José M. Conchillo

Addition of esophageal impedance monitoring to pH monitoring increases the yield of symptom association analysis in patients off PPI therapy

BACKGROUND:The additional yield of esophageal impedance monitoring in identification of reflux as the cause of reflux symptoms is unknown.OBJECTIVES:To compare the yield of symptom–reflux association analysis of combined esophageal pH-impedance data with the yield of analysis of pH data alone.METHODS:In 60 patients with symptoms of heartburn and regurgitation combined, 24-h pH-impedance monitoring was performed. Acid-suppressive medication was stopped 1 wk in advance. Patients (48) with at least one symptom during the measurement period were selected for further analysis. Patients were instructed to note the time and nature of their symptoms. Eleven types of reflux episodes were defined, based on combinations of magnitude of the pH drop, nadir pH, and nature of the refluxate (gas and liquid) on impedance tracings. Symptom association analysis—symptom index, the symptom sensitivity index, and the symptom association probability (SAP)—was performed for each definition of reflux.RESULTS:The proportion of patients with a positive SAP (≥95.0%) varied between 62.5% and 77.1%, depending on the definition of reflux episodes. When both pH and impedance parameters were used to identify reflux, a higher proportion of patients had a positive SAP than with pH alone (77.1%vs 66.7%, p < 0.05). Symptom association analysis for acidic and weakly acidic reflux separately did not result in a higher yield than analysis with all reflux episodes pooled, regardless of pH.CONCLUSION:In patients off proton pump inhibitor, the addition of impedance monitoring to esophageal pH monitoring leads to an increase in the proportion of patients in whom an association between reflux episodes and symptoms can be identified.

Small intestinal permeability is increased in diarrhoea predominant IBS, while alterations in gastroduodenal permeability in all IBS subtypes are largely attributable to confounders

Intestinal permeability has been studied in small groups of IBS patients with contrasting findings.

Rectal hypersensitivity as hallmark for irritable bowel syndrome: defining the optimal cutoff

Background  Visceral hypersensitivity is a frequently observed hallmark of irritable bowel syndrome (IBS). Studies have reported differently about the presence of visceral hypersensitivity in IBS resulting from lack of standardization of the barostat procedure and due to different criteria used to assess hypersensitivity. We aimed to calculate the optimal cutoff to detect visceral hypersensitivity in IBS.

Review article: the clinical relevance of transient lower oesophageal sphincter relaxations in gastro-oesophageal reflux disease

Aliment Pharmacol Ther 2011; 33: 650–661

Review article: Clinical relevance of transient lower esophageal sphincter relaxations (TLESR) in gastroesophageal reflux disease.

Aliment Pharmacol Ther 2011; 33: 650–661

Revisiting concepts of visceral nociception in irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common disorder characterized by abdominal pain related to defecation with a change in bowel habit. Patients with IBS often exhibit increased visceral sensitivity, which can be tested clinically by rectal balloon distension procedures. This paper aims to give an overview of mechanisms involved in visceral hypersensitivity in IBS by reviewing recent literature.

Randomized controlled trial of transoral incisionless fundoplication vs. proton pump inhibitors for treatment of gastroesophageal reflux disease.

Objectives:Transoral incisionless fundoplication (TIF) was developed in an attempt to create a minimally invasive endoscopic procedure that mimics antireflux surgery. The objective of this trial was to evaluate effectiveness of TIF compared with proton pump inhibition in a population consisting of gastroesophageal reflux disease (GERD) patients controlled with proton pump inhibitors (PPIs) who opted for an endoscopic intervention over lifelong drug dependence.Methods:Patients with chronic GERD were randomized (2:1) for TIF or continuation of PPI therapy. American Society of Anesthesiologists >2, body mass index >35 kg/m2, hiatal hernia >2 cm, and esophageal motility disorders were exclusion criteria. Primary outcome measure was GERD-related quality of life. Secondary outcome measures were esophageal acid exposure, number of reflux episodes, PPI usage, appearance of the gastroesophageal valve, and healing of reflux esophagitis. Crossover for the PPI group was allowed after 6 months.Results:A total of 60 patients (TIF n=40, PPI n=20, mean body mass index 26 kg/m2, 37 male) were included. At 6 months, GERD symptoms were more improved in the TIF group compared with the PPI group (P<0.001), with a similar improvement of distal esophageal acid exposure (P=0.228) compared with baseline. The pH normalization for TIF group and PPI group was 50% and 63%, respectively. All patients allocated for PPI treatment opted for crossover. At 12 months, quality of life remained improved after TIF compared with baseline (P<0.05), but no improvement in esophageal acid exposure compared with baseline was found (P=0.171) and normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of PPIs in 61%.Conclusion:Although TIF resulted in an improved GERD-related quality of life and produced a short-term improvement of the antireflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved.

Impedance measurements and high-resolution manometry help to better define rumination episodes

Abstract Background. Rumination syndrome is a disorder of unknown etiology characterized by regurgitation of recently ingested food. We aimed to improve the diagnosis of rumination syndrome by classification of separate rumination symptoms using (1) an ambulatory manometry/impedance (AMIM) measurement and (2) a single-catheter high-resolution manometry/impedance (HRIM) measurement. Methods. A total of 96 symptoms during AMIM and 37 symptoms during HRIM were analyzed in five patients with clinically diagnosed rumination syndrome. Key results. AMIM identified rumination events in 85 out of 96 reported symptoms (symptom index (SI): 89%). Of these events, 63% were non-acidic and would have been missed by pH-metry. HRIM identified 32 out of 37 reported symptoms (SI: 86%). Upper esophageal sphincter (UES) relaxation was observed during all rumination events identified by HRIM and could be an additional criterion in the definition of rumination events. Conclusions. Impedance measurement and high-resolution manometry contribute to a more detailed description of rumination events. Rumination events defined as gastric strain, common cavity phenomenon, retrograde esophageal fluid flow, and UES relaxation show a high SI when measured with AMIM or single-catheter HRIM.

Electrical stimulation therapy of the lower oesophageal sphincter for refractory gastro-oesophageal reflux disease - interim results of an international multicentre trial.

A previous single‐centre study showed that lower oesophageal sphincter electrical stimulation therapy (LES‐EST) in gastro‐oesophageal reflux disease (GERD) patients improves reflux symptoms and decreases oesophageal acid exposure.

Randomized clinical trial on the effect of a multispecies probiotic on visceroperception in hypersensitive IBS patients

Irritable bowel syndrome (IBS) is characterized by heterogeneous pathophysiology and low response to treatment. Up to 60% of IBS patients suffers from visceral hypersensitivity, which is associated with symptom severity and underlying pathophysiological mechanisms. Recently, positive effects of probiotics in IBS have been reported, but overall the response was modest. We performed a study in IBS patients, characterized by visceral hypersensitivity measured with the rectal barostat, aiming to assess the effect of 6 weeks of multispecies probiotic mix on visceral pain perception.