indications the long-term results of endoscopic or surgical procedures are equal, but endoscopic mucosectomy is favoured due to its lower invasiveness. Indications for surgery by limited or radical esophagectomy are incomplete removal of neoplasia after mucosectomy, long Barrett's esophagus with multifocal lesions or suspicion of submucosal carcinoma.

Halitosis and gastroesophageal reflux disease: a possible association

Previous reports have suggested that gastrointestinal (GI) diseases may cause halitosis. The aim of this study was to evaluate the relationship between upper GI conditions, especially gastroesophageal reflux disease (GERD), and halitosis. One hundred and thirty two consecutive patients complaining of upper GI symptoms were included in the study. All the patients completed a validated questionnaire that was designed to characterize and measure the severity of their symptoms. The questionnaire also contained questions about awareness and severity of oral bad breath. Following the filling of the questionnaire, the patients were physically examined and subjected to an upper GI endoscopy. The final diagnosis among the 132 patients (M/F = 70/62, mean age 45.2 years, range 20-87 years) was GERD in 72 patients (55%), Functional dyspepsia in 52 (39%), Peptic ulcer in seven patients (5%) and gastric cancer in one patient (1%). Halitosis was significantly associated with the occurrence and severity of heartburn (P = 0.027), regurgitation (P = 0.002) sour taste (P < 0.001), belching (P = 0.001) and burburigmus (P = 0.006). Halitosis was not associated with upper abdominal pain, bloating, early satiety and chest pain. In relation to the final diagnosis, halitosis was significantly associated only with GERD (P = 0.002) but not with functional dyspepsia (P = 0.855) and peptic ulcer disease (0.765). No correlation was found between Helicobacter pylori infection status and halitosis occurrence and severity (analysis of variance F = 0.001, P = 0.977). Halitosis is a frequent symptom of GERD and may be considered as an extra-esophageal manifestation of GERD. On the other hand, we did not find an association between functional dyspepsia, peptic ulcer disease and H. pylori infection with halitosis occurrence or severity.

Review on extraesophageal reflux disease

BACKGROUND: Gastroesophageal reflux disease (GERD) has become the most common upper gastrointestinal disorder in modern civilization and recently extraesophageal manifestations of GERD have been recognized as an important entity. METHODS: A literature research on the current status of extraesophageal manifestations of GERD was undertaken using Pubmed. RESULTS: Extraesophageal manifestations of GERD include asthma, chronic cough, hoarseness, otitis media, atypical loss of dental enamel, idiopathic pulmonary fibrosis, recurrent pneumonia, chronic bronchitis and even sudden infant death syndrome. This article focuses on the various disorders that have been associated with extraesophageal GERD. Currently insufficient data on the prevalence and incidence of each of these manifestations is available. Diagnosis and therapy are closely linked and for many of the above mentioned disorders a therapeutic trial with proton pump inhibitors is suggested. The exact role of antireflux surgery in the treatment of extraesophageal manifestations of GERD has not yet been determined. CONCLUSIONS: The link between GERD and disease of the lung, throat and teeth has a significant impact of future treatment modalities for these disorders.

Performance, Tolerability, and Symptoms Related to Prolonged pH Monitoring Using the Bravo System in Mexico

The traditional system for esophageal 24-h pH monitoring requires transnasal introduction of the catheter with pH sensors; this technique produces discomfort, inconvenience, and interference with daily activity. Recently, a catheter-free pH monitoring system (Bravo) has been proposed as an alternative and promising method for 24-h pH. To evaluate performance, tolerability, and symptoms related to this new technology in our population. Consecutive patients with gastroesophageal reflux disease (GERD) with indication for 24-h pH were included. pH Bravo capsule was placed 6 cm above the squamocolumnar junction using endoscopic measurement. Symptoms associated were evaluated daily in a personal diary until 7 days after the capsule attachment. Severity of symptoms was assessed by a 5-point Likert scale. Capsule detachment was assessed by chest X-ray. Eighty-four patients were included. Forty-nine were female (mean age 44 +/- 12 yr). Indications for pH monitoring were: nonresponse to proton pump inhibitor therapy in 38 (45%), preoperative evaluation for anti-reflux surgery in 36 (43%), previous failed transnasal 24-h pH monitoring in 6 (7%), and extra-esophageal manifestations of GERD in 4 (5%). The capsule was successfully attached in 95% of patients. At day 7, capsule detachment occurred spontaneously in all cases. Symptoms related to capsule attachment were: chest pain in 26 (33%), foreign body sensation in 11 (14%), nausea in 5 (6%), and 9 (11%) patients had more than one symptom. Severities of those symptoms were mild, and no patient required removal of the capsule. Women and younger patients had more symptoms related to the procedure (p < 0.05). Esophageal pH monitoring with Bravo capsule is a safe, reliable, and tolerable method in patients with GERD.