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Impedance-pH Monitoring for Diagnosis of Reflux Disease: New Perspectives

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Abstract

Heartburn is the most specific symptom of gastroesophageal reflux disease (GERD). In clinical practice, heartburn relief by a proton pump inhibitor (PPI) trial does suffice to confirm GERD. However, an objective diagnosis of GERD is required before anti-reflux endoscopic or surgical interventions, independently from PPI response. Thus, since normal findings at upper endoscopy are detected in the majority of patients with heartburn, reflux monitoring is often required. When traditional catheter-based or wireless pH tests are used, reflux episodes are conventionally identified by pH drops below 4.0 units. Combined impedance-pH monitoring has the advantage to provide a comprehensive assessment of both physical and chemical properties of refluxate and the distinction between acid and weakly acidic refluxes, both proven to cause heartburn. Unfortunately, the conventional impedance-pH parameters, namely acid exposure time and number of reflux events, are characterized by suboptimal diagnostic sensitivity, and the reliability of symptom–reflux association indexes remains questionable. Therefore, novel impedance parameters, namely the post-reflux swallow-induced peristaltic wave (PSPW) index and the mean nocturnal baseline impedance (MNBI), have recently been proposed in order to achieve a better diagnostic yield. In fact, they proved to be highly accurate in distinguishing reflux-related from reflux-unrelated heartburn, off- as well as on-PPI therapy. Currently, manual review of impedance-pH tracings is needed because of the modest accuracy of available software tools for automated analysis. PSPW index and MNBI are highly applicable and reproducible, and their calculation requires a few additional minutes during the manual review of impedance-pH tracings. So far, we believe that PSPW index and MNBI are ready for prime time and should become part of the standard analysis of impedance-pH tracings for GERD diagnosis in patients with endoscopy-negative heartburn.

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Abbreviations

AUC:

Area under the curve

AET:

Acid exposure time

ERD:

Erosive reflux disease

FH:

Functional heartburn

GERD:

Gastroesophageal reflux disease

HE:

Hypersensitive esophagus

MNBI:

Mean nocturnal baseline impedance

NERD:

Non-erosive reflux disease

PSPW:

Post-reflux swallow-induced peristaltic wave

ROC:

Receiver operating characteristic

SAP:

Symptom association probability

SI:

Symptom index

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The manuscript was prepared without any financial or technical support.

Author's contributions

MF wrote the manuscript. N de B, LF, ST, VS, ES critically revised the manuscript.

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Authors and Affiliations

  1. Digestive Pathophysiology Unit, Baggiovara Hospital, Viale Giardini 1355, 41100, Modena, Italy

    Marzio Frazzoni & Leonardo Frazzoni

  2. Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy

    Nicola de Bortoli

  3. Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy

    Leonardo Frazzoni

  4. General and Bariatric Surgery Unit, Department of Surgery, 2nd University of Napoli, Naples, Italy

    Salvatore Tolone

  5. Gastroenterology Unit, Department of Internal Medicine, University of Genova, Genoa, Italy

    Vincenzo Savarino

  6. Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy

    Edoardo Savarino

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  1. Marzio Frazzoni
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  2. Nicola de Bortoli
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Correspondence to Marzio Frazzoni.

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Frazzoni, M., de Bortoli, N., Frazzoni, L. et al. Impedance-pH Monitoring for Diagnosis of Reflux Disease: New Perspectives. Dig Dis Sci 62, 1881–1889 (2017). https://doi.org/10.1007/s10620-017-4625-8

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