Lack of improvement of impaired chemical clearance characterizes PPI-refractory reflux-related heartburn

Background & aims The Lyon Consensus defines LA grades C&D erosive esophagitis (EE) or acid exposure time (AET) >6% as the conclusive evidence for gastro‐esophageal reflux disease (GERD). However, most of EE is LA grade A&B and the rate of AET exceeding 6% is low in China. We aimed to evaluate patients with EE in the Chinese population based on the Lyon Criteria. Methods A retrospective study was performed among patients with EE who had esophageal function tests performed in a tertiary hospital from 2013 to 2017. Erosive esophagitis was staged according to the Los Angeles classification. Their motor profiles from high‐resolution manometry (HRM), reflux profiles from multichannel intraluminal impedance‐pH (MII‐pH) monitoring and proton pump inhibitor (PPI) efficacy were analyzed. Patients were categorized as conclusive or inconclusive GERD. Results Among 112 patients with EE who underwent esophageal function tests, EE of LA grade C&D was found in only 4.46% (N = 5). Almost 35% (N = 37) of patients with LA grade A&B EE had AET exceeded 6%, who had good PPI response similar to those with LA grade C&D EE (77.42% vs 100%, P = .559). The remaining 70 patients (62.50%) were inconclusive GERD, of whom 56.25% responded to PPI. Inconclusive GERD patients had a wide range (7.14%‐97.14%) of positive adjunctive evidences from HRM and MII‐pH monitoring without significant correlation to PPI response rate. Conclusions The reflux burden within patients with EE is predominantly low in China, and adjunctive HRM and MII‐pH profiles from Lyon criteria do not segregate PPI response.

Section: Discussionmentioning

confidence: 99%

Esophageal physiologic profiles within erosive esophagitis in China: Predominantly low‐grade esophagitis with low reflux burden

Zhang

Tan

et al. 2019

“…PSPW can be identified on pH‐impedance monitoring as a distally migrating sequential impedance drop following a reflux episode, reaching the distal esophagus (Figure B) . PSPW index, the ratio of the PSPW count to number of reflux episodes, records the efficiency of chemical clearance and predicts reflux‐related heartburn responsive to PPIs . The relationship of PSPW to contraction reserve deserves further study, as reflux‐induced primary peristalsis, and potentially, RACs on FLIP topography will be influenced by the integrity of esophageal neural connections and smooth muscle function, which is the basis for contraction reserve.…”

Section: Supplementary Investigationmentioning

confidence: 99%

“…PSPW index, the ratio of the PSPW count to number of reflux episodes,77 records the efficiency of chemical clearance and predicts reflux-related heartburn responsive to PPIs 78,79. The relationship of PSPW to contraction reserve deserves further study, as reflux-induced primary peristalsis,F I G U R E 4 Adjunctive evaluation of esophageal peristaltic performance using novel metrics and techniques.…”

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confidence: 99%

Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium

Gyawali

Sifrim

Carlson

et al. 2019

Self Cite

Background Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450 mm Hg cm s) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high‐resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals. Purpose A 1‐day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.

“…Adults (age > 18 years) referred for esophageal physiologic testing for persisting typical and atypical reflux symptoms despite doubledose acid-suppressive therapy for at least 8 weeks at five centers (4 in Europe and one in the United States) were eligible for inclusion in this retrospective observational cohort study. Patients were included if alternate esophageal mechanisms for symptoms had been excluded with endoscopy, if they underwent ambulatory pH-impedance studies off acid-suppressive therapy, and if 10 acceptable supine water swallows were available for HRM analysis using Chicago Classification version 3.0 (CCv3.0).…”

Section: Me Thodsmentioning

confidence: 99%

“…1 An increase in frequency, duration and amount of reflux, and/or an inability to clear refluxed content can lead to gastroesophageal reflux disease (GERD). [3][4][5][6] Since the advent of high-resolution manometry (HRM), enhanced recognition of esophageal body motor patterns and esophagogastric junction (EGJ) morphology has improved our understanding of the relationship between motor abnormalities and gastroesophageal reflux disease (GERD). [3][4][5][6] Since the advent of high-resolution manometry (HRM), enhanced recognition of esophageal body motor patterns and esophagogastric junction (EGJ) morphology has improved our understanding of the relationship between motor abnormalities and gastroesophageal reflux disease (GERD).…”

Section: Introductionmentioning

confidence: 99%

Fragmented and failed swallows on esophageal high‐resolution manometry associate with abnormal reflux burden better than weak swallows

Rogers

Rengarajan

Ghisa

et al. 2019

Self Cite

Background Association between proportions of hypomotile swallows on esophageal high‐resolution manometry (HRM) and esophageal reflux burden remains incompletely understood. We investigated relationships between hypomotility, acid exposure time (AET), and mean nocturnal baseline impedance (MNBI) on ambulatory reflux monitoring. Methods Clinical data, HRM, and ambulatory pH‐impedance studies (performed off acid suppression) from patients with persisting reflux symptoms were reviewed from five international centers. AET (abnormal > 6%) and MNBI (abnormal < 2292 ohms) were extracted from pH‐impedance studies. Distal contractile integral (DCI) designated esophageal peristalsis into normal (DCI > 450 mmHg.cm.s), fragmented (DCI > 450 mmHg.cm.s with breaks > 5 cm), weak (DCI 100‐450 mmHg.cm.s), and failed (DCI < 100 mm mmHg.cm.s) sequences. Univariate and multivariate analyses were performed to identify motor associations of abnormal reflux burden. Key Results Of 351 patients (52.1 ± 0.8 years, 67%F), 29.3% had AET > 6% and 61.8% had MNBI < 2292 ohms. On univariate analysis, both fragmented peristalsis and IEM associated with abnormal AET (P ≤ .01) and MNBI (P ≤ .03); reflux burden was more profound with >70% fragmented as well as ineffective sequences compared to ≤70% for each (P < .05 for each comparison). When weak and failed sequences within IEM were separately analyzed, ≥50% failed sequences predicted abnormal AET (P ≤ .009), and ≥50% weak sequences did not (P = .14). On multivariate regression, ≥50% failed sequences predicted abnormal AET (P = .02), and >70% ineffective sequences trended strongly (P = .069); >70% ineffective sequences predicted abnormal MNBI (P = .046), and >70% fragmented sequences trended strongly (P = .076). Conclusions and Inferences Breaks in esophageal peristaltic integrity seen with fragmented and failed sequences are more relevant to abnormal esophageal acid burden than weak sequences.