Esophageal pH Monitoring in Symptomatic Patients on PPI Therapy
Esophageal pH Monitoring in Symptomatic Patients on PPI Therapy
Background: Ambulatory pH monitoring while on therapy is often recommended in gastroesophageal reflux disease (GERD) patients with continued symptoms. However, to date, little data exist to justify this indication.
Aim: To assess the role of pH monitoring in symptomatic patients despite aggressive therapy with typical or extra esophageal GERD.
Methods: Retrospective review of 2,291 ambulatory pH tracings (1999–2003) identified subgroup of studies performed on proton pump inhibitor (PPI) therapy. Patients with prior fundoplication or Barrett's esophagus were excluded. Patients grouped on predominant presenting GERD symptoms: typical (heartburn and regurgitation) or extra esophageal (chest pain, cough, hoarseness, sore throat, shortness of breath, asthma). The distribution of abnormal pH parameters in each group calculated and univariate analyses assessed the probability of abnormal pH in each group. Abnormal cutoff values traditionally used in clinical practice and more stringent cutoff values used to determine distribution of abnormality as a function of cutoff values.
Results: A total of 250 patients (mean age 54.3 yrs, 59% female) underwent pH monitoring on either daily (b.i.d.) or twice daily (q.d.) on PPI therapy: 115 (46%) with extra esophageal and 135 (54%) with typical GERD symptoms. Extra esophageal GERD patients were more likely to undergo pH monitoring on b.i.d. PPIs (OR = 2.7; 95% CI = 1.6–4.4; p< 0.01). 52 (93%) of typical and 74 (99%) of extra esophageal GERD patients on b.i.d. PPIs tested normal. The odds of a normal pH values were 11 times higher for patients on b.i.d. PPIs (OR = 11.4; 95% CI = 4.3–30.1, p< 0.01) than those on q.d. PPIs.
Conclusions: 1) The likelihood of an abnormal esophageal pH for symptomatic GERD patients on b.i.d. PPI is very small. 2) In this group of patients failing b.i.d. PPIs causes other than GERD should be sought.
Gastroesophageal reflux disease (GERD) is a common disorder affecting approximately 35–40% of the adult population in the western world. Ambulatory pH monitoring is still considered by some to be the gold standard in GERD diagnosis and quantifying degree of esophageal acid exposure. The current indications for this test include evaluation of patients with either normal (or equivocal) endoscopic findings who are refractory to therapy, documenting abnormal esophageal acid exposure in endoscopy negative patients prior to surgical antireflux repair, and evaluating competence of the antireflux procedure in those with return of symptoms. Additionally, pH monitoring may also be useful to assess association between esophageal acid and persistent extra esophageal symptoms post therapy such as noncardiac chest pain, asthma, chronic cough, or laryngeal symptoms suspected GERD-related.
Proton pump inhibitors (PPIs) are the most potent agents for the medical management of GERD; they act by selective noncompetitive inhibition of H/K ATPase in parietal cells. Although, many patients respond to empiric therapy with PPIs, a subgroup of patients initially suspected of having GERD do not improve on either conventional or higher doses of PPIs. This may be due to lack of compliance, poor esophageal acid exposure control, or because the symptoms are not due to GERD. The latter may be true especially in patients with persistent extra esophageal symptoms on aggressive acid suppression. The pH monitoring while on PPI twice daily (b.i.d.) is currently recommended for such patients in order to assess the degree of acid suppression and determine if continued symptoms are due to poor acid control. However, to date no sufficient data exist to justify this indication. Thus, the aim of this study was to evaluate the clinical utility of pH monitoring in a group of patients with typical and extraesophageal symptoms suspected to be GERD-related and who remain symptomatic despite PPI therapy and to determine if persistent symptoms indicate either the need for more aggressive therapy or the likelihood of another etiology.
Background: Ambulatory pH monitoring while on therapy is often recommended in gastroesophageal reflux disease (GERD) patients with continued symptoms. However, to date, little data exist to justify this indication.
Aim: To assess the role of pH monitoring in symptomatic patients despite aggressive therapy with typical or extra esophageal GERD.
Methods: Retrospective review of 2,291 ambulatory pH tracings (1999–2003) identified subgroup of studies performed on proton pump inhibitor (PPI) therapy. Patients with prior fundoplication or Barrett's esophagus were excluded. Patients grouped on predominant presenting GERD symptoms: typical (heartburn and regurgitation) or extra esophageal (chest pain, cough, hoarseness, sore throat, shortness of breath, asthma). The distribution of abnormal pH parameters in each group calculated and univariate analyses assessed the probability of abnormal pH in each group. Abnormal cutoff values traditionally used in clinical practice and more stringent cutoff values used to determine distribution of abnormality as a function of cutoff values.
Results: A total of 250 patients (mean age 54.3 yrs, 59% female) underwent pH monitoring on either daily (b.i.d.) or twice daily (q.d.) on PPI therapy: 115 (46%) with extra esophageal and 135 (54%) with typical GERD symptoms. Extra esophageal GERD patients were more likely to undergo pH monitoring on b.i.d. PPIs (OR = 2.7; 95% CI = 1.6–4.4; p< 0.01). 52 (93%) of typical and 74 (99%) of extra esophageal GERD patients on b.i.d. PPIs tested normal. The odds of a normal pH values were 11 times higher for patients on b.i.d. PPIs (OR = 11.4; 95% CI = 4.3–30.1, p< 0.01) than those on q.d. PPIs.
Conclusions: 1) The likelihood of an abnormal esophageal pH for symptomatic GERD patients on b.i.d. PPI is very small. 2) In this group of patients failing b.i.d. PPIs causes other than GERD should be sought.
Gastroesophageal reflux disease (GERD) is a common disorder affecting approximately 35–40% of the adult population in the western world. Ambulatory pH monitoring is still considered by some to be the gold standard in GERD diagnosis and quantifying degree of esophageal acid exposure. The current indications for this test include evaluation of patients with either normal (or equivocal) endoscopic findings who are refractory to therapy, documenting abnormal esophageal acid exposure in endoscopy negative patients prior to surgical antireflux repair, and evaluating competence of the antireflux procedure in those with return of symptoms. Additionally, pH monitoring may also be useful to assess association between esophageal acid and persistent extra esophageal symptoms post therapy such as noncardiac chest pain, asthma, chronic cough, or laryngeal symptoms suspected GERD-related.
Proton pump inhibitors (PPIs) are the most potent agents for the medical management of GERD; they act by selective noncompetitive inhibition of H/K ATPase in parietal cells. Although, many patients respond to empiric therapy with PPIs, a subgroup of patients initially suspected of having GERD do not improve on either conventional or higher doses of PPIs. This may be due to lack of compliance, poor esophageal acid exposure control, or because the symptoms are not due to GERD. The latter may be true especially in patients with persistent extra esophageal symptoms on aggressive acid suppression. The pH monitoring while on PPI twice daily (b.i.d.) is currently recommended for such patients in order to assess the degree of acid suppression and determine if continued symptoms are due to poor acid control. However, to date no sufficient data exist to justify this indication. Thus, the aim of this study was to evaluate the clinical utility of pH monitoring in a group of patients with typical and extraesophageal symptoms suspected to be GERD-related and who remain symptomatic despite PPI therapy and to determine if persistent symptoms indicate either the need for more aggressive therapy or the likelihood of another etiology.
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