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Esophageal pH monitoring
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Esophageal pH monitoring
In gastroenterology, esophageal pH monitoring is the current gold standard for diagnosis of gastroesophageal reflux disease (GERD). It provides direct physiologic measurement of acid in the esophagus and is the most objective method to document reflux disease, assess the severity of the disease and monitor the response of the disease to medical or surgical treatment. It can also be used in diagnosing laryngopharyngeal reflux.
The importance of refluxed gastric contents in the pathogenesis of GERD was emphasized by Winkelstein who introduced the term "peptic esophagitis" and by Bernstein and Baker who reported the symptom of heartburn following instillation of hydrochloric acid in the distal esophagus in what then became known as the acid perfusion test. Formal measurement of acid in the esophagus was first described in 1960 by Tuttle. He used a glass pH probe to map the gastroesophageal pH gradient, and demonstrated a sharp gradient in normal subjects and a gradual, sloping gradient in patients with esophagitis. Four years later, Miller used an indwelling esophageal pH electrode to continuously measure esophageal and gastric pH for a period up to 12 hours. This technique required that the patient keep their hands immersed in saline to serve as a reference. Prolonged monitoring became feasible in 1974 when Johnson and DeMeester developed a dependable external reference electrode. Using this technique to monitor esophageal acid exposure patients for periods up to 24 hours, DeMeester and Johnson were able to identify the most important parameters of esophageal acid exposure, and they developed a composite pH score to quantify gastroesophageal reflux. The initial 24-hour pH studies required hospitalization until the introduction of microcircuits in the 1980s that allowed portable esophageal pH monitoring in an outpatient setting.[citation needed]
Gastroesophageal reflux disease (GERD) is a common disease in western countries. In the United States, 7% of the population experiences heartburn daily and 44% at least once a month. Heartburn occurs when esophageal mucosa is exposed to the acidic gastric content, but the complaint of heartburn is not always a reliable guide to the presence of acid reflux in the esophagus. Further, only half of the patients with increased esophageal acid exposure will have esophagitis. Therefore, the diagnosis of gastroesophageal reflux disease (GERD) on the basis of symptoms or endoscopic findings is problematic.[citation needed]
Although there remains no gold standard for the diagnosis of GERD, ambulatory esophageal pH monitoring can provide data to guide further evaluation and treatment of patients with GERD-associated symptoms. In the past, an indwelling nasoesophageal catheter was the only way to measure esophageal acid exposure. Because this method is associated with nasal and pharyngeal discomfort and rhinorrhea, patients may have limited their activity and become more sedentary during the monitored period. This may have resulted in less acid reflux and a false negative test. A catheter-free radio telemetric system allows a longer period of monitoring and may be better tolerated.
Esophageal pH monitoring is currently performed using one of the following three techniques:
The duration of the test is 24 hours in the first and second techniques and 48 hours for the Bravo capsule or more (96 hours) for OMOM capsule.
In assessment of distal esophageal pH, the sensor is placed 5 cm above the upper border of the lower esophageal sphincter (LES) determined by esophageal manometry. To measure proximal esophageal acid exposure, the second sensor is placed 1-5 below the lower border of the upper esophageal sphincter (UES). The Bravo pH capsule is placed either transnasally based on manometric measurements, or following endoscopy. In transnasal placement, the capsule is placed 5 cm above the upper border of the LES, and in endoscopic placement 6 cm above the gastroesophageal junction. The same applies to OMOM pH monitoring capsule.
A reflux episode is defined as esophageal pH drops below four. Esophageal pH monitoring is performed for 24 or 48 hours and at the end of recording, a patient's tracing is analyzed and the results are expressed using six standard components. Of these 6 parameters, a pH score called Composite pH Score or DeMeester Score has been calculated, which is a global measure of esophageal acid exposure. A Demeester score > 14.72 indicates reflux.
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Esophageal pH monitoring
In gastroenterology, esophageal pH monitoring is the current gold standard for diagnosis of gastroesophageal reflux disease (GERD). It provides direct physiologic measurement of acid in the esophagus and is the most objective method to document reflux disease, assess the severity of the disease and monitor the response of the disease to medical or surgical treatment. It can also be used in diagnosing laryngopharyngeal reflux.
The importance of refluxed gastric contents in the pathogenesis of GERD was emphasized by Winkelstein who introduced the term "peptic esophagitis" and by Bernstein and Baker who reported the symptom of heartburn following instillation of hydrochloric acid in the distal esophagus in what then became known as the acid perfusion test. Formal measurement of acid in the esophagus was first described in 1960 by Tuttle. He used a glass pH probe to map the gastroesophageal pH gradient, and demonstrated a sharp gradient in normal subjects and a gradual, sloping gradient in patients with esophagitis. Four years later, Miller used an indwelling esophageal pH electrode to continuously measure esophageal and gastric pH for a period up to 12 hours. This technique required that the patient keep their hands immersed in saline to serve as a reference. Prolonged monitoring became feasible in 1974 when Johnson and DeMeester developed a dependable external reference electrode. Using this technique to monitor esophageal acid exposure patients for periods up to 24 hours, DeMeester and Johnson were able to identify the most important parameters of esophageal acid exposure, and they developed a composite pH score to quantify gastroesophageal reflux. The initial 24-hour pH studies required hospitalization until the introduction of microcircuits in the 1980s that allowed portable esophageal pH monitoring in an outpatient setting.[citation needed]
Gastroesophageal reflux disease (GERD) is a common disease in western countries. In the United States, 7% of the population experiences heartburn daily and 44% at least once a month. Heartburn occurs when esophageal mucosa is exposed to the acidic gastric content, but the complaint of heartburn is not always a reliable guide to the presence of acid reflux in the esophagus. Further, only half of the patients with increased esophageal acid exposure will have esophagitis. Therefore, the diagnosis of gastroesophageal reflux disease (GERD) on the basis of symptoms or endoscopic findings is problematic.[citation needed]
Although there remains no gold standard for the diagnosis of GERD, ambulatory esophageal pH monitoring can provide data to guide further evaluation and treatment of patients with GERD-associated symptoms. In the past, an indwelling nasoesophageal catheter was the only way to measure esophageal acid exposure. Because this method is associated with nasal and pharyngeal discomfort and rhinorrhea, patients may have limited their activity and become more sedentary during the monitored period. This may have resulted in less acid reflux and a false negative test. A catheter-free radio telemetric system allows a longer period of monitoring and may be better tolerated.
Esophageal pH monitoring is currently performed using one of the following three techniques:
The duration of the test is 24 hours in the first and second techniques and 48 hours for the Bravo capsule or more (96 hours) for OMOM capsule.
In assessment of distal esophageal pH, the sensor is placed 5 cm above the upper border of the lower esophageal sphincter (LES) determined by esophageal manometry. To measure proximal esophageal acid exposure, the second sensor is placed 1-5 below the lower border of the upper esophageal sphincter (UES). The Bravo pH capsule is placed either transnasally based on manometric measurements, or following endoscopy. In transnasal placement, the capsule is placed 5 cm above the upper border of the LES, and in endoscopic placement 6 cm above the gastroesophageal junction. The same applies to OMOM pH monitoring capsule.
A reflux episode is defined as esophageal pH drops below four. Esophageal pH monitoring is performed for 24 or 48 hours and at the end of recording, a patient's tracing is analyzed and the results are expressed using six standard components. Of these 6 parameters, a pH score called Composite pH Score or DeMeester Score has been calculated, which is a global measure of esophageal acid exposure. A Demeester score > 14.72 indicates reflux.
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