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Ambulatory Esophageal Monitoring

Esophageal Esophageal pH recording provides quantitative data on both esophageal acid exposure and on the correlation between patient symptoms and reflux events.

Indications
1. To detect refractory reflux in members with chest pain after cardiac evaluation using a symptom reflux association scheme, preferably the symptom association probability calculation (pH study done after a trial of proton pump inhibitor [PPI] therapy for at least 4 weeks)

2. To document abnormal esophageal acid exposure in an endoscopy-negative member being considered for surgical antireflux repair (pH study done after withholding anti-secretory drug regimen for more than 1 week) 3. To document concomitant gastro-esophageal reflux disease (GERD) in an adult onset, non-allergic asthmatic suspected of having reflux-induced asthma (pH study done after withholding anti-secretory drugs for more than 1 week). Note: a positive test does not prove causality

4. To evaluate members after anti-reflux surgery who are suspected to have ongoing abnormal reflux (pH study done after withholding anti-secretory drug regimen for more than 1 week)

Contraindications
Patients with known or suspected

digestive tract malformation, gastrointestinal obstruction, perforation of digestive tract, strictures, or fistulas based on the clinic picture or pre-procedure testing and profile.

* Patients with cardiac pacemaker or other implantable electro-medical devices. * Patients with swallowing disorders. * Patients with various acute enteritis, serious ischemia diseases, radioactive colonitis, such as season of bacillary dysentery action, acute stage ulcerative colitis, especially patients of fulminating form are forbidden to use.

*It is forbidden for patients who are sensitive to high molecular material. *Psychopath should be treated cautiously.

*Patients aged under 18 or above 70 should be treated cautiously.


*Pregnancy

Advantages
* Detects episodes of reflux * Determines temporal association between acid GER and symptoms

Limitations
* Cannot detect non-acidic reflux * inability to prove causality between symptoms and acid reflux

Complications
Nasal & Pharygeal Discomfort Rhinorrhea Patients may have limited activity

Equipments
Gloves Adhesive Tape Esophageal Probes The recording device (Acidogastrometer) A glass of water with drinking-straw

Esophageal Probes
A probe that measures pH, connected to an external Monitoring Device

Acidogatrometer

Different Types of pH Monitoring

Single sensor pH monitoring using a pH catheter

Dual sensor pH monitoring using a pH catheter

Wireless pH monitoring using Bravo pH capsule or OMOM pH monitoring capsule

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.

Preparation
The patient will be asked to refrain from

consuming alcohol or smoking for at least 24 hours before the test. The patient will be asked to refrain from eating or drinking anything for at least 6 hours before the test. The physician may give instructions that disallow consuming any antacid medication at least 24-36 hours before the test.

Preparation
Stop medications used for treating reflux and for

treating stomach acid problems unless indicated by the physician. Advice the patient to wear a shirt or blouse which opens in the front so that it is easier to dress after the probe is placed.

The Procedure
In assessment of distal esophageal pH, the sensor is placed 5 cm above 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 upper border of the LES, and in endoscopic placement 6 cm above gastroesophageal junction. The same applies to OMOM pH monitoring capsule.

Bernstein Test
Since the use of the aambulatory pH monitoring, this evaluation tool is used infrequently.

Performed to evaluate complaints of acidrelated chest or epigastric pain.

Procedure
HCl is instilled through a small feeding

tubepositioned in the esophagus. This is done to elicit reported chest pain. Resultant signs and symptoms are compared with the usual symptoms the patient reports.

a: Dual-channel proximal and distal esophageal pH monitoring is used to monitor patients with reflux symptoms off therapy. b: Dual channel distal esophageal and gastric pH monitoring is used to monitor patients with reflux symptoms on acid suppressive therapy.

Components of esophageal pH Monitoring


A reflux episode is defined as esophageal pH drop below four. Esophageal pH monitoring is performed for 24 or 48 hours and at the end of recording, patients 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 JD score > 14.72 indicates reflux.

Components of 24-h Esophageal pH Monitoring Percent total time pH<4 Percent Upright time pH<4 Percent Supine time pH<4 Number of reflux episodes Number of reflux episodes 5 min Longest reflux episode (minutes)