Ambulatory 24-hour esophageal pH monitoring

If 24-hour esophageal pH monitoring is to be a useful diagnostic tool, it must reliably discriminate gastroesophageal reflux patients despite daily variations in distal esophageal acid exposure. To address this issue, we studied 53 subjects (14 healthy normals, 14 esophagitis patients, and 25 patients with atypical symptoms) with two ambulatory pH tests performed within 10 days of each other. Intrasubject reproducibility of 12 pH parameters to discriminate the presence of abnormal acid reflux was determined. As a group, the parameters of percent time with pH<4 (total, upright, recumbent) were most reproducible (80%). Therefore, a subject was defined as having gastroesophageal reflux disease if at least one of these three values were abnormal. Intrasubject reproducibility for the diagnosis of reflux disease was 89% for the entire sample. Among subsets, the reproducibility was 93% for the normals and esophagitis patients and 84% for the atypical symptom patients. Total percent time with pH<4 was the single most discriminate pH parameter (85%) and nearly equaled that of the three combined parameters (89%). The intrasubject variability of this parameter was determined by the mean ±2sd of the relative differences between the two test results for all 53 subjects. Total percent time with pH<4 may vary between tests by a factor of 3.2-fold or less (218% higher to 69% lower). We conclude: (1) ambulatory 24-hr esophageal monitoring is a reproducible test for the diagnosis of gastroesophageal reflux disease; and (2) the large intrastudy variability in 24-hr total acid exposure may limit this test's usefulness as a measurement of therapeutic improvement.Supported, in part, by Public Health Services Grant AM 34200-01A1 from NIADDIK.     

食管pH值监测观察酸相关疾病103例

目的 探讨24小时食管pH值监测在诊断上消化道疾病中（尤其胃食管反流病）的临床意义。方法 对2001年4月-2004年5月于我院进行食管pH值监测的103例临床患者，根据有无症状分为两组，无症状组20例为对照组，有症状组83例，其中反流性食管炎（RE）并慢性胃炎的患者30例，占36．1％，然后依次为十二指肠溃疡19例（22．9％）、非糜烂性食管炎13例（15．6％）、单纯反流性食管炎11例（13．3％）及胃溃疡10例（12．0％）。结果 RE并十二指肠溃疡组在各项指标中均高于其他各组（P〈0．05）。结论 RE多合并其他上消化道疾病（尤其酸相关疾病）发生．罹患十二指肠溃疡可能是RE发生和加重的原因之一。     

采用多指标分析在食道24小时pH监测中的意义

目的了解多指标分析在食道24小时pH监测中的意义.方法通过对280例反流性食道炎患者和20例正常人进行食道24小时pH监测,引用总酸反流指数、总酸反流面积、食道卧位酸清除平均时间、总碱反流指数、总碱反流面积、食道卧位碱清除平均时间六项指标,对比分析各指标在诊断反流性食道炎中意义.结果反流性食道炎组和正常组总酸反流指数、总酸反流面积、食道卧位酸清除平均时间、总碱反流指数、总碱反流面积、食道卧位碱清除平均时间分别为7.56±6.26和1.46±0.92、112.0±10.8和24.5±20.8、0.90±0.88和0.38±0.32、0.55±0.43和0.02±0.01、4.21±3.95和1.38±1.11、0.16±0.12和0.01±0.008,两者对比仅卧位碱清除平均时间的P值小于0.05,其余均小于0.01.结论采用多指标分析可以良好地分析和判断反流性食道炎及其程度,并能通过食道卧位酸、碱清除平均时间来反映食道体蠕动清除反流物的能力,故多指标分析是Demeester计分的良好补充.     

24-hour esophageal pH monitoring. An analysis of 21 cases]

Esophageal pH monitoring was carried out with self-made portable pH recorder in 21 subjects for 24 hours under normal conditions. The results were as follows: the number of physiological gastroesophageal reflux (GER, pH < 4) was less than 23 times; the percentage of GER duration calculated by dividing the cumulative time of pH less than 4 by the total monitoring time was less than 1.4; the percentage was about 2 in upright position and less than 0.2 in lying position; the duration of the longest reflux episode was less than 5 minutes; the physiological gastroesophageal reflux occurred more often in upright position; while the pathological GER took place both in upright and lying position. Our study also indicated that the degree of esophagitis had no relation with the type of GER.     

Acid perfusion test and 24-hour esophageal pH monitoring with symptom index

The acid perfusion (Bernstein) test and esophageal pH monitoring are the two most popular tests for identifying esophageal acid sensitivity in difficult cases of reflux disease. Therefore, we prospectively compared these test results in 75 consecutive noncardiac chest pain patients who had both an acid perfusion test and chest pain during 24-hr pH testing. A positive acid perfusion test was defined by the replication of the patient's typical chest pain twice by the acid infusion. Esophageal pH testing identified abnormal amounts of acid reflux and correlated symptoms with acid reflux-the symptom index. Fifteen patients (20%) had a positive acid perfusion test while 45 patients (59%) had a positive symptom index (range 6–100%). Only 9/34 (26%) patients with abnormal reflux had a positive acid perfusion test. Although it had excellent specificity (83–94%), the acid perfusion test had poor sensitivity (32–46%) when compared to the symptom index regardless of the percent positive cutoff level. The best positive predictive value for the acid perfusion test was 87%, but this occurred when the test sensitivity was 32%. Modifying the end point of a positive acid perfusion test to include heartburn improves the sensitivity (52–67%) while markedly compromising specificity and positive predictive value. Thus, esophageal pH monitoring correlating symptoms with acid reflux is superior to the acid perfusion test for identifying an acid sensitive esophagus in patients with noncardiac chest pain.     

24h双通道食管pH监测在食管酸相关疾病诊断中的应用

24 h食管pH测定用以监测食管是否存在异常酸反流是目前最好的检查方法之一,有助于诊断食管酸相关疾病,但24 h单通道食管pH监测只能观察远端食管酸反流情况,不能监测近端食管酸反流.24 h双通道食管pH测定,可同时观察食管远端、近端酸反流情况,对胃食管反流病(GERD)患者伴食管外症状、食管上段异位胃黏膜有重要临床价...     

Age- and gender-related differences in 24-hour esophageal pH monitoring of normal subjects

Twenty-four-hour esophageal pH monitoring is currently the most sensitive test for diagnosing gastroesophageal reflux. Little is known, however, about the effect of aging and gender on esophageal acid exposure in asymptomatic individuals. Thirty asymptomatic volunteers underwent 24-hr esophageal pH monitoring. Fifteen were <65 years (eight female, seven male) and 15 were 65 years (seven female, eight male). In this asymptomatic group no significant difference was seen by age, while males were found to have significantly more esophageal acid exposure than females. The need for sex-specific normal 24-hr pH monitoring values is suggested. Thirty percent of these asymptomatic subjects were abnormal by conventional 24-hr pH criteria. The clinical importance of these silent refluxers is unknown.     

Ambulatory 24-hour esophageal pH monitoring: why,when, and what to do

The incidence of gastroesophageal reflux disease (GERD) is increasing and if left untreated can lead to significant patient morbidity and even death. The disease results from the abnormal reflux of gastric contents into the distal esophagus causing symptoms in most and subsequent mucosal damage in some. Several investigations can be used to confirm the diagnosis, but most are dependent on the presence of sequelae and complications of the disease. The physiologic test of ambulatory 24-hour esophageal pH monitoring has proved to be the most sensitive and specific diagnostic investigation. It measures increased esophageal exposure to gastric juice by detecting the concentration of hydrogen ions (pH <4) in the distal esophagus. The technique measures gastric juice exposure at a point 5 cm above the manometrically determined upper border of the lower esophageal sphincter. The exposure is measured in components of frequency of reflux episodes, duration of reflux episodes, and accumulated exposure time. The components are integrated into a composite score, which is reproducible, gender and race independent, and correlates with the degree of esophageal epithelial damage determined histologically. The composite score has been shown to be the most reliable measurement of a therapeutic acid suppression regimen or an effective antireflux operation.     

糖尿病患者食管和胃24小时pH动态监测及临床意义

目的 了解糖尿病患者食管酸碱反流情况及胃内ｐＨ变化,探讨其诊断胃、食管分泌及运动障碍的临床意义。方法 采用便携式２４小时ｐＨ动态监义,对３４例２型糖尿病患者进行非卧床食管和胃２４小时ＰＨ动态监测,对食管反流的６项ＰＨ指标综合分析,并与４０例正常人进行比较。结果 糖尿 有一食管酸反流的６项指标及总计分明显高于对照组（Ｐ〈０．００１）。食管碱反流及胃内２４小时各项ＰＨ指标与对照组相比无显著性差异（Ｐ〉     

A computer-assisted technique for 24-hour esophageal monitoring

Modern computer design offers the opportunity to rapidly and objectively analyze the large quantity of data obtained during prolonged intraesophageal monitoring. The purpose of this study is: (1) to describe a rapid automated technique for acquisition and analysis of esophageal parameters, using a microcomputer; and (2) to compare computerized versus manual analysis of physiograph recordings. Ten normal subjects underwent 24-hr computerized monitoring of intraesophageal function, including: (1) pH recording at 5 and 10 cm above the lower esophageal sphincter (LES); (2) pharyngeal contraction; (3) esophageal contraction at 5 and 10 cm; (4) posteriorly directed LES pressures; and (5) gastric pressure. Segments from several studies were chosen for comparison of physiograph data with that obtained by computer. No significant differences were found except for the number of esophageal contractile events. This difference stems from a problem of shifting baseline related to subject position. Thus, the computer can be used for analysis of large quantities of data obtained from prolonged esophageal monitoring.This study was supported by NIH grant AM26371-02.     

Combined 24-hour recording of esophageal pH and pressure

Twenty-four-hour ambulatory recording of esophageal pH and pressure is a newly developed technique that has the potential of proving that a patient's noncardiac chest pain is of esophageal origin (esophageal reflux or motor abnormality). Until now four groups described their experiences with application of the technique in the work-up of noncardiac chest pain. It is now clear that the diagnostic yield of the technique in this syndrome is rather limited, especially when the incidence of pain episodes is low. Reflux appears to be a more common cause of chest pain than esophageal motor disorders. Complete quantitative analysis of the 24-hr motility data by hand is very time-consuming, so that automated, computerized data analysis is a prerequisite for more widespread clinical use of the technique.     

Simultaneous two-level esophageal 24-hour pH monitoring in patients with mild and severe esophagitis

Simultaneous ambulatory esophageal pH monitoring was performed in 10 patients (group 1) with normal distal acid exposure and in 40 patients (group 2) with pathological distal reflux. The probes were placed 5 and 10 cm above the lower esophageal sphincter to quantify variations of pH values that can be due to a displacement of pH sensor. In group 1 the median percent time with pH<4 for total and upright monitoring periods and composite score were significantly lower at the proximal than the distal level. In group 2 all pH data were significantly lower at the proximal than the distal level. The patients with pathological reflux were subdivided into two subgroups based on endoscopic findings (mild and severe esophagitis). The patients with severe esophagitis showed a proximal acid reduction higher than in patients with mild esophagitis. Nine patients with mild esophagitis showed normal values at 10 cm, but all patients with severe esophagitis had abnormal proximal acid exposure.     

含餐8 h食管pH监测与常规24 h pH监测对胃食管反流病的诊断价值比较

目的探讨含餐8h食管pH监测对胃食管反流病(GERD)的诊断意义,并以常规24hpH监测为标准验证其灵敏度及特异度。方法对2003年3月至2006年9月北京大学人民医院消化科221例患者进行食管测压和pH监测。首先由系统计算24h DeMeester积分,≥14.72分诊断为胃食管反流病。入选患者晚餐开始共计8h的监测数据,同样计算DeMeester积分,相同的标准诊断胃食管反流病。比较两种方法的一致性及积分的相关性。结果221例患者经常规24hpH监测诊断胃食管反流病124例,正常97例,含餐8hpH监测方法诊断胃食管反流病120例,正常101例。含餐8h的灵敏度为93.5%,特异度95.9%,经Kappa及Mc-nemar检验2种方法具有良好的一致性,部分结果的差异不具有显著性。2种检测方式DeMeester积分的相关系数为0.929。结论含餐8小时监测法和24hpH监测法具有良好的一致性,有望用于GERD特别是内镜阴性GERD的诊断。     

Accurate placement of the esophageal pH electrode for 24-hour pH monitoring using a combined pH/manometry probe

OBJECTIVE: Accurate placement of a pH electrode requires manometric localization of the lower esophageal sphincter (LES). Combined manometry/pH devices using water-perfused tubes attached to pH catheters and the use of an electronic "LES locator" have been reported. We investigated whether accurate placement of pH probes can be achieved using such a probe, and whether this may reduce the need for the performance of the usual stepwise pull-back manometry. METHODS: Thirty consecutive patients (15 men, 15 women; median age, 56 yr; interquartile range, 42-68 yr) referred for manometry and pH testing were included in the study. The localization of the LES was determined with standard esophageal manometry. After that, a second 3-mm pH electrode with an internal perfusion port was passed into the stomach. Using this catheter, a single stepwise pull-through manometry was performed and the LES position was noted. LES location, mean pressure, and length obtained with standard manometry were compared to data from the combined pH/manometry catheter. Additionally the time necessary to perform each of the procedures was noted and the patient's discomfort caused by the catheter was evaluated using a standardized questionnaire. RESULTS: The LES location with the pH/manometry probe was proximal to that with standard manometry in 19 patients (63%), the same in nine patients (30%), and distal in two patients (7%). The differences were <2 cm in 29 of 30 (97%) patients. The LES location with the pH/manometry probe required a median of 6.5 min (interquartile range: 3.5-8.5 min) versus a median of 21.5 min (interquartile range: 14.5-26.5 min) for standard manometry (p < 0.0001). In addition, LES evaluation using the combined pH/manometry probe provided accurate data on the resting pressure, as well as overall and intraabdominal length of the LES. All patients tolerated the combination probe better than the standard manometry probe (p < 0.001). CONCLUSIONS: Placement of the esophageal electrode for 24-h esophageal pH monitoring using a combined pH/manometry probe is accurate. The technique is simple, time-saving, and convenient for the patients. Because it is possible to accurately evaluate the LES using this technique, it may even replace conventional manometry before pH probe placement.     

Validation of a new method of measuring esophageal acid exposure: comparison with 24-hour pH monitoring

Recently, we developed a disposable acid exposure sensor whose in vitro response to acid below pH 4 is linearly determined by the duration of exposure and the degree of acidity. The aim of the present study was to compare the SR to simultaneous esophageal pH and duodenogastroesophageal reflux (DGER) monitoring (Bilitec) in patients investigated for presumed gastroesophageal reflux disease (GERD). Twenty-six patients (16 men, mean age 46 ± 2 years) with symptoms suggestive of GERD underwent 24-hr ambulatory pH monitoring and SR monitoring at 5 cm proximal to the LES. DGER monitoring was performed in 21 patients. Exposure of the esophagus to acid and to DGER were analyzed. These data were compared to SR. A significant correlation was found between the exposure of the distal esophagus to acid and SR (R = 0.85; P < 0.0001). Similarly, the area below a cutoff pH 4 was significantly correlated to SR (r = 0.81; P < 0.0001). SR was not correlated to DGER (r = 0.16; NS). At a cutoff of 50, the sensitivity and specificity of SR to predict esophageal acid exposure >5% of time were 91% and 93%, respectively conclusion, the response of the acid exposure sensor is strongly correlated with the results of simultaneous esophageal pH monitoring. The sensor seems able to reliably predict pathological esophageal acid exposure. These findings warrant larger studies of the clinical potential of the acid exposure sensor in the diagnosis and quantification of GERD.     

Spontaneous noncardiac chest pain. Evaluation by 24-hour ambulatory esophageal motility and pH monitoring

Noncardiac chest pain can be a diagnostic dilemma because patients rarely experience spontaneous chest pain in the laboratory. Therefore, we studied 24 patients with chronic, daily, substernal chest pain with a prototype 24-h ambulatory esophageal motility and pH system. Spontaneous chest pain episodes were correlated with pH less than 4 and abnormal motility changes (mean amplitude and duration, maximum amplitude and duration, or percentage of abnormal peristalsis) defined as exceeding the patient's normal esophageal motility pattern. Twenty-two patients experienced a total of 92 spontaneous chest pain episodes. Eleven chest pain episodes (12%) occurred during abnormal motility, whereas 18 episodes (20%) were associated with pH less than 4 and four episodes (4%) had both abnormalities. The majority of chest pain episodes, 59 events (64%), did not have any association with motility or pH. Abnormal maximum duration and amplitude were the motility changes most frequently associated with chest pain. Overall, 13 of 22 patients (59%) had at least one chest pain episode correlating with abnormal motility or pH (range 33%-100%). Therefore, we conclude that ambulatory esophageal motility and pH monitoring is useful in the evaluation of noncardiac chest pain. pH abnormalities (20%) are more commonly associated with chest pain than motility abnormalities (12%). However, the majority of chest pain episodes (64%) did not correlate with either abnormality and may be the result of lowered esophageal pain threshold for distention, i.e., the "irritable esophagus."