Original article—alimentary tract
The Utility of Intraluminal Impedance in Patients With Gastroesophageal Reflux Disease–Like Symptoms But Normal Endoscopy and 24-Hour pH Testing

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Background & Aims: Fifty percent of patients with gastroesophageal reflux disease–like symptoms and negative endoscopy have negative 24-hour pH testing, suggesting that symptoms are not caused by abnormal esophageal acid exposure. Multichannel intraluminal impedance (MII)–24-hour pH allows the recognition of major acid, minor acid, nonacid, and gas reflux. Recorded symptoms can be correlated with all reflux events (eg, acid, minor acid, nonacid, and gas) and a symptom score can be generated. We aimed to determine whether the Symptom Index (SI) obtained using MII-pH identified an association of symptoms with reflux events in nonclassic acid-reflux disease. Methods: Thirty–seven patients with heartburn or regurgitation, negative endoscopy, and 24-hour pH were enlisted. Acid suppression was stopped, a 24-hour MII-pH test was performed, and an SI was calculated for major acid reflux alone and for all reflux episodes including major, minor, and nonacid. On this basis patients were divided into 4 groups: (1) standard acid reflux: positive standard pH test; (2) acid sensitive: positive SI for major acid but normal pH test; (3) general reflux: positive SI for major, minor, and nonacid combined, but not for major acid alone; and (4) no reflux: negative SI. Results: Six patients (16%) had standard reflux, 10 patients (27%) had acid-sensitive esophagus, 14 patients (38%) had general reflux, and 7 patients (19%) had a negative SI. Conclusions: Fifty-seven percent of patients received a diagnosis unachievable with standard pH testing (38% had symptoms associated with general reflux and 19% had no reflux symptom associations). These findings support a potential role for MII-pH testing in this difficult group.

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Subjects

Patients were eligible for this study if they had symptoms of heartburn (defined as a substernal burning sensation) or regurgitation (defined as a sensation of liquid moving into the chest and/or mouth from the stomach not associated with nausea) at least twice a week for at least 1 year that failed to respond to antisecretory therapy, had a negative upper endoscopy, and a normal 24-hour pH test defined as total time pH was less than 4, less than 4.5%, upright time less than 6.3%, and recumbent

Results

The study patients included 29 women and 8 men, with an average age of 53 years (range, 33–72 y), who had symptoms for an average of 3.3 years (range, 1.5–8.0 y). Seventeen patients (46%) used twice-daily proton pump inhibitor (PPI) therapy, 10 patients (27%) used once-daily PPI therapy, and the others used H2-receptor antagonist (H2RA), all without improvement of their GERD-like symptoms.

Six (16%) of the 37 study patients had a positive 24-hour pH study (Figure 1). Five patients were taking

Discussion

MII-pH testing combined with an SI revealed evidence consistent with reflux as a cause of GERD-like symptoms in 81% of 37 patients with a negative upper endoscopy and with no evidence of abnormal intraesophageal acid exposure on standard 24-hour pH testing. The remaining 19% of patients had no evidence of symptoms owing to any sort of reflux events and therefore were diagnosed with no reflux disease—or functional heartburn. Six patients (16%) initially had a negative standard pH test and

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