Title:
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Combined multichannel intraluminal impedance -pH in patients with typical and atypical symptoms refractory to proton pump therapy.
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Proton pump inhibitor therapy (PPI) has been used for over a decade to
successfully treat patients with gastro-oesophageal reflux disease (GORD);
however it has been shown that 35-40% of patients with GORD have persistent
symptoms on therapy. Combined multichannel intraluminal impedance-pH (MIIpH)
is a clinically available tool that has the ability to detect reflux episodes
independent of the pH. MIl-pH identifies the refluxate by impedance changes
produced by the bolus presence in the oesophagus and classifies it into acid or
non-acid by concomitant changes in intraluminal pH. The 2.1 mm MIl-pH
cathteter is positioned Scm above the manometrically located proximal border of
the lower oesophageal sphincter (LOS) and allows monitoring changes in
. intraluminal impedance at 3, 5, 7, 9, 15 and 17cm above the LOS. In our
institution we have showed that approximately half of the patients with typical
symptoms and almost one-quarter with atypical symptoms despite PPI b.d are
associated with reflux (non-acid or acid). This means that the majority of
patients with persisting atypical symptoms despite PPI b.d have no reflux
associated with their symptoms and an alternative cause should be sought.
Medical therapy is potentially available in the form of baclofen, a y-aminobutyric
acid Bagonist which inhibits transient lower oesophageal relaxations, but
unfortunately its therapeutic use is limited by its side-effects. Laparascopic
Nissen fundoplication (LNF) has been used to treat patients' refractory to PPI therapy with a positive symptom index with reflux after MIl-pH testing. Eighteen
patients with symptoms identified as associated with reflux during MIl-pH testing
referred for to surgery for LNF. In conclusion MIl-pH testing should be used to
clarify the diagnosis of patients who continue to have persistent symptoms on
maximal acid suppression therapy. Those patients with proven symptom
association with impedance-documented ongoing reflux may benefit from
antireflux surgery.
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