Management of the patient with incomplete response to PPI therapy

Proton pump inhibitors (PPIs) remove most of the acid from the gastroesophageal refluxate. However, PPIs do not eliminate reflux and the response of specific GERD symptoms to PPI therapy depends on the degree to which acid drives those symptoms. PPIs are progressively less effective for heartburn, regurgitation, chest pain and extra-oesophageal symptoms. Hence, with an incomplete PPI response, obtaining an accurate history, detailing which symptoms are ‘refractory’ and exactly what evidence exists linking these symptoms to GERD is paramount. Reflux can continue to cause symptoms despite PPI therapy because of persistent acid reflux or weakly acidic reflux. Given these possibilities, diagnostic testing (pH or pH-impedance monitoring) becomes essential. Antireflux surgery is an alternative in patients if a clear relationship is established between persistent symptoms, particularly regurgitation, and reflux. Treating visceral hypersensitivity may also benefit the subset of GERD patients whose symptoms are driven by this mechanism.     

Upper oesophageal images and Z-line detection with 2 different small-bowel capsule systems

Transmission of oesophageal images may vary between different small-bowel capsule endoscopy models.A retrospective review of 100 examinations performed with 2 different Small-bowel capsule endoscopy(SBCE) systems(PillCam and MiroCam) was performed.The oral cavity/aero-digestive tract(i.e.,tongue,uvula and/or epiglottis) was captured/identified in almost all(99%) of PillCam videos but in none of MiroCam cases,P 0.0001.Furthermore,oesophageal images(i.e.,from the upper oesophageal sphincter to the Z-line were captured in 99% of PillCam videos(mean ± SD,60.5 ± 334.1 frames,range:0-3329 frames) and in 66% of MiroCam cases(mean ± SD,11.1 ± 46.5 frames,range:0-382 frames),P 0.0001.The Z-line was identified in 42% of PillCam videos and 17% of MiroCam,P = 0.0002.This information might be useful when performing SBCE in patients with high risks for aspiration.