04 Extraesophageal Manifestations.pdf

Use of pH-Impedance Testing to Evaluate Patients With Suspected Extraesophageal Manifestations of Gastroesophageal Reflux Disease Ashish Malhotra, MD,* James W. Freston, MD, PhD,w and Khalid Aziz, MDw Goals: To report the use of pH-impedance testing in evaluating patients with suspected gastroesophageal reflux disease (GERD) with atypical symptoms. Background: Although the role of acid reflux in causing atypical GERD symptoms is generally accepted, the role, if any, of nonacid reflux is controversial, largely because until recently it has not been possible to detect nonacid reflux. The advent of intraluminal combined pH impedance testing (MII-pH), to detect nonacid reflux has heightened interest in its possible contribution to atypical symptoms. Study: Fifty consecutive patients referred for MII-pH testing to evaluate the cause of atypical symptoms presumed due to GERD were evaluated. The symptoms were either refractory to acid inhibition therapy or so atypical that further work up was desired by the referring physician. Patients underwent MII-pH testing to determine whether reflux was present, and, if so, if it was due to acid, nonacid, or gas. Results: Only 16%, 22%, and 2% patients were found to have symptoms due to acid reflux, nonacid reflux, or both, respectively. Ten percent of these patients had gas reflux. MII- pH testing was useful in redirecting the management of patients who did not have reflux as the cause of their symptoms. Conclusions: MII-pH testing is useful in determining whether gastroesophageal reflux is present in patients with atypical symptoms that have not responded to proton pump inhibitor therapy. It also distinguishes between reflux due to acid, nonacid, and gas, with consequences for management. Key Words: extraesophageal GERD, atypical GERD, nonacid reflux, pH-impedance testing, MII-pH (J Clin Gastroenterol 2008;42:271–278) Gastroesophageal reflux disease (GERD) is defined asthe presence of symptoms or lesions that occur due to the reflu