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

Gyawali, C. Prakash; Tutuian, Radu; Zerbib, Frank; Rogers, Benjamin D.; Frazzoni, Marzio; Roman, Sabine; Savarino, Edoardo; Bortoli, Nicola de; Vela, Marcelo F.; Sifrim, Daniel

doi:10.1053/j.gastro.2021.07.004

Cited by 36 publications

(43 citation statements)

References 30 publications

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“…9,33 In particular, 24-hour impedance-pH monitoring off PPI may be preferred in the evaluation of extraesophageal symptoms, 34 and is the optimal reflux monitoring system in symptomatic patients with previously proven GERD with the test performed on twice-aday PPI therapy. 35…”

Section: Ambulatory Reflux Monitoringmentioning

confidence: 99%

“…48 Clinicians should consider ambulatory 24-hour pH-impedance monitoring on PPI as an option to determine the mechanism of persisting esophageal symptoms despite therapy (BPA 9), particularly in patients without a known major abnormality in the anti-reflux barrier, to confirm PPI refractory GERD and exclude other etiologies of ongoing symptoms such as an overlap with reflux hypersensitivity, rumination syndrome, or a belching disorder. 35 Clinicians should then escalate therapy via a precision approach based on the pattern of reflux on impedance-pH monitoring, integrity of the antireflux barrier, presence of obesity, and/or psychological considerations (Figure 3). 34,35…”

Section: Inadequate Symptom Response Despite Optimizationmentioning

confidence: 99%

“…35 Clinicians should then escalate therapy via a precision approach based on the pattern of reflux on impedance-pH monitoring, integrity of the antireflux barrier, presence of obesity, and/or psychological considerations (Figure 3). 34,35…”

Section: Inadequate Symptom Response Despite Optimizationmentioning

confidence: 99%

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AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review

Yadlapati

Gyawali

Pandolfino

et al. 2022

Clinical Gastroenterology and Hepatology

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168

134

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Section: Ambulatory Reflux Monitoringmentioning

confidence: 99%

Section: Inadequate Symptom Response Despite Optimizationmentioning

confidence: 99%

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AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review

Yadlapati

Gyawali

Pandolfino

et al. 2022

Clinical Gastroenterology and Hepatology

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168

134

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“…Therefore, we focused our attention on impedance metrics, namely total reflux episodes, PSPW index, and MNBI adopting the recently defined threshold values 15 . Total reflux episodes represent reflux burden comprising acid and weakly acidic refluxes, the latter constituting the majority of reflux events during PPI therapy 13,20 ; of note, the value of 40 as the physiological threshold adopted in the present study is the same proposed by the Lyon Consensus for total reflux episodes 5 and was recently validated in multicentre studies, off‐ 15 as well as on 25 PPI therapy. PSPW index represents esophageal chemical clearance, in turn, elicited by the esophago‐salivary reflex with an attendant increase of esophageal pH, higher increments contributing to PPI responsiveness in GERD 12 ; of note, lack of improvement of chemical clearance, as measured with PSPW index, and persistent abnormal reflux burden, as measured with the number of total reflux episodes, distinguish PPI‐refractory from PPI‐responsive reflux‐related heartburn 20 .…”

Section: Discussionmentioning

confidence: 92%

Applying Lyon Consensus criteria in the work‐up of patients with proton pump inhibitory‐refractory heartburn

Frazzoni

Ribolsi

et al. 2022

Aliment Pharmacol Ther

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Summary Background A hierarchical approach for gastro‐oesophageal reflux disease (GERD) diagnosis by impedance‐pH monitoring was proposed by the Lyon Consensus, based on acid exposure time (AET) and supportive impedance metrics. Aims To establish the clinical value of Lyon Consensus criteria in the work‐up of patients with proton pump inhibitory (PPI)‐refractory heartburn. Methods Expert review of off‐therapy impedance‐pH tracings from unproven GERD patients with PPI‐refractory heartburn prospectively evaluated at referral centers. Impedance metrics, namely total reflux episodes, postreflux swallow‐induced peristaltic wave index, and mean nocturnal baseline impedance, were assessed. Expert review of on‐therapy preoperative impedance‐pH tracings from a separate cohort of surgically treated erosive/nonerosive GERD cases. Results Off‐therapy, normal, inconclusive, and abnormal AET was found in 59%, 17%, and 23% of 317 cases. Supportive evidence of GERD was provided by abnormal impedance metrics in up to 22% and 62% of cases in the normal and inconclusive AET groups, respectively. Adding the cases with inconclusive AET and abnormal impedance metrics to the abnormal AET group, a significant increase in GERD evidence was observed (from 23% to 37% of cases, p < 0.0002). At the on‐therapy presurgical evaluation, abnormal/inconclusive AET and supraphysiological values of impedance metrics showed ongoing reflux in 21% and 90% of 96 cases, respectively (p < 0.00001); a relationship between on‐therapy ongoing reflux and PPI‐refractory heartburn was confirmed by the favorable surgical outcome at 3‐year follow‐up, 88% of cases being in persistent off‐PPI heartburn remission. Conclusions Impedance‐pH monitoring, off‐ and on‐therapy, is of high clinical value in the work‐up of patients with PPI‐refractory heartburn.

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“…The authors found that, both in patients with overtly abnormal (> 6%) or borderline AET (4-6%), a low MNBI identified patients who showed improvement with anti-reflux treatment. Recently, Gyawali et al [70] investigated MII-pH metrics in patients with refractory GERD symptoms undergoing on-therapy reflux monitoring. The authors observed that, among 20 patients with AET > 4%, reflux episodes > 80, and MNBI < 1500 ohms, 85% improved with invasive GERD management.…”

Section: Mean Nocturnal Baseline Impedancementioning

confidence: 99%

Clinical use of mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index for the diagnosis of gastro-esophageal reflux disease

et al. 2022

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The clinical diagnosis of gastro-esophageal reflux disease (GERD) is based on the presence of typical esophageal troublesome symptoms. In clinical practice, heartburn relief following a proton pump inhibitor (PPI) trial or endoscopy can confirm a diagnosis of GERD. In cases of diagnostic uncertainty or before anti-reflux interventions, combined impedance-pH monitoring (MII-pH) provides a comprehensive assessment of both physical and chemical properties of the refluxate, allowing to achieve a conclusive diagnosis of GERD. Recently, the Lyon Consensus proposed the use of mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave index (PSPW-I) as novel MII-pH metrics to support the diagnosis of GERD. The calculation of MNBI and PSPW-I currently needs to be performed manually, but artificial intelligence systems for the automated analysis of MII-pH tracings are being developed. Several studies demonstrated the increased diagnostic yield MNBI and PSPW-I for the categorization of patients with GERD at both on- and off-PPI MII-pH monitoring. Accordingly, we performed a narrative review on the clinical use and diagnostic yield of MNBI and PSPW-I when the diagnosis of GERD is uncertain. Based on currently available evidence, we strongly support the evaluation of PSPW-I and MNBI as part of the standard assessment of MII-pH tracings for the evaluation of GERD, especially in patients with endoscopy-negative heartburn.

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

Cited by 36 publications

References 30 publications

AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review

AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review

Applying Lyon Consensus criteria in the work‐up of patients with proton pump inhibitory‐refractory heartburn

Clinical use of mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index for the diagnosis of gastro-esophageal reflux disease

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