12 Normalization of Number of Reflux Episodes on Ph-Impedance Monitoring Associates With Improved Symptom Outcome and Treatment Satisfaction in Gastroesophageal Reflux Disease (Gerd) Patients With Regurgitation

Value of pH Impedance Monitoring While on Twice-Daily Proton Pump Inhibitor Therapy to Identify Need for Escalation of Reflux Management

“…Patients were categorized first into those with abnormal reflux burden and abnormal mucosal integrity. This consisted of nonphysiologic AET (>4.0%), 2,11 conclusively elevated reflux episodes (>80 episodes), 2,6 and lower MNBI than that described in healthy asymptomatic volunteers (<1500 ohms). 11 This category included 32.6% of the European heartburn cohort and 40.5% of the North American regurgitation cohort, but no healthy volunteers (Figure 1B).…”

“…17 In addition, >80 reflux episodes, as proposed by the Lyon Consensus, has been demonstrated to predict improvement in regurgitation following invasive therapy with MSA. 6 Finally, low MNBI is considered to be a longitudinal marker of reflux-induced mucosal damage, and a threshold of 1500 ohms was described as the lower threshold of normal (5th percentile value) in a large multicenter multinational normative cohort study. 11 We identified subsets of both heartburn-and regurgitation-predominant patients fulfilling these characteristics in sequence, giving more weight to AET >4% and >80 reflux episodes, which accounted for 32.6% of heartburn patients and 40.5% of regurgitation patients in our study.…”

“…We included data from 3 groups: 1) tracings from healthy volunteers recruited by the individual motility centers in Europe and North America by advertisement, who received bid PPI for 5-7 days; 2) tracings from heartburn-predominant proven GERD patients from Europe with prior abnormal reflux monitoring off PPI, studied on bid PPI, data from some of which have been previously published 8 ; and 3) tracings from a previously published cohort of regurgitation predominant proven GERD patients with prior abnormal reflux monitoring off PPI, studied on bid PPI therapy (PPI arm of a prospective PPI and magnetic sphincter augmentation [MSA] study performed in North America). 6 In both comparison cohorts, patients were studied on PPI regardless of symptom response status with bid PPI, and therefore these cohorts included both responders and nonresponders to PPI therapy. This post hoc analysis involved deidentified pH impedance tracings with no links to the original study subjects, so institutional review board approval was not deemed to be necessary.…”

“…5 Moreover, there is limited evidence indicating that <40 reflux episodes on therapy is associated with improvement in GERD symptoms and satisfaction with therapy on validated questionnaires, and that >80 reflux episodes despite PPI therapy is associated with likelihood of symptom improvement with the use of invasive GERD management. 6 Other metrics extracted from pH impedance monitoring (baseline impedance, post-reflux swallowinduced peristaltic wave [PSPW]) have very limited evidence to support their use in individuals studied while on PPI. 7 Thus, the Lyon Consensus thresholds may be too high to have optimal sensitivity for recognition of refractory acid burden while on PPI, whereas previous published thresholds using pH-metry alone potentially suffer from lack of specificity.…”