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Introduction Prolonged wireless pH-monitoring (Bravo) increases diagnostic yield compared to 24 hr pH-studies. Studies have shown a weak association between oesophageal acid exposure from 24 hr pH-studies and mucosal disease on distal oesophageal histology. This study assessed the association between Bravo, endoscopic findings and distal oesophageal histology. Methods From July 2009 to August 2010, 63 consecutive patients with typical reflux symptoms had endoscopy with biopsies taken from 3 & 9 o'clock position at and 2cm proximal to the Z-line prior to pH capsule fixation 6cm proximal to the Z-line for prolonged (up to 96 hr) Bravo. All biopsies were assessed by the 6-parameter Zentilin histology score (Zentilin et al Gastroenterol 2005). GORDdiagnosis was based on "Average" acid exposure (Total Reflux; TR > 5.3% time pH < 4) over the time period measured and/or symptom-association (symptom index; SI > 50%) Results Adequate biopsy samples were available from 57/63 patients (mean age 44 (range 17-78); 27M). 37/57(65%) patients had GORD based on either TR (n = 30) or SI(n = 32). 20/57(35%) were both TR & SI negative (Functional Heartburn; FH). 18 FH patients had no mucosal changes, 2 had grade A oesophagitis. There was no difference in individual histology parameters between GORD vs. FH (p > 0.05) apart from increased 'intra-epithelial neutrophils' (IEN) at the Z-line (9/37 vs. 1/20 positive; p = 0.031) and 2cm proximally (6/37 vs. 0/20 positive; p = 0.012). The combined Zentilin histology score was also higher in GORD at the Z-line (p = 0.079) and 2 cm proximally (p = 0.05).Using GORD diagnosis from 96 hr Bravo as reference, ROC analysis revealed that, although sensitivity remained poor, specificity of GORD diagnosis based on histology improved with IEN and total histology score. With increased IEN, sensitivity was 30% at the Z-line and 20% 2 cm above while specificity was 92.6% at the Z-line and 100% 2cm proximally. For the optimal Zentilin histology score of ≥7, sensitivity was 40.5% at the Z-line and 18.9% 2cm above while specificity was 95% at the Z-line and 100% 2 cm proximally.Histology corroborated GORD diagnosis (based on positive TR) in 11/30 and 20/30 patients at the Z-line and in 6/30 and 11/30 patients 2 cm proximally. Conclusion Histology lacks sensitivity as a stand-alone diagnostic test; however high IEN or total histology scores have high specificity for GORD diagnosis based on pH-study results. Thus, routine biopsy of the distal oesophagus may be sufficient to diagnose GORD and obviate the need for ambulatory pH-studies in this subgroup of patients. Disclosure of Interest None Declared.

Introduction Recently we presented novel methodology for the assessment of oesophageal function and symptoms during and after a standard test meal.1 In the absence of a “gold standard”, outcome data provides insight into the clinical impact of this test in patients with reflux symptoms Methods 18 patients referred for investigation of reflux symptoms and 10 healthy volunteers underwent High Resolution Manometry (HRM) with 5ml water, 200ml water drink and test meal followed by 10min post-prandial observation. 24hr pH studies were performed in patients. The number of Symptoms Associated with oesophageal Dysfunction(SAD) was calculated. HRM findings and initial diagnosis were compared with the final diagnosis and outcome at 2 years Results No symptoms occurred with 5ml water. 12/18(67%) patients had SAD (mean SAD 2(range 0–7)) during/after the meal. Compared to 5ml water, manometric diagnosis was altered in 12/18(67%). No healthy volunteers had SAD. 11/18 patients had GORD on pH studies. By 2 years, 5/11 had anti-reflux surgery with excellent outcome. All 5 exhibited dysmotility (e.g. hypotensive/failed peristalsis) during the meal with symptomatic postprandial reflux events (transient lower oesophageal sphincter relaxation + common cavity). Of the 6/11 with GORD who did not have surgery, 2 declined it despite pathological pH results and symptomatic reflux events after the meal; both remain symptomatic despite acid-reducing therapy. The remaining 4 of 6 patients also had symptomatic dysmotility but were not offered surgery. 2 with severe hypotensive dysmotility and symptomatic reflux responded to acid suppression. 1 with (peptic) outlet obstruction and 1 with diffuse spasm did not respond to medication. Of the 7 with functional heartburn (negative pH results), 2 who had normal HRM responded to dietary/stress management. 2 with symptomatic reflux during HRM had good response to acid-suppression (i.e. false neg pH study). The final 3 with reflux-like symptoms had outflow obstruction identified only during the meal; 1 had good outcome after dilatation, 1 was too frail for therapy and remains symptomatic and the last was lost to follow-up. Conclusion HRM studies which include a test meal and post-prandial observation provide an objective explanation for symptoms in the majority of patients referred for investigation of “reflux” symptoms. Long-term follow-up suggests this information can guide management especially in patientswithout definitive diagnosis following standard 5 ml water HRM and negative pH-studies Disclosure of Interest None Declared Reference Sweis R et al. Gastro 2011; 140