Bile reflux in patients with nerd is associated with more severe heartburn and lower values of mean nocturnal baseline impedance and chemical clearance

Abstract

Background: Mean nocturnal baseline impedance (MNBI) and postreflux swallowinduced peristaltic wave (PSPW) index are novel impedance-based markers of reflux, but the effect of bile reflux on these metrics is unknown. The aim of this study was to evaluate bile reflux, MNBI, and PSPW index in patients with endoscopy-negative GERD partially responsive to PPI therapy. Methods: All patients underwent off-PPI endoscopy, esophageal manometry, multichannel intraluminal impedance pH (MII-pH), and bile reflux monitoring. Abnormal esophageal acid exposure time (AET) was required for inclusion. Symptom intensity (using 10-cm visual analog scales), and conventional and novel MII-pH metrics were compared between patients with and without abnormal bile reflux. Key Results: We evaluated 42 NERD patients (29 males, mean age: 53.4 ± 13. years), mean AET 6.1 ± 2%, of which 21 had abnormal bile reflux (Group A, 10.2 ± 4.9%), and 21 had normal bile reflux (Group B, 0.4 ± 0.1%, P < .05 compared with Group A). Heartburn reporting on PPI was higher in Group A (7.2 ± 2.1 vs 5.8 ± 0.9; P = .002), but AET, number of reflux events (acidic and weakly acidic), did not differ between the two groups. However, both PSPW index and MNBI were lower in Group A (P < .001). A strong inverse linear correlation was found between bile reflux and both MNBI

Pathophysiology and treatment options for gastroesophageal reflux disease: looking beyond acid

“…19 Still, the reverse may be true such that the presence of bile acid reflux may predict a poor response to PPIs. 20 Moreover, as previously mentioned, the simultaneous presence of both bile acid and gastric acid exposure is associated with increased severity of GERD. 20,21 Whether these effects are synergistic or mechanistically distinct is unclear; however, the role of bile acid detection and its treatment may lead to further symptom improvement in the settings of both severe and/or refractory GERD.…”

Overlap of functional heartburn and reflux hypersensitivity with proven gastroesophageal reflux disease

“…Ambulatory reflux monitoring evaluates cross‐sectional reflux burden, which is subject to day‐to‐day variation, 14 and if a patient is evaluated on their “best” day, a diagnosis of NERD could be missed in favor of FH 15 . In contrast, baseline impedance measures longitudinal reflux burden, where compromised mucosal integrity from chronic reflux exposure contributes to low baseline impedance, 16 and potentially more severe symptoms 17 . There exists evidence that low mean nocturnal baseline impedance (MNBI) correlates with elevated acid exposure time and segregates reflux phenotypes from functional syndromes and controls 18,19 .…”

“…15 In contrast, baseline impedance measures longitudinal reflux burden, where compromised mucosal integrity from chronic reflux exposure contributes to low baseline impedance, 16 and potentially more severe symptoms. 17 There exists evidence that low mean nocturnal baseline impedance (MNBI) correlates with elevated acid exposure time and segregates reflux phenotypes from functional syndromes and controls. 18,19 Indeed, the cohort of FH where both AET and MNBI were physiologic had more prevalent psychological diagnoses, and higher proportions of concurrent FD, both favoring a functional process.…”

Esophageal reflux hypersensitivity: Non-GERD or still GERD?

“…Nowadays, we know that stimuli other than acid can be responsible for reflux symptoms, that is WAR and weakly alkaline refluxes. Indeed, also bile reflux plays an important role in the origin of GERD symptoms, as recently shown by De Bortoli et al [40] , who have demonstrated that the presence of bile in the refluxate of NERD patients is associated with more severe heartburn and lower values of MNBI and chemical clearance. It is likely that only the future availability of more accurate diagnostic techniques will permit to understand better the complexity of the universe of Rome IV functional esophageal disorders and to refine the diagnosis of both RH and FH in further pathophysiological subsets.…”