As you are aware, access to a modern oesophageal testing lab had been available through our private rooms for well over 6 months. This has assisted us in diagnosing problematic patients who are thought to have “reflux” but have not followed the script in terms of response to conventional medications. This update will help GPs interpret the results which, at times, can be quite technical.
Patient 1: Typical reflux symptoms responsive to PPIs
This patients has typical acid reflux symptoms but required high doses of PPI, sometimes with concurrent antacids or prokinetic agents, to help with breakthrough symptoms. An oesophageal study was performed to reveal normal manometry (ruling out dysmotility conditions which are a contraindication to anti-reflux surgery). A Bravo capsule was deployed endoscopically (a pH sensor within a disposable capsule which is attached to the lower oesophageal mucosa with a pin and detaches within a few days). This captures significant reflux episodes with GOOD CORRELATION with patient symptoms. This patient was referred for a fundoplication and achieved excellent symptomatic relief with only occasional use of PPIs.
Patient 2: Typical acid reflux symptoms unresponsive to PPIs+ prokinetic agents
Oesophageal testing is very important for these patients as they have had no response to maximal medical therapy for reflux. Oesophageal manometry was normal. Oesophageal pH did not show significant reflux episodes and there was no correlation with patient symptoms. These patients probably have “hypersensitive oesophagus” – that is they experience typical symptoms of acid reflux without the prerequisite stimulus of a low enough pH. These patients can be very difficult to treat and respond poorly to fundoplication and therefore should not be pushed down the surgical pathway. They are probably best treated as “chronic pain” patients with CBT, lifestyle modifications (essentially weight loss if BMI is over 25), food elimination if a food diary is useful for symptom production and a trial of pain modulators such as Tricyclic Antidepressants (TCA) like nortryptilline.
In our next instalment on interpreting oesophageal tests, we will discuss other clinical problems such as Laryngopharyngeal Reflux (LPR) and volume reflux.
