Gloria Pulliam

Effect of ambulatory 24-hour esophageal pH monitoring on reflux-provoking activities.

Ambulatory 24-hr esophageal pH monitoring isconsidered the gold standard for diagnosinggastroesophageal reflux disease (GERD). The currentapproach is to encourage patients to pursue theireveryday activity in order to obtain near-physiologicalrecordings. However, the effect of the test itself onreflux-provoking activities has never been evaluated.Thus, the aim of our study was to assess daily foodconsumption, habits, symptoms, sleep, and perceivedexperience of patients undergoing pH testing as comparedto an off test (normal) day. Patients reported type andtime spent in each activity pursued, food ingested and length of each meal, habits, frequency andseverity of GERD and other related symptoms, sleepdisturbances, side effects, and overall perceivedexperience during pH testing and four weeks later,during a normal day. Fifty-four patients enrolled. pHtesting significantly reduced time spent being active,number of meals and cups of coffee consumed, andfrequency of GERD symptoms. Almost half of the patients reported having dysphagia during the test. Mostpatients experienced side effects and stated that thetest bothered them most of the time. In conclusion, pHtesting has a significant effect on decreasing reflux-provoking activities — patientstend to assume a more sedentary lifestyle. This mayinfluence the reliability of the test as a physiologicmeasure of acid reflux.

Correlation of oesophageal acid exposure with Barrett's oesophagus length

BACKGROUND Gastro-oesophageal reflux disease (GORD) plays a major role in the development of Barretts oesophagus. However, it has yet to be elucidated what factors determine the length of Barretts mucosa in each individual patient. AIMS To determine if there is a correlation between oesophageal acid exposure and the length of Barretts mucosa. We also compared the extent of oesophageal acid exposure between patients with short segment (SSBE) and long segment (LSBE) Barretts oesophagus. METHODS Twenty seven patients with Barretts oesophagus were recruited prospectively into the study from the outpatient gastroenterology clinic at the Southern Arizona VA Health Care System. Diagnosis of Barretts oesophagus and its anatomical characteristics were determined during upper endoscopy. Ambulatory 24 hour oesophageal pH monitoring assessed the extent of oesophageal acid exposure. RESULTS There was a significant correlation between per cent total time pH less than 4 and length of Barretts mucosa (r=0.6234, p=0.0005). In addition, there was a significant correlation between per cent upright and supine time pH less than 4 and length of Barretts mucosa (r=0.5847, p=0.0014 andr=0.6265 p=0.0006, respectively). Patients with SSBE had significantly less oesophageal acid exposure than patients with LSBE, in terms of both per cent total time and per cent supine time pH less than 4 (p<0.05). CONCLUSIONS The length of Barretts mucosa correlated with the duration of oesophageal acid exposure. Patients with LSBE experienced significantly more oesophageal acid exposure than patients with SSBE. Duration of oesophageal acid exposure appears to be an important contributing factor in determining the length of Barretts mucosa.

The Value of Ambulatory 24 hr Esophageal pH Monitoring in Clinical Practice in Patients Who Were Referred with Persistent Gastroesophageal Reflux Disease (GERD)-Related Symptoms While on Standard Dose Anti-Reflux Medications

To determine the value of pH testing in clinical practice in gastroesophageal reflux disease patients who failed anti-reflux treatment. Patients resistant to standard dose proton pump inhibitor or an H2-blocker underwent pH testing. Randomly selected patients from the proton pump inhibitor failure group underwent the modified acid perfusion test as compared to patients with non-erosive reflux disease. In the proton pump inhibitor failure group (n = 70), 63.8% had a normal pH test as compared to 29% in the H2-blocker group (n = 31) (P = 0.007). Sensory intensity rating and acid perfusion sensitivity score were significantly higher in the non-erosive reflux disease control group than the proton pump inhibitor failure group (P < 0.05). Most patients who continued to be symptomatic on proton pump inhibitor once daily demonstrated a normal pH test and overall lack of increased chemoreceptor sensitivity to acid.

Effect of doses of glucagon used to treat food impaction on esophageal motor function of normal subjects.

Abstract. We studied 10 normal subjects to determine the effect of doses of intravenous glucagon used to treat food impaction on esophageal motor function. With a multilumen assembly perfused by a low compliance pneumohydraulic infusion pump, esophageal manometry was performed during baseline and after randomized administration of 0.25, 0.5, and 1 mg intravenous glucagon. Mean proximal and distal amplitudes of contraction, proximal and distal amplitude of contraction duration, lower esophageal sphincter (LES) resting pressure, percentage of LES relaxation, and glucagon-related side effects were evaluated. No effect on proximal amplitude of contraction and proximal or distal esophageal contraction duration was noted. Mean amplitude of contraction in the distal esophagus was further reduced with increased dosage of glucagon but did not achieve statistical significance. Mean LES resting pressure was significantly reduced after 0.25 mg (18.7 ± 1.8 vs. 10.2 ± 1.5 mmHg, p= 0.0001) and further reduced after 0.5 mg (5.9 ± 1.2 mmHg, p= 0.0009). Mean LES relaxation was significantly reduced after 0.25 mg (93.1 ± 2.4% vs. 63.6 ± 8.8%, p= 0.0031). The 1-mg dose versus the 0.5-mg did not provide further reduction in any LES function parameters. One subject experienced transient nausea after 0.5 mg, and 4 subjects experienced nausea after 1 mg glucagon. In conclusion, increased doses of glucagon further reduce mean distal esophageal amplitude of contraction. Although maximum reduction in mean LES resting pressure was achieved with 0.5 mg, it did not provide any potential therapeutic advantage over 0.25 mg glucagon. Nausea is a common, transient side effect predominantly affecting subjects treated with the 1-mg dose.

Relationship between rate of change in acid exposure along the esophagus and length of Barrett's epithelium

OBJECTIVE:Gastroesophageal reflux disease (GERD) plays a major role in the development of Barretts esophagus. Recently, we demonstrated that duration of esophageal acid exposure in the distal esophagus correlates with the length of Barretts mucosa. The aim of this study was to determine whether there is a relationship between the rate of the change in acid exposure along the esophagus and the length of Barretts esophagus.METHODS:A total of 17 patients (16 men and one woman; mean age 66 ± 15 yr, range 41–83 yr) with varying lengths of biopsy-proven Barretts esophagus were recruited prospectively into the study. Ambulatory 24-h esophageal pH monitoring was performed using a commercially available pH probe with four sensors located 5 cm apart. For each patient, a least squares regression line of the fraction of the study that the pH was <4 against the height of the sensor above the lower esophageal sphincter was fit. The slope of the regression line was used to represent the rate of change in acid exposure. Linear regression analysis was conducted to analyze the relationship between the rate of change in acid exposure and the length of Barretts mucosa.RESULTS:The mean Barretts length was 5 ± 3 cm (range 1–11 cm). Linear regression demonstrated a statistically significant relationship between the rate of change in acid exposure and the length of Barretts esophagus for the 24-h duration of the study, as well as for the fraction of the study that patients were in the upright position (p = 0.0096 and 0.0076, respectively). For the supine position, the relationship did not reach statistical significance (p = 0.095).CONCLUSIONS:We demonstrated a significant relationship between the rate of change in acid exposure and the length of Barretts mucosa. Thus, as the rate at which recorded acid exposure values increases from the proximal to distal esophagus, the length of Barretts esophagus significantly increases (for percent total time and upright position).

Impact of a formulary change in proton pump inhibitors on health care costs and patients' symptoms.

Patients may fail to successfully undergo a switch in therapy associated with a formulary change. The aim of this study was to measure health care costs and outcomes among patients who failed a formulary change in proton pump inhibitors in a VA medical center. Patients who failed a switch from omeprazole to lansoprazole (N = 51) were matched with patients who were successfully switched (N = 51). Health care utilization data was gathered from VA electronic databases and medical records for six months before and after the switch and, for failure patients, during the lansoprazole trial period. Statistical comparisons between failure and success patients were performed on changes in health care costs between these time periods. Health outcome data for the lansoprazole trial period and subsequent omeprazole reinstatement period were obtained through a telephone questionnaire of failure patients. Changes in total health care utilization costs did not differ significantly between failure and success groups for any of the time periods. Failure patients had significantly poorer health outcomes during their lansoprazole trial periods with significantly greater severity of heartburn and severity and frequency of acid regurgitation (P < 0.001). In conclusion, the formulary change had a negative impact upon health outcomes among failure patients but did not significantly affect their health care utilization costs. Identification of failure patients early in their lansoprazole trial periods could improved their health outcomes and satisfaction with medical care.