Abstract
Background
Gastroesophageal reflux disease (GERD) affects nearly 25 % of adults; however, an objective diagnosis is rarely established. We hypothesized that patients’ symptoms and response to acid-reducing therapy are poor predictors of the outcome of 24-h esophageal pH monitoring.
Methods
A review of 24-h esophageal pH monitoring studies performed at an ambulatory tertiary care center between 2004 and 2011 was performed. Demographics, type of GERD symptoms, and duration and response to acid-reducing medications before referral for pH monitoring were collected. DeMeester score, symptom sensitivity index (SSI), and symptom index (SI) were tabulated and compared with the patients’ symptoms and response to medical therapy.
Results
One hundred patients were included. Of all reported symptoms, only heartburn was more common in patients with positive DeMeester scores, but there were no correlations between any symptoms and SSI or SI scores. Sixty-nine percent of patients with esophageal symptoms had a positive DeMeester score compared with only 29 % of patients with extraesophageal symptoms (P < 0.01). Esophageal symptoms and endoscopic evidence of GERD significantly increased the likelihood of having a positive DeMeester score, but they had no influence on SSI or SI scores. There was no correlation between response to acid-reducing medications and DeMeester, SSI, or SI scores. A total of 536 person-years of acid-reducing medications were prescribed to the study population, of which 151 (28 %) were prescribed to patients who had a negative pH study.
Conclusions
Extraesophageal symptoms and response to empiric trials of acid-reducing medications are poor predictors of the presence of GERD and the DeMeester score is more likely to identify GERD in patients who met other empiric diagnostic criteria than SSI or SI. Early referral for 24-h esophageal pH monitoring may avoid lengthy periods of unnecessary medical therapy.
Similar content being viewed by others
References
Locke GR 3rd, Talley NJ, Fett SL, Zinsmeister AR, Melton LJ 3rd (1997) Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterology 112:1448–1456
El-Serag HB, Petersen NJ, Carter J, Graham DY, Richardson P, Genta RM, Rabeneck L (2004) Gastroesophageal reflux among different racial groups in the United States. Gastroenterology 126:1692–1699
Shaheen NJ, Hansen RA, Morgan DR, Gangarosa LM, Ringel Y, Thiny MT, Russo MW, Sandler RS (2006) The burden of gastrointestinal and liver diseases, 2006. Am J Gastroenterol 101:2128–2138
Zhao Y, Encinosa W (2006) Gastroesophageal reflux disease (GERD) hospitalizations in 1998 and 2005: statistical brief #44. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs, Rockville
Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R (2006) The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 101:1900–1920 quiz 1943
Moraes-Filho J, Cecconello I, Gama-Rodrigues J, Castro L, Henry MA, Meneghelli UG, Quigley E (2002) Brazilian consensus on gastroesophageal reflux disease: proposals for assessment, classification, and management. Am J Gastroenterol 97:241–248
Mujica VR, Rao SS (1999) Recognizing atypical manifestations of GERD. Asthma, chest pain, and otolaryngologic disorders may be due to reflux. Postgrad Med 105:53–55, 60, 63–56
Maceri DR, Zim S (2001) Laryngospasm: an atypical manifestation of severe gastroesophageal reflux disease (GERD). Laryngoscope 111:1976–1979
Wong WM, Fass R (2004) Extraesophageal and atypical manifestations of GERD. J Gastroenterol Hepatol 19(Suppl 3):S33–S43
DiBaise JK, Olusola BF, Huerter JV, Quigley EM (2002) Role of GERD in chronic resistant sinusitis: a prospective, open label, pilot trial. Am J Gastroenterol 97:843–850
Mays EE, Dubois JJ, Hamilton GB (1976) Pulmonary fibrosis associated with tracheobronchial aspiration. A study of the frequency of hiatal hernia and gastroesophageal reflux in interstitial pulmonary fibrosis of obscure etiology. Chest 69:512–515
Tobin RW, Pope CE 2nd, Pellegrini CA, Emond MJ, Sillery J, Raghu G (1998) Increased prevalence of gastroesophageal reflux in patients with idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 158:1804–1808
Kahrilas PJ (2008) Clinical practice. Gastroesophageal reflux disease. N Engl J Med 359:1700–1707
Qadeer MA, Phillips CO, Lopez AR, Steward DL, Noordzij JP, Wo JM, Suurna M, Havas T, Howden CW, Vaezi MF (2006) Proton pump inhibitor therapy for suspected GERD-related chronic laryngitis: a meta-analysis of randomized controlled trials. Am J Gastroenterol 101:2646–2654
Vaezi MF, Hicks DM, Abelson TI, Richter JE (2003) Laryngeal signs and symptoms and gastroesophageal reflux disease (GERD): a critical assessment of cause and effect association. Clin Gastroenterol Hepatol 1:333–344
Kamal A, Vaezi MF (2010) Diagnosis and initial management of gastroesophageal complications. Best Pract Res Clin Gastroenterol 24:799–820
Kahrilas PJ, Shaheen NJ, Vaezi MF (2008) American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease. Gastroenterology 135:1392–1413, 1413 e1391–1395
Galmiche JP, Scarpignato C (1998) Modern diagnosis of gastroesophageal reflux disease (GERD). Hepatogastroenterology 45:1308–1315
Richter JE (1997) Ambulatory esophageal pH monitoring. Am J Med 103:130S–134S
Fuchs KH, DeMeester TR, Albertucci M (1987) Specificity and sensitivity of objective diagnosis of gastroesophageal reflux disease. Surgery 102:575–580
Behar J, Biancani P, Sheahan DG (1976) Evaluation of esophageal tests in the diagnosis of reflux esophagitis. Gastroenterology 71:9–15
DeMeester TR, Johnson LF (1976) The evaluation of objective measurements of gastroesophageal reflux and their contribution to patient management. Surg Clin North Am 56:39–53
Sarani B, Gleiber M, Evans SR (2002) Esophageal pH monitoring, indications, and methods. J Clin Gastroenterol 34:200–206
Bredenoord AJ, Weusten BL, Smout AJ (2005) Symptom association analysis in ambulatory gastro-oesophageal reflux monitoring. Gut 54:1810–1817
Johnson LF, Demeester TR (1974) Twenty-four-hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol 62:325–332
Johnson LF, DeMeester TR (1986) Development of the 24-hour intraesophageal pH monitoring composite scoring system. J Clin Gastroenterol 8(Suppl 1):52–58
Breumelhof R, Smout AJ (1991) The symptom sensitivity index: a valuable additional parameter in 24-hour esophageal pH recording. Am J Gastroenterol 86:160–164
Ward BW, Wu WC, Richter JE, Lui KW, Castell DO (1986) Ambulatory 24-hour esophageal pH monitoring. Technology searching for a clinical application. J Clin Gastroenterol 8(Suppl 1):59–67
Weusten BL, Roelofs JM, Akkermans LM, Van Berge-Henegouwen GP, Smout AJ (1994) The symptom-association probability: an improved method for symptom analysis of 24-hour esophageal pH data. Gastroenterology 107:1741–1745
Aanen MC, Bredenoord AJ, Numans ME, Samson M, Smout AJ (2008) Reproducibility of symptom association analysis in ambulatory reflux monitoring. Am J Gastroenterol 103:2200–2208
Naunton M, Peterson GM, Bleasel MD (2000) Overuse of proton pump inhibitors. J Clin Pharm Ther 25:333–340
Nardino RJ, Vender RJ, Herbert PN (2000) Overuse of acid-suppressive therapy in hospitalized patients. Am J Gastroenterol 95:3118–3122
Heidelbaugh JJ, Goldberg KL, Inadomi JM (2009) Overutilization of proton pump inhibitors: a review of cost-effectiveness and risk [corrected]. Am J Gastroenterol 104(Suppl 2):S27–S32
Heidelbaugh JJ, Goldberg KL, Inadomi JM (2010) Magnitude and economic effect of overuse of antisecretory therapy in the ambulatory care setting. Am J Manag Care 16:e228–e234
Gawron AJ, Rothe J, Fought AJ, Fareeduddin A, Toto E, Boris L, Kahrilas PJ, Pandolfino JE (2012) Many patients continue using proton pump inhibitors after negative results from tests for reflux disease. Clin Gastroenterol Hepatol 10:620–625
Ali T, Roberts DN, Tierney WM (2009) Long-term safety concerns with proton pump inhibitors. Am J Med 122:896–903
Chen J, Yuan YC, Leontiadis GI, Howden CW (2012) Recent safety concerns with proton pump inhibitors. J Clin Gastroenterol 46:93–114
Freston JW (1997) Long-term acid control and proton pump inhibitors: interactions and safety issues in perspective. Am J Gastroenterol 92:51S–55S discussion 55S–57S
Thomson AB, Sauve MD, Kassam N, Kamitakahara H (2010) Safety of the long-term use of proton pump inhibitors. World J Gastroenterol 16:2323–2330
Chan K, Liu G, Miller L, Ma C, Xu W, Schlachta CM, Darling G (2010) Lack of correlation between a self-administered subjective GERD questionnaire and pathologic GERD diagnosed by 24-h esophageal pH monitoring. J Gastrointest Surg 14:427–436
Lacy BE, Chehade R, Crowell MD (2011) A prospective study to compare a symptom-based reflux disease questionnaire to 48-h wireless pH monitoring for the identification of gastroesophageal reflux (revised 2–26–11). Am J Gastroenterol 106:1604–1611
Patti MG, Gorodner MV, Galvani C, Tedesco P, Fisichella PM, Ostroff JW, Bagatelos KC, Way LW (2005) Spectrum of esophageal motility disorders: implications for diagnosis and treatment. Arch Surg 140:442–448 discussion 448–449
Chander B, Hanley-Williams N, Deng Y, Sheth A (2012) 24 versus 48-hour bravo pH monitoring. J Clin Gastroenterol 46:197–200
Tseng D, Rizvi AZ, Fennerty MB, Jobe BA, Diggs BS, Sheppard BC, Gross SC, Swanstrom LL, White NB, Aye RW, Hunter JG (2005) Forty-eight-hour pH monitoring increases sensitivity in detecting abnormal esophageal acid exposure. J Gastrointest Surg 9:1043–1051 discussion 1051–1042
Iqbal A, Lee YK, Vitamvas M, Oleynikov D (2007) 48-Hour pH monitoring increases the risk of false positive studies when the capsule is prematurely passed. J Gastrointest Surg 11:638–641
Ayazi S, Hagen JA, Zehetner J, Banki F, Augustin F, Ayazi A, DeMeester SR, Oh DS, Sohn HJ, Lipham JC, DeMeester TR (2011) Day-to-day discrepancy in Bravo pH monitoring is related to the degree of deterioration of the lower esophageal sphincter and severity of reflux disease. Surg Endosc 25:2219–2223
Tamhankar AP, Peters JH, Portale G, Hsieh CC, Hagen JA, Bremner CG, DeMeester TR (2004) Omeprazole does not reduce gastroesophageal reflux: new insights using multichannel intraluminal impedance technology. J Gastrointest Surg 8:890–897 discussion 897–898
Blonski W, Vela MF, Castell DO (2009) Comparison of reflux frequency during prolonged multichannel intraluminal impedance and pH monitoring on and off acid suppression therapy. J Clin Gastroenterol 43:816–820
Acknowledgement
This investigation was supported in part by grant TL1RR024998 of the Clinical and Translational Science Center at Weill Cornell Medical College.
Disclosures
Dr. Kleiman, Mr. Sporn, and Drs. Beninato, Metz, Crawford, Fahey and Zarnegar have no conflicts of interest or financial ties to disclose.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Kleiman, D.A., Sporn, M.J., Beninato, T. et al. Early referral for 24-h esophageal pH monitoring may prevent unnecessary treatment with acid-reducing medications. Surg Endosc 27, 1302–1309 (2013). https://doi.org/10.1007/s00464-012-2602-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-012-2602-z