Supine Reflux Research Articles

Comparison of daytime and nighttime supine gastroesophageal reflux by pH monitoring of individuals with clinical suspicion of gastroesophageal reflux disease.

This study aims to compare pHmetric characteristics of diurnal and nocturnal supine reflux. We studied 500 consecutive individuals with clinical suspicion of gastroesophageal reflux disease (GERD) who underwent esophageal high-resolution manometry and prolonged ambulatory pH monitoring. Patients were classified with supine GERD pattern when the percentage of acid reflux time in the supine position was equal to or greater than 2.2%. Data on acid reflux in the supine position during daytime and nighttime recumbency were: (i) acid exposure time, (ii) number of reflux episodes, (iii) longest reflux episode, (iv) interval between the last meal and the supine position, (v) interval between the supine position and the first acid reflux episode, and (vi) reported symptoms. Of the 500 evaluated patients, 238 (48%) had GERD. Among these, supine pattern was observed in 134 (56%) patients, bipositional in 53 (23%), and orthostatic in 51 (21%). In patients with daytime recumbency, 112 (51% of 217) were pathological refluxers, with a mean DeMeester score of 45 ± 26. Total acid exposure time (P = 0.8) and reported Symptom Index (P = 0.2) did not differ depending on the period, whether diurnal or nocturnal. All other pHmetric parameters were lower during daytime recumbency. In conclusion, diurnal supine reflux has similar acid exposure time and temporal correlation between symptoms and reflux episodes as nocturnal supine reflux. Other pHmetric parameters are lower for diurnal supine reflux.

PHoenix score: development and validation of a novel approach to decrease the number of inconclusive GERD diagnoses

BackgroundThe Johnson–DeMeester composite score (DMS) is the historical gold standard for diagnosing gastroesophageal reflux disease (GERD). The Lyon Consensus outlines criteria for diagnosing GERD by pH monitoring, defining normal acid exposure time (AET) as < 4% and pathological as > 6%, presenting diagnostic uncertainty from 4 to 6%. We aimed to (i) calculate the proportion of borderline studies defined by total AET alone that are reclassified as normal or pathological by the DMS, (ii) determine the importance of supine AET for reclassification, and (iii) propose a new classification system using a composite score that considers positional changes.MethodsThis single-center, retrospective, observational study analyzed data from patients with an overall total AET from 2 to 6% on 48-h pH monitoring (Bravo pH capsule). Preselected predictors (supine and upright AET) were included in a model to create a composite score (i.e., pHoenix score) using the regression coefficients. The model was internally validated, and discriminative ability was tested against the DMS and compared to the total AET.ResultsWe identified 114 patients (80 [70.2%] women; median age, 55 years). Using the total AET, 26 (22.8%) were classified as normal and 88 (77.2%) as borderline; however, using the DMS, 45 (39.5%) were classified as normal and 69 (60.5%) as pathological. The new pHoenix score demonstrated strong discriminative ability (AUC: 0.957 [95% CI 0.917, 0.998]) with high sensitivity and specificity (lower threshold, 94.4% and 79.2%; upper threshold, 87 and 95.8%). Compared to the total AET alone, the pHoenix score significantly decreased the proportion of inconclusive cases (77.2% vs. 13.2%, p < 0.001).ConclusionTotal AET has low sensitivity to identify pathological reflux as it disregards supine versus upright reflux. The pHoenix score improves the distinction between normal and pathological cases and reduces ambiguity, offering an alternative approach to diagnosing GERD that addresses the limitations of using total AET alone or the DMS.Graphical abstract

Clinical Characteristics of Patients With Ineffective Esophageal Motility by Chicago Classification Version 4.0 Compared to Chicago Classification Version 3.0

Chicago classification version 4.0 (CCv4.0) of esophageal motility disorders developed a more stringent diagnostic criteria for ineffective esophageal motility (IEM) than version 3.0. We studied the implications of the new diagnostic criteria on the prevalence of IEM, and clinically characterized and compared the population of patients who no longer meet diagnostic criteria for IEM to those who retain the diagnosis. We included all consecutively performed high-resolution esophageal impedance manometries from 2014 to 2021. Three cohorts of patients with IEM were created: Patients with IEM by Chicago classification version 3.0 (CCv3.0; CC3 group), by CCv4.0 only (CC4 group), and by CCv3.0 who are now considered normal (Normal group). Demographics, manometric and reflux parameters, and clinical outcomes were compared. A total of 594 manometries were analyzed. Of those, 66 (11.1%) met criteria for IEM by CCv3.0 (CC3), 41 (62.0%) retained an IEM diagnosis using CCv4.0 criteria (CC4), while 25 (38.0%) patients no longer met criteria for IEM (Normal). The CC4 group had higher esophageal acid exposure, especially supine (% time - 18.9% vs 2.2%; P = 0.005), less adequate peristaltic reserve (22.0% vs 88.0%; P = 0.003), and higher Demeester score (49.0 vs 21.2; P = 0.017) compared to the Normal group. There was no difference in bolus clearance between the groups. IEM under CCv4.0 has a stronger association with pathologic reflux, especially supine reflux, and inadequate peristaltic reserve, but impairment in bolus clearance is unchanged when compared with IEM diagnosed based on CCv3.0. Further studies are required to determine the implications of these findings on management strategies.

S414 POEM Is Associated with Increased Reflux in All Positions Compared to Heller Myotomy

Introduction: Achalasia is an esophageal motility disorder that results from a disruption of the neuromodulatory responses of the esophagus and lower esophageal sphincter (LES). A common consequence of treating the hypercontractile LES is worsened gastroesophageal reflux (GER). It is well-established that peroral endoscopic myotomy (POEM) leads to a higher absolute rate of GER than Laparoscopic Heller Myotomy with Dor fundoplication (LHM); however, the exact patterns of reflux have not been well-described. Methods: The charts of patients who underwent LHM or POEM between 2017 and 2019 at our institution were reviewed, and patients who had completed a 2-month post-treatment esophageal pH study off acid-lower agents were included. We also included patients who underwent EGD but did not undergo pH monitoring due to finding erosive esophagitis. Patients with a history of prior myotomy or who underwent Heller without Dor fundoplication were excluded. Results: Of the 236 patients included, 85 (36%) had undergone POEM while 151 (64%) had undergone LHM. Overall, 45% of POEM patients experienced more than 30 reflux episodes per day compared to 12% for LHM, p< 0.001. POEM patients had more GER in all positions compared to LHM, identified by a mean total % time spent in reflux of 9.3% vs 3.2%, upright 7.8% vs 2.6%, and supine 10.1% vs 3.5%, p< 0.001 for all. POEM patients also developed significantly more long refluxes (episodes > 5 minutes) per day (4.0 vs 1.7, p< 0.001). 47% of POEM patients experienced at least one reflux episode longer than 30 minutes, compared to 19% of LHM patients (p< 0.001). POEM patients who developed relatively more reflux in the supine position than upright comprised 41.1% compared to 21.7% of LHM, p=0.007. Conclusion: This study sheds light on the pattern of reflux in POEM as compared to LHM. POEM patients had evidence of significantly more esophageal acid exposure across all indices. POEM patients on average spent 9.3% of their day in reflux as compared to 3.2% for LHM. POEM patients had higher supine to upright ratios of reflux exposure. The finding of abnormal reflux in both the upright and supine position, with relative skew towards supine reflux after POEM may help to better tailor anti-reflux therapies in this population (Table). Table 1. - Reflux pattern differences between POEM and LHM. p-value significant if p<0.05 Characteristic POEM LHM p-value TOTAL Number of refluxes /24h 40.0 15.4 < 0.001 Percent time in reflux 9.3% 3.2% < 0.001 Number of long refluxes /24h 4.0 1.7 < 0.001 Average of longest reflux (mins) 45.7 19.0 < 0.001 UPRIGHT Number of refluxes /1h 1.8 0.6 < 0.001 Percent time in reflux 7.8% 2.6% < 0.001 Number of long refluxes /1h 0.18 0.06 < 0.001 Average of longest reflux (minutes) 19.0 9.9 < 0.001 SUPINE Number of refluxes /24h 1.4 0.5 0.003 Percent time in reflux 10.1% 3.5% < 0.001 Number of long refluxes /1h 0.2 0.1 0.001 Average of longest reflux (minutes) 35.8 12.4 < 0.001 OVERALL DeMeester Score 37.2 13.2 < 0.001 % Time reflux in supine/upright >1 41.1% 21.7% 0.007

Diagnosing Laryngopharyngeal Reflux: A Comparison between 24-hour pH-Impedance Testing and Pharyngeal Probe (Restech) Testing, with Introduction of the Sataloff Score

The purpose of this study was to compare the diagnostic utility of pH monitoring using 24-hour esophageal pH-Impedance (HEMII-pH) testing versus pharyngeal pH (Restech) testing (Respiratory Technology Corporation, Houston, Texas) for diagnosing laryngopharyngeal reflux (LPR). Retrospectively, patients were reviewed who had completed a Reflux Symptom Index (RSI) survey and stroboscopy within 60 days before or after undergoing simultaneous esophageal pH-Impedance monitoring and Restech testing. Reflux Finding Score (RFS) was determined by 4 blinded observers. 80.45% of patients were on anti-reflux medications at the time of study and had incomplete response to treatment for reflux. Improvement on reflux treatment was determined by evaluating presenting pre-pH monitoring RFS, post treatment RFS, and improvement of symptoms. Pearson correlation coefficients were calculated to assess relationships among RSI, RFS, and test results from HEMII-pH and Restech tests. Eighty-seven patients were included in the analysis. The inter-rater reliability of the RFS determination was 74.57%, and the intra-rater reliability was 67.00%. Subjects who had a positive RYAN Score had a significant correlation with RFS (r of 0.222 and p-value of 0.0492). There was no correlation between RFS and number or percent time of reflux events, longest event, total number of events, or percent of time at alkaline pH for either HEMII-PH or Restech test. RSI correlated better with HEMII-pH test than with Restech for percent time spent in both upright (r of 0.226 and p-value of 0.029) and supine position (r of 0.261 and a p-value of 0.032). Restech correlated better with total patient symptom Scores including cough, heartburn, burping, and throat clearing, with a r of 0.242 and a p-value of 0.048. Restech detected more percent time in reflux for total reflux, supine reflux, and upright reflux (p-value less than 0.0001). Restech also detected longer event times than Impedance (p-value of less than 0.0001).When diagnosis of LPR is based on the definition of CRC, the Sataloff Score test had 70.45% sensitivity and 80.95% specificity. The RYAN Score had a sensitivity of 72%, and a specificity of 56.45%, and the Wu Score had a sensitivity of 62.16%, and specificity of 54.05%. When the Sataloff and Wu Score were used together, the sensitivity was 71.45%, specificity 100%, positive predictive value of 100%, and a negative predictive value of 59.46%. The amount of time of reflux events correlates with symptoms better than the number of events. The HEMII-pH test was able to detect more events of pH<4 than Restech, possibly because there might have been more acid events below than above the upper esophageal sphincter, while Restech detected more total events. Restech recorded longer event times than HEMII-pH test. Since length of time correlates with RFS (probably reflecting laryngeal inflammation), and since laryngeal clearance of acid is more similar to pharyngeal than esophageal clearance, this finding might prove valuable clinically. The Sataloff Score has a sensitivity of 70.45%, and a specificity of 80.95% and appears useful clinically to detect mild to moderate that is missed by the RYAN Score. A combination of Sataloff Score and Wu Score may be clinically valuable to identify LPR with an increased sensitivity of 71.45% and increased specificity of 100%. The Wu Score is not yet available for the general clinical use, but the Sataloff Score is.

ESOPHAGEAL FUNCTIONAL DISORDERS IN THE PRE-OPERATORY EVALUATION OF BARIATRIC SURGERY.

Obesity is an independent risk factor for esophageal symptoms, gastroesophageal reflux disease (GERD), and motor abnormalities. When contemplating bariatric surgery, patients with obesity type III undergo esophagogastroduodenoscopy (EGD) and also esophageal manometry (EMN), and prolonged pHmetry (PHM) as part of their pre-operative evaluation. Description of endoscopy, manometry and pHmetry findings in patients with obesity type III preparing for bariatric surgery, and correlation of these findings with the presence of typical GERD symptoms. Retrospective study in which clinical symptoms of GERD were assessed, focusing on the presence of heartburn and regurgitation. All patients underwent EMN, PHM and most of them EGD. 114 patients (93 females-81%), average age 36 years old, average BMI of 45.3, were studied. Typical GERD symptoms were referred by 43 (38%) patients while 71 (62%) were asymptomatic. Eighty two patients (72% of total) underwent EGD and 36 (42%) evidenced esophageal abnormalities. Among the abnormal findings, hiatal hernia was seen in 36%, erosive esophagitis (EE) in 36%, and HH+EE in 28%. An abnormal EMN was recorded in 51/114 patients (45%). The main abnormality was a hypotensive lower esophageal sphincter (LES) in 32%, followed by ineffective esophageal motility in 25%, nutcracker esophagus in 19%, IEM + hypotensive LES in 10%, intra-thoracic LES (6%), hypertensive LES (4%), aperistalsis (2%) and achalasia (2%). Among the 43 symptomatic patients, 23 (53%) had abnormal EMN and 31/71 asymptomatic cases (44%) also presented this finding (P=0.30). PHM showed abnormal reflux in 60/114 patients (53%), with a predominance of bi-positional reflux (42%), followed by supine reflux (33%) and upright reflux (25%). Abnormal PHM was found in 26/43 symptomatic cases (60%) and also among 34/71 asymptomatic cases (48%) (P=0.19). Manometric abnormalities were common in obesity type III patients, the most frequent being hypotensive LES, followed by IEM. Most patients were asymptomatic. There was no correlation between the finding of motor abnormalities and the presence of symptoms. More than half the patients had abnormal reflux at PHM. We found no significant correlation between abnormal reflux and the presence of symptoms.

The Prevalence of Esophageal Disorders Among Voice Patients With Laryngopharyngeal Reflux—A Retrospective Study

The goal of this study was to determine the prevalence of esophageal disorders among voice patients with intractable laryngopharyngeal reflux (LPR) who have undergone 24 pH impedance and esophageal manometry. A retrospective chart review was performed of patients with LPR-associated dysphonia in the absence of subjective dysphagia who presented between January 1, 2007 and June 30, 2019 and underwent 24 pH impedance and esophageal manometry studies after inadequate response to lifestyle modifications, high dose of Proton Pump Inhibitor (PPIs), H2 blockers, alkaline water, and Gaviscon (GlaxoSmithKline, Warren, NJ, USA). The comorbidities, medications, Strobovideolaryngoscopy findings, 24 pH impedance, and esophageal manometry results were analyzed. The study included 109 patients ages 19 to 80 years old, with a mean age of 51.5 (SD 16.8). About 24.8% of the 109 subjects were found to have peristaltic wave abnormalities indicating esophageal dysmotility (11% with esophageal stasis). Lower esophageal sphincter pressures were normotensive in 56.9% of patients, hypertensive in 24.8%, and hypotensive in 18.4% of patients. In addition, the upper esophageal sphincter pressures were normotensive in 57.8% of patients, hypertensive in 36.7%, and hypotensive in 2.8% of patients. About 12.6% had both lower esophageal sphincter and upper esophageal sphincter dysfunction (hypertensive or hypotensive). The average total reflux events in patients exhibiting dysmotility on manometry 101.81, which was significantly higher compared with the mean total of 61.28 in the group of patients without dysmotility (P= 0.0396). In addition, there was a significantly higher prevalence of total events that were weakly acidic in the group with dysmotility compared with the group without (all patients performed the study on reflux medications, mean of total weakly acidic events 70.2 in dysmotility group vs 44.2 in normal motility group, P= 0.0427).Finally, the average number of total supine reflux events and the total acidic supine events were both significantly higher in the dysmotility group compared with the group without motility problems (P = 0.0199 and P = 0.0213, respectively). Esophageal dysmotility may be a significant cofactor in voice patients with refractory LPR on appropriate reflux medications and lifestyle modifications. Further research is advised.

The correlation between gastric bubble size and laryngopharyngeal reflux pattern in patients with laryngopharyngeal reflux disease

Objective: To investigate the correlation between gastric bubble size and laryngopharyngeal reflux pattern in patients with laryngopharyngeal reflux disease(LPRD). Methods: A total of 52 LPRD patients who underwent Dx-pH monitoring and anteroposterior chest radiography at the same time from February 2016 to November 2018 were retrospectively studied. Patients were devided into three position-related groups according to the Ryan score of upright and supine: isolated upright reflux(IUR), isolated supine reflux(ISR) and bipositional reflux(BR) groups. In addition, 13 healthy volunteers with negative pH monitoring were selected as the control group. Gastric bubble size and pH monitoring data among the four groups were compared. SPSS 24.0 was used for statistical analysis. Results: In all the 52 patients, 35 cases (67.3%) were classified as IUR, 9 cases (17.3%) as ISR, and 8 cases (15.4%) as BR. The height of gastric bubbles in the four groups were: IUR (26±14) mm, ISR (9±8) mm, BR (20±13) mm, control (17±15) mm, and statistical difference was found among the four groups(P=0.004). Post Hoc Multiple Comparisons found that IUR group had statistical difference between ISR group and control group (P=0.001, P=0.034 respectively). There was no statistical difference of gastric bubble width and area among the four groups(P=0.340, P=0.186 respectively). The ROC curve of the gastric bubble height with isolated upright and supine reflux patterns was obtained, and the optimal cutoff value of the gastric bubble height was 11 mm. Accordingly, we divided the patiens into two groups with high and low gastric bubble. LPRD reflux pattern distribution was significantly different between the two groups(P<0.001). The comparison of reflux parameters in pH monitoring also showed that the supine reflux parameters in the lower group were significantly higher than those in the higher group, and the upright reflux parameters in the higher group were significantly higher than those in the lower group(P<0.001). Conclusions: The height of gastric bubble is significantly correlated with the reflux patterns in LPRD patients. The gastric bubble of patients with IUR is significantly higher than that of patients with ISR. Taking 11 mm as the cutoff value, patients with higher gastric bubble are more prone to upright laryngopharyngeal reflux, while those with lower gastric bubble are more prone to supine laryngopharyngeal reflux.

450 Esophageal Motility Disorders and GERD in Patients With Pulmonary Nontuberculous Mycobacterial Infection: A Growing Medical Problem

INTRODUCTION: The prevalence of pulmonary infections by nontuberculous mycobacteria (NTM) is increasing worldwide. The etiology of this increase is unclear. There is evidence that gastroesophageal reflux disease (GERD) is associated with NTM infections and can increase the severity of pulmonary disease. Data regarding esophageal motility in this population is sparse. We aimed to characterize esophageal motility disturbances and GERD in patients with bronchiectatic NTM and explore its associations with pulmonary pathology and lung function. METHODS: We conducted a retrospective review of all patients with a confirmed diagnosis of bronchiectatic NTM at a single center who underwent high resolution esophageal manometry (HRM) between November 2014 and March 2018. Chicago Classification 3.0 was used to characterize HRM findings. Combined multichannel intraluminal impedance-pH (pH-MII) was utilized to assess reflux burden. Statistical relationships between proportions and percentages were evaluated by Fisher’s exact test. Linear regression was utilized to assess associations with pulmonary function testing. RESULTS: A total of 32 patients underwent HRM, of which 27 underwent pH-MII. The mean age of all was 70 (SD 10), mean body mass index was 23.4 (SD 6.1), 78% were female, and 44% had a smoking history. The mean lower esophageal sphincter (LES) resting and residual pressures (mmHg) were 36.12 (SD 17.12) and 11 (SD 8.37), respectively. HRM motility disorders included 38% ineffective esophageal motility, 38% normal esophageal motility, 19% esophagogastric outflow obstruction, and 6% jackhammer esophagus. Significant evidence of GERD on pH testing was seen in 12 patients (44%). pH testing showed similar upright and supine reflux burdens of 7.6% and 7.4% respectively. On endoscopy, 2 patients (6.25%) had Barrett’s esophagus. No statistically-significant correlations were found between BMI, gender, mycobacterial organism, imaging characteristics, pulmonary function, HRM diagnosis or presence of significant reflux. CONCLUSION: Esophageal motility is frequently abnormal among patients with NTM. NTM patients also have a high prevalence of GERD, including supine GERD, and Barrett’s esophagus, which is far greater than the general population. Consideration should be given to screening for BE among patients with NTM related bronchiectasis. Larger studies are warranted to further characterize esophageal physiology in these patients and the potential impact on pulmonary pathology.

Peripheral venous hypertension in chronic venous disease

BackgroundMicrovascular venous hypertension has emerged as a central feature of chronic venous disease (CVD). Yet, the incidence and severity of peripheral venous hypertension in the clinical setting have not been reported. This is an observational study of venous hypertension in the lower limb of a large cohort of patients with suspected CVD referred to a single referral center during a 16-year period. MethodsClinical and venous laboratory test data for 8868 limbs of 5792 patients with CVD symptoms seen from 1999 to 2015 were analyzed. Subset A limbs had a mix of obstruction/reflux or neither (n = 4132). These are limbs in which duplex ultrasound reflux (yes/no) status is known. The incidence and severity of obstruction in these limbs are unknown as tests of obstruction were not routinely performed. Subset B limbs had central obstruction (n = 159). These are limbs with intravascular ultrasound-proven stenosis in the iliac veins that was corrected by stent placement. Reflux was assessed by duplex ultrasound and air plethysmography (venous filling index [VFI90]). Pressure measurements included supine venous pressure, erect venous pressure, and ambulatory venous pressure (AMVP). Pressure measurements are categorized according to Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class, reflux and obstruction with Venn distributions of prevalence. ResultsAll pressures (supine, erect, and ambulatory) trended worse in higher CEAP clinical classes. Supine foot venous pressures were elevated in 70% and 76% of subsets A and B, respectively. A positive association between elevated supine pressures and reflux could not be shown in this study. Supine foot venous pressure did not worsen with increasing reflux in the two subsets, but erect foot venous pressure did. Elevated supine pressures were associated with obstruction in subset B. AMVP worsened in most higher reflux categories. Ambulatory venous hypertension was dominantly associated (Venn distribution) with reflux, less commonly with obstruction. ConclusionsSupine venous hypertension is associated with obstruction and does not worsen with reflux. In contrast, erect foot venous pressure worsens in severe reflux categories. Ambulatory venous hypertension worsens in higher CEAP clinical classes. It worsens with increasing reflux. AMVP is dominantly associated (Venn distribution) with reflux, not obstruction.

The Development and Validation of an Endoscopic Grading System for Hiatal Hernia: The Houston Hiatal Criteria

Introduction: A hiatal hernia (HH) is frequently found during esophagogastroduodenoscopy (EGD). Length of the HH is routinely measured as the distance between the gastroesophageal junction (GEJ) and the diaphragmatic pinch. Although gastroenterologists routinely perform examination of the gastric fundus in retroflexion, the diaphragmatic diameter and Hill grade of the gastroesophageal flap valve are not routinely reported during EGD. Methods: A multidisciplinary GERD group at our institution developed the Houston Hiatal criteria, standardized criteria for endoscopic assessment and reporting of HH. These criteria include length (L), diaphragmatic diameter (D) and Hill grade (H). We retrospectively applied these criteria to a prospectively maintained database of patients undergoing 96-hour wireless pH evaluation, and compared the results between groups of patients with and without HH. Results: In our cohort of 257 consecutive patients (94 male, mean age 52.6 years (19-84 years)), 46 patients met the Houston Hiatal criteria for HH, defined as L > 1 cm, D > 1 cm and H ≥ 2. Patients with HH based on these criteria were twice as likely to have endoscopic evidence of esophagitis compared to patients without HH (40% vs 19%, p < 0.01). We also found a positive correlation between higher DeMeester scores and increasing Houston Hiatal criteria scores of HH on 96-hour wireless pH studies (p < 0.01). Patients with HH also had higher mean DeMeester scores (32.38 ± 28 vs 21.54 ± 22, p < 0.01). 96-hour pH study results were more frequently abnormal in patients with HH compared to patients without HH: Total time spent in reflux (91% patients with HH vs 78% patients without HH, p <0.01), upright reflux (96% vs 81%, p < 0.01), supine reflux (89% vs 62%, p < 0.01), and postprandial reflux (98% vs 81%, p < 0.01). Conclusion: The Houston Hiatal criteria for HH allowed accurate endoscopic assessment, description, and grading of HH. Patients with HH based on these criteria were more likely to have esophagitis and objective findings of GERD on 96-hour pH study.328 Figure 1. Houston Hiatal Hernia statistic report

PS01.054: GASTROESOPHAGEAL REFLUX DISEASE PHENOTYPES IN THE MODERN ERA: CLINICAL, ENDOSCOPIC, MANOMETRIC AND PH TESTING PROPERTIES

Abstract Background Reflux phenotypes have classically been divided into supine, upright, and bipositional predominant reflux. Recent data on clinical, endoscopic, and manometric features in these patient groups are scant and most prior reports occurred prior to the advent of high resolution impedance manometry and prolonged wireless pH monitoring. We aimed to evaluate the distribution, demographic, manometric, and endoscopic characteristics of the reflux phenotypes in this modern era of testing. Methods Patients who had esophageal physiology testing at a single tertiary care center over a one year period were retrospectively reviewed for demographic, clinical, endoscopic, manometric and pH impedance data. We included consecutive patients who had undergone pH-impedance or wireless pH testing with an EGD within 6 months. Results 139 patients were included and 91 (65.5%) patients were women was mean age of 51.9 + /- 15.2 years and mean BMI of 29.1 + /- 6.4. The most common reflux pattern was bipositional (46% of patients), followed by supine (25%). Baseline characteristics, endoscopic and manometric data across groups are included in Table 1. Barrett's esophagus was most common in the non-acid group. Endoscopically, esophagitis was most common in the supine and bipositional groups. Manometric findings were similar across groups. Conclusion The epidemiology of GERD patients appears to be changing as evidenced by a higher mean BMI than in the largest prior study from 1999. Despite demographic changes in GERD and more widespread use of advanced esophageal physiology testing, the manometric and endoscopic characteristics of GERD phenotypes remains fairly similar. Disclosure All authors have declared no conflicts of interest.

PS01.050: IMPACT OF FUNDOPLICATION IN THE OUTCOME OF TRACHEAL STENOSIS PATIENTS WITH GASTROESOPHAGEAL ACID REFLUX: A RETROSPECTIVE PROPENSITY SCORE-MATCHED STUDY

Abstract Background Abnormal gastroesophageal acid reflux (GEaR) is often found in laryngeal diseases and tracheal stenosis. The study focuses on the prevalence of GEaR and the impact of anti-reflux surgery in the outcome of post-intubation tracheal stenosis Methods Prospective non-randomized study of patients with post-intubation tracheal stenosis. Inclusion criteria: adult with subglottic or recurrent tracheal stenosis. Exclusion criteria: previous gastroesophageal surgery. Patients were submitted to esophageal manometry and pH study. Patients were divided in 3 groups: one with pH study negative, one with pH study positive receiving treatment with proton pump inhibitor and one with pH study positive submitted to Nissen fundoplication. Follow-up was 24 months. Outcome was considered satisfactory when airway stenosis could be successfully managed by resection, no need for dilatation or definitive decannulation. In order to match the 3 groups, it was used a propensity score match (PSM) and them they were compared. Statistical significance was assumed for P &lt; 0.05 Results Prevalence of GEaR was assessed in 175 patients. Abnormal pH study was found in 74 (42%) with a predominance of supine reflux. Typical GEaR symptoms were found in only 21%. Abnormal manometry was found in 37%, and hypotonic lower sphincter was the most frequent finding. Of the 124 patients who met the inclusion criteria, pH study was normal in 72 and abnormal in 52 (32 underwent clinical treatment and 20 nissen fundoplication). There were no peri-operative complications. After PSM, patients with abnormal pH study submitted to fundoplication had a higher chance of a satisfactory outcome of the stenosis compared to those treated with Omeprazole (OR 5.31; CI 2.41–11.07; P = 0.03) which was similar to those without GEaR (OR 1; CI 0.47–2.11; P = 0.99). Patients without GeAR had a higher chance of resolution of the tracheal stenosis compared to the patients treated with Omeprazole (OR 3.54; CI 2.02–6.19; P = 0.02). Conclusion Asymptomatic GEaR is a frequent finding in tracheal stenosis. Nissen fundoplication was safe and effective in selected patients with tracheal stenosis and GEaR. Control of the airway stenosis was superior after fundoplication if compared to medical treatment of GEaR. A larger prospective randomized multicenter trial is needed to confirm these findings Disclosure All authors have declared no conflicts of interest.

Secrets for successful laparoscopic antireflux surgery: predictors

Gastroesophageal reflux disease (GERD) is a common malady. It is a protean disease with many manifestations. Most patients seek medical attention due to symptoms. When a surgical remedy is contemplated, it is incumbent upon the surgeon to identify those patients in whom antireflux surgery (ARS) will lead to elimination of pathologic reflux and symptomatic improvement. There are many patient-related factors and technical factors which can predict success or failure of ARS. These predictors can be divided into proper diagnosis of GERD-like symptoms, GERD-related patient factors, non-GERD related patient factors, and operation-related factors. Proper diagnosis includes insuring that the GERD-like symptoms are in fact related to pathologic reflux and not some other disease or psychological process. GERD-related patient factors include differentiating between typical and atypical symptoms, as well as upright and supine reflux. This also includes assessing for reflux related complications, such as ulcers, strictures and neoplasia. Non-GERD-related patient factors include other gastrointestinal disorders such as irritable bowel syndrome (IBS), gastroparesis and peptic ulcer disease. Psychological disorders, such as anxiety and depression, can also affect the outcomes of ARS. Lastly, technical aspects, such as the type and geometry of the fundoplication, hiatal closure, division of the short gastric vessels and addition of a pyloroplasty can affect success. Attention to these details will place the surgeon in the best position to insure a favorable outcome of an antireflux operation.

OC-065 Motility and Oesophageal Clearance in Barrett’s Oesophagus

Introduction It is not clear if Barrett’s is a consequence of excessive reflux only or reduced clearance of refluxed materials. This study compares oesophageal reflux over 24 hours and High Resolution Manometry (HRM) response to solids in Barrett’s with non-Barrett’s reflux (NBR). Methods Reports for 19 consecutive patients (M58:F14) with ≥2 cm Barrett’s during 2015 were compared with 25 patients with NBR (M10:F16) and 13 patient controls with normal physiology/endoscopy (M3:F10). All had at least one typical symptom of heartburn, regurgitation or chest pain. All had HRM with the intention of completing 10x5cc water and 5x1cc bread. Contractile vigour was measured with the Distal Contractile Integral (amplitude x length x contraction time); DCI > 450 mmHg.cm.s and breaks in peristalsis of Results Lower oesophageal sphincter pressure was lower in Barrett’s (8 vs. 14 mmHg; p = 0.009). Compared to NBR, patients with Barrett’s (2–10 cm) had significantly reduced DCI for both 5 ml water (318 vs. 650 mmHg.cm.s; p = 0.007) and solid (1096 vs. 2002 mmHg.cm.s; p = 0.009). On the other hand, the likelihood of measuring a DCI of >450 was significantly reduced in Barrett’s only with solids (69% vs. 100%; p only for solids (44% vs. 65%; p = 0.029). All reflux parameters were similar between the two groups: total (p = 0.116), upright (p = 0.233) and supine reflux (p = 0.110), symptom index (p = 0.16), symptom association probability (p = 0.106) and total number of reflux events (p = 0.063). On the other hand, bolus clearance time (BCT) was significantly prolonged for Barrett’s (13 vs. 10 s; p = 0.009) solely due to prolonged supine BCT (14 vs. 10 s; p Comparing those with prior endoscopic Barrett’s therapy (n = 6) with treatment naive (n = 13), there was no difference in any motility or pH monitoring parameter apart from BET which was greater in those who received therapy (5.87% vs. 1.99%; p = 0.046). Conclusion Solids were superior to water swallows in demonstrating ineffective contractility in Barrett’s. This was associated with reduced nocturnal oesophageal clearance and increased exposure to refluxate during the day/night. These findings contribute to the theory of impaired contractility and reduced clearance despite acid-reducing medication in Barrett’s. Disclosure of Interest R. Sweis Conflict with: Organised Symposium funded by Given img/Diagmed, A. Raeburn: None Declared, E. Athanasakos: None Declared, N. Zarate-Lopez: None Declared, L. Lovat: None Declared, R. Haidry: None Declared, M. Banks: None Declared, A. Emmanuel: None Declared

The relationship between idiopathic pulmonary fibrosis and gastroesophageal reflux disease

To study the prevalence and characteristics of gastroesophageal reflux disease (GERD) in patients with idiopathic pulmonary fibrosis (IPF). A total of 48 patients with diffuse parenchymal lung disease (DPLD) including 25 IPF and 23 other DPLD were enrolled from Department of Respiratory Disease in the First Affiliated Hospital of China Medical University. All patients were subjected to 24-hour esophageal pH monitoring. Pulmonary function test and HRCT of lung were performed at the same time. The prevalence of GERD in IPF patients was 64.0%, which was significantly higher than that in other DPLD patients. DeMeester scores were significantly higher in IPF patients than those in non-IPF group [(22.8 ± 21.5) score vs (15.7 ± 14.0) score respectively P < 0.05]. Numbers of reflux longer than 5 minutes [(3.8 ± 4.1) time vs (2.1 ± 2.1) time respectively) and reflux index (1.8 ± 1.7 vs 1.3 ± 1.2) in IPF group were higher than those in non-IPF group, yet without statistical significance. Patients with IPF had significantly higher values of following parameters than those in non-IPF patients including percentage of total reflux time (pH < 4.0) (9.2 ± 5.1)%, percentage of upright reflux time (8.5 ± 5.2)%, percentage of supine reflux time (10.8 ± 10.7)%, numbers of reflux (54.2 ± 22.7) time, numbers of regurgitation longer than 5 minutes (6.3 ± 4.2) time, the longest reflux time (14.5 ± 15.3) min, reflux index 2.5 ± 1.7 and DeMeester scores (34.9 ± 20.3) time (P < 0.05). DeMeester score was positively correlated with gastroesophageal reflux diseases questionnaire (GerdQ) score (r = 0.667, P < 0.01). The prevalence of typical GERD sympotoms in the IPF-GERD patients was higher (heartburn 7/16, regurgitation 6/16) than that in IPF patients without GERD (heartburn 2/9, regurgitation 1/9). Patients with IPF have a high prevalence of GERD, but usually without typical GERD symptoms. In the hospitals 24-hour esophageal pH monitoring not available, GerdQ can be used to identify GERD in IPF patients.

Supraesophageal Reflux: Correlation of Position and Occurrence of Acid Reflux–Effect of Head-of-Bed Elevation on Supine Reflux

Supraesophageal reflux of gastric contents can contribute to perennial nasopharyngitis, cough, and asthma. However, effective treatment strategies for supraesophageal reflux disease (SERD) remain inadequately defined. The purpose of this study is to assess the prevalence and timing of SERD and to investigate the efficacy of head-of-bed elevation in its treatment. A retrospective chart review of patients seen at Scripps Clinic Division of Allergy, Asthma and Immunology was performed who had undergone overnight nasopharyngeal pH monitoring with a commercially available nasopharyngeal pH-monitoring device, Dx-pH Measurement System from Restech, San Diego, Calif. Subjects with reflux were classified based on the position of reflux as either supine only, upright only, or both supine and upright. In a subset of subjects with supine-only reflux, pH monitoring was compared before and after elevating the head of bed 6 inches. Adequate nasopharyngeal pH-monitoring data were obtained for 235 patients. Reflux was detected in 113 (48%) patients. The pattern of reflux observed was 62 (55%) supine only, 4 (4%) upright only, and 47 (42%) upright and supine. Sequential overnight nasopharyngeal pH monitoring before and after head-of-bed elevation was obtained in 13 individuals with supine-only reflux. Ten subjects demonstrated significant improvement, 8 of whom demonstrated complete resolution of supine reflux with 6 inches of head-of-bed elevation. This study provides new evidence that SERD frequently occurs in the supine position and that 6 inches of head-of-bed elevation is effective in reducing supine SERD.

Gastroesophageal Reflux in a Cohort of Morbidly Obese Patients Before and After Sleeve Gastrectomy

Introduction: Laparoscopic sleeve gastrectomy (LSG) offers excellent sustainable weight loss for morbidly obese patients. Previous studies have demonstrated an increase in gastroesophageal reflux (GER) following LSG. The aim of this study was to compare acid reflux parameters in a cohort of obese patients before and after surgery. Methods: We prospectively enrolled adult obese patients greater than 18 years old undergoing preoperative evaluation for LSG. Patients underwent PPIs pre-operative 24 hour combined ambulatory pH and impedance testing off of PPI. Studies were repeated at least 6 months after LSG. Reflux data collected included Johnson-DeMeester (JD) score, to include percent total time pH<4, percent supine time pH<4, percent upright pH <4, number of reflux episodes <5 minutes, longest reflux episode, and impedance testing results. Results: We enrolled 18 consecutive adult patients presenting for preoperative evaluation for LSG with a mean age of 51.5 (SD); 7 were white (78%), and 2 were male (22%). Sixteen patients successfully underwent LSG, of which 9 patients completed their post-operative testing. After LSG, there was a statistical increase in mean acid reflux episodes from 24.36 to 51.57 (p=0.03) and mean distal esophageal impedance episodes from 47.67 to 69.78 (p=0.04), but no change in proximal impedance (p=0.16). Although there was an almost 2-fold increase in mean JD score from 16.68 to 31.23 (p=0.09), this was not statistically significant. Likewise, there was no statistically significant change in total percent time (p=0.23), percent upright reflux (p=0.44), percent supine reflux (p=0.08), number of reflux episodes >5 minutes (p=0.21), or longest reflux episode (p=0.37). Conclusion: In this small ongoing study, LSG significantly increased the number of acid and impedance reflux episodes. A trend towards an increase in JD score was observed.

A Comparison of the Three Objective Measures of Gastroesophageal Reflux Disease: Johnson-DeMeester Score, DeMeester Score, and Percent Time pH&lt;4

Purpose: The Johnson-DeMeester (JD) and DeMeester (D) scoring systems, as well as, percent total time pH < 4, have been used to determine the presence of abnormal gastroesophageal reflux (GERD) in clinical and research settings. While all methods are commonly used in practice, no prior study has compared them. The goal of this study was to compare these three objective measures of GERD in a large cohort of adult patients undergoing ambulatory 24-hour pH monitoring. Methods: A retrospective study was performed on 160 patients who underwent 24-hour pH testing off proton-pump inhibitors for at least 1 week for the evaluation of GERD. For each 24-hour pH study, both JD and D composite scores were calculated using the following parameters: percent total time pH<4, percent upright time pH<4, percent supine time pH<4, total number of reflux episodes, number of reflux episodes>5 minutes, and time of longest reflux episode. An abnormal JD score was defined as a score>22.0, and an abnormal D score defined as a score>14.7. The JD and D scores were compared to each other and in their ability to detect the presence of acid reflux expressed as the percent total time pH < 4, using a normal threshold of 4.5%. Results: The study cohort consisted of 52% (83/160) males and 66% (106/160) Caucasians, with a mean (SD) age of 46 (12) years. There was significant correlation between the JD and D composite scores (R2 0.961, p<0.001). The JD and D scores agreed in classifying normal vs. abnormal results in 96% of the studies (153/160), in which 102 study results were normal and 51 studies were abnormal by both scoring systems (kappa 0.903, p=0.000). Disagreement occurred in seven of 160 studies, primarily (4/7) due to differences in upright reflux, where the JD score was normal (range 16.9 to 20.5) and the D score was abnormal (range 14.9 to 18.5). The JD and D scores significantly correlated with percent total reflux (R2=0.793 and R2=0.919, respectively). Furthermore, the JD and D scores significantly correlated to percent upright reflux (R2 = 0.380 and R2= 0.564, respectively) and percent supine reflux (R2=0.789 and R2= 0.628, respectively). When using a value of 4.5% for the normal threshold of total percent time acid reflux, the JD score misclassifi ed 12% (19/16) of patients and the D score misclassified 8% (12/160) of patients, p=0.257. Conclusion: There was a strong agreement (kappa 0.903) between the JD score and D score in classifying a 24-hour pH test as normal or abnormal, with a significant correlation of each scoring system to percent total time pH < 4. Physicians can reliably utilize either the JD score, D score, or total percent time < pH 4 to determine if a patient has a normal or abnormal degree of acid reflux.

Tu1779 Factors Associated With Erosive Esophagitis in Patients Undergoing Esophageal Manometry and Combined 24 Hour pH Monitoring and Multichannel Intraluminal Impedance Studies

Background: A subset of patients with gastroesphageal reflux disease (GERD) symptoms has erosive esophagitis (E+) on upper endoscopy (EGD). Those whose symptoms persist despite proton pump inhibitor (PPI) therapy may further undergo testing with combined multichannel intraluminal impedance and 24 hour pH (MII-pH) to determine if acid is adequately suppressed and if non-acid reflux plays a role in symptoms. Aim: To determine which factors on esophageal manometry (EM) and MII-pH were associated with E+. A secondary aim is to examine the relationship between the degree of E+ and 24 hour pH score. Methods: A clinical database was searched for EM and MII-pH studies performed off acid suppressive therapy between 2006 and 2011. Patients referred for evaluation had typical GERD symptoms (heartburn or acid regurgitation) or atypical symptoms (chest pain, cough, hoarseness, dysphagia or dyspepsia). Data was further extracted to patients who had an EGD performed within 6 months of the MII-pH study. Patients with a normal esophagus on EGD or eosinophilic esophagitis were excluded from this study. Erosive esophagitis was defined and graded according to the Los Angeles classification system. A Johnson-DeMeester score of ≥22 was considered diagnostic for GERD by pH testing. An abnormal impedance study was defined as .73 distal reflux episodes. Categorical data was expressed as percentages and continuous data as means and standard deviation. Fisher's exact tests and parametric statistics were used to analyze data. A p-value ≤ 0.05 was considered statistically significant. Results: Of 348 patients identified in the database, 21 patients had E+ (67% were males, 76% were Caucasians and 79%hadGrade A esophagitis). Themajority of patients (95%)were previously treated with PPI, however all cases were performed off PPI for at least one week. Significantly more patients with E+ had hiatal hernias compared to patients without esophagitis (E-), (43% vs 19%,p=0.021). E+ patients had significantly more acid reflux episodes than Epatients (46±40 vs 27±26, p=0.011). There was also significantly more distal impedance episodes (73±59 vs 49±27,p=0.014) and decreased lower esophageal sphincter (LES) pressure in E+ patients (12±11 mm Hg vs 15±11 mm Hg, p=0.012). E+ and Epatients had similar degree of upright acid reflux (pH:4.91±4.0 vs pH:4.98±6.3, p=0.224). E+ patients had more supine acid reflux than Epatients without statistical significance (pH:5.8 ±14.8 vs pH:2.4±7.3, p=0.177). Conclusions: Hiatal hernia, decreased LES pressure, and total number of reflux episodes were associated with E+. There was a trend in more supine reflux in E+ patients, however no difference in upright reflux was observed between the two groups. Due to the small number of higher grade E+ cases, a correlation could not be made between severity of degree of E+ and 24 hour pH score.