Indicators of Esophageal pH-Impedance Monitoring and High-Resolution Manometry in Patients with Various Forms of Gastroesophageal Reflux Disease

Aim.  The aim of the study is to analyze the regularities of changes in the basic indicators of esophageal pH-impedance monitoring and high-resolution manometry in patients with non-erosive reflux disease (NERD), erosive reflux disease (ERD) and Barrett’s esophagus (BE) in comparison with healthy individuals.

Materials and methods.  69 patients were examined, including 19 patients with NERD, 16 patients with ERD, 14 patients with BE and 20 individuals comprising the control group (CG). The gender structure was as follows: 44 male and 25 female patients. The average age of the examined patients was 46 years. All patients underwent 24-hour esophageal pH-impedance monitoring and high resolution manometry.

Results.  According to the data of 24-hour pH-impedance monitoring, the total time in the esophagus with pH < 4 was 2.4 % in the control group, 9 % in the NERD group, 20.25 % in the ERD group and 23.5 % in the patients with BE (p < 0.05). The average number of acid refluxes was 22.5 in CG, 61 in the NERD group, 77 in the ERD group and 86 in patients with BE (p < 0.05). The time of chemical clearance was 1.7 minutes in CG, 2.2 minutes in the group of patients with NERD, 2.9 minutes in the ERD group and 3 minutes in the BE group (p < 0.05). The mean nocturnal baseline impedance was 2483.5 Ohm in CG, 1775.0 Ohm in the NERD group, 771.0 Ohm in the ERD group and 911.0 Ohm in the BE group (p < 0.05). The normal parameters of the esophagogastric junction (EGJ) structure and function according to the data of highresolution manometry were observed among 85 % of the control group, 63 % of patients with NERD, 25 % of patients with ERD and 36 % of BE group. The presence of hiatal hernia (HH) and/or hypotension of lower esophageal sphincter (LES) was observed in 15 % of patients from the CG, in 37 % of patients with NERD, in 75 % of patients with ERD and in 64 % of patients with BE. The normal parameters of the motor function of the esophagus were observed in CG (85 %), as well as in patients with NERD (79 %). In patients with ERB and BE, normal motor activity was noted in 25 % and 29 % of the cases, respectively. Disturbances of the motor function of the thoracic esophagus in CG were represented in 10 % of the cases by ineffective peristalsis and hypercontractility in the form of distal esophagospasm in 5 % of the cases. In the NERD group, 16 % of patients had ineffective peristalsis and 5 % of patients had hypercontractility in the form of a hypercontractile esophagus. In patients of ERD and BE groups, the disorders of the motor function of the thoracic esophagus were predominantly represented by ineffective peristalsis, in 75 % and 50 % of the patients, respectively. In addition, in the group of patients with BE, in 21 % of the cases, motor function disorders were observed in the form of absence of thoracic esophagus contractions.

Conclusion.  It is shown that such indicators as increased level of acid exposure, increased amount of acid reflux, slowed chemical clearance, lowered mean nocturnal baseline impedance, as well as disorders in the structure and function of the esophageal-gastric junction and motility of the thoracic esophagus are associated with the severity of GERD. 

1. El-Serag H., Sweet S., Winchester C., et al. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2014;63:871–80.

2. Vakil N., Zanten S., Kahrilas P., Dent J., Jones R. Global Consensus Group The Montreal definition and classification of gastroesophageal reflux disease: a global evidencebased consensus Am J Gastroenterol. 2006;101(8):1900–20.

3. Ивашкин В.Т., Маев И.В., Трухманов А.С., Баранская Е.К., Дронова О.Б., Зайратьянц О.В., Сайфутдинов Р.Г., Шептулин А.А., Лапина Т.Л., Пирогов С.С., Кучерявый Ю.А., Сторонова О.А., Андреев Д.Н. Клинические рекомендации Российской гастроэнтерологической ассоциации по диагностике и лечению гастроэзофагеальной рефлюксной болезни. Рос журн гастроэнтерол гепатол колопроктол. 2017;27(4):75–95 [Ivashkin V.T., Maev I.V., Trukhmanov A.S., Baranskaia E..K., Dronova О.B., Zayratyants О.V., Sayfutdinov R.G., Sheptulin A.A., Lapina T.L., Pirogov S.S., Kucheryavyi Y.A., Storonova O.A., Andreev D.N. Diagnostics and treatment of gastroesophageal reflux disease: clinical guidelines of the Russian gastroenterological association. Rus J Gastroenterol Hepatol Coloproctol. 2017; 27(4):75–95 (In Rus.)].

4. Лазебник Л.Б., Машарова А.А., Бордин Д.С., Васильев Ю.В., Ткаченко Е.И., Абдулхаков Р.А. Результаты мультицентрового исследования «Эпидемиология гастроэзофагеальной рефлюксной болезни в России» (МЕГРЕ). Тер. Архив. 2011;83:45–50 [Lazebnik L.B., Masharova A.A., Bordin D.S., Vasiliev Yu.V., Tkachenko E.I., Abdulkhakov R.A., Butov M.A., Eremina E.Yu., Zinchuk L.I., Tsukanov V.V. Results of a multicenter trial «Epidemiology of Gastroesophageal Reflux Disease in Russia» (MEGRE). Ther. Archive. 2011;83:45–50 (In Rus.)].

5. Bor S., Lazebnik L., Kitapcioglu G., Manannikof I., Vasiliev Y. Prevalence of gastroesophageal reflux disease in Moscow. Dis Esophagus. 2016;29(2):159–65.

6. Rubenstein J., Taylor J. Meta-analysis: the association of oesophageal adenocarcinoma with symptoms of gastrooesophageal reflux. Alimentary Pharmacology & Therapeutics 2010;32:1222–7.

7. Маев И.В., Андреев Д.Н., Кучерявый Ю.А., Щегланова М.П. Аденокарцинома пищевода: факторы риска и современные стратегии скрининга Рос журн гастроэнтерол гепатол колопроктол 2017;27(2):4–12 [Maev I.V., Andreev D.N., Kucheryavyi Y.A., Scheglanova M.P. Esophageal adenocarcinoma: risk factors and modern screening strategy. Rus J Gastroenterol Hepatol Coloproctol. 2017; 27(2):4–12 (In Rus.)].

8. Gyawali C., Kahrilas P., Savarino E., et al. Modern diagnosis of GERD: the Lyon Consensus Gut Published Online First: 03 February 2018.

9. Gyawali C., Roman S., Bredenoord A., et al. Classification of esophageal motor findings in gastro-esophageal reflux disease: conclusions from an international consensus group. Neurogastroenterol Motil. 2017;29:e13104.

10. Roman S., Gyawali C., Savarino E., Yadlapati R., Zerbib F., Wu J., Vela M., Tutuian R., Tatum R., Sifrim D., Keller J., Fox M., Pandolfino J., Bredenoord A. The GERD consensus group. Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: Update of the Porto consensus and recommendations from an international consensus group. Neurogastroenterol Motil. 2017.

11. Маев И.В., Баркалова Е.В., Овсепян М.А., Кучерявый Ю.А., Андреев Д.Н. Возможности рН-импедансометрии и манометрии высокого разрешения при ведении пациентов с рефрактерной гастроэзофагеальной рефлюксной болезнью. Тер. архив. 2017;89(2):76–83 [Maev I.V., Barkalova E.V., Ovsepyan M.A., Kucheryavyi Y.A., Andreev D.N. Possibilities of pH impedance and high-resolution manometry in managing patients with refractory gastroesophageal reflux disease Ther. Archive. 2017;89(2):76–83 (In Rus.)].

12. Kessing B., Bredenoord A., Smout A. Erroneous diagnosis of gastroesophageal reflux disease in achalasia. Clin Gastroenterol Hepatol. 2011 Dec;9(12):1020–4.

13. Андреев Д.Н., Кучерявый Ю.А. Перспективы лечения гастроэзофагеальной рефлюксной болезни. Consilium Medicum. Гастроэнтерология. 2013;2:9–14 [Andreev D.N., Kucheryavyi Y.A. Prospects for the treatment of gastroesophageal reflux disease. Consilium Medicum. Gastroenterology. 2013;2:9–14 (In Rus.)].

14. Арутюнов Г.П., Мартынов А.И., Спасский А.А. Руководство по внутренней медицине. М., 2015 [Arutyunov G.P., Martynov A.I., Spassky A.A. Guide to Internal Medicine. Moscow, 2015 (In Rus.)].

15. Баркалова Е.В., Овсепян М.А, Андреев Д.Н., Кучерявый Ю.А., Лямина С.В., Маев И.В. Оценка показателей рН-импедансометрии и манометрии пищевода высокого разрешения у пациентов с различными формами гастроэзофагеальной рефлюксной болезни и пищеводом Барретта. Фарматека. 2017;(20):50–56 [Barkalova E.V., Ovsepyan M.A., Andreev D.N., Kucheryavyi Y.A., Lyamina S.V., Maev I.V. Evaluation of indicators of esophageal ph-impedancemetry and high-resolution manometry in patients with various forms of gastroesophageal reflux disease and Barret’s esophagus. Pharmateca. 2017;(20):50–56 (In Rus.)].

16. Трухманов А.С., Кайбышева В.О. рН-импедансометрия пищевода. Пособие для врачей / под ред. акад. РАМН, проф. В.Т. Ивашкина. М.: ИД «МЕДПРАКТИКА-М», 2013. 32 с. [Trukhmanov A.S., Kaybysheva V.O. pH impedance measurement of the esophagus: manual for physicians / Ed.: V.T. Ivashkin. Moscow: MEDPRAKTIKA-M, 2013. 32 p. (In Rus.)].

17. Kahrilas P., Bredenoord A., Fox M., et al. The Сhicago classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil. 2015;27:160–174.

18. Сторонова О.А., Трухманов А.С., Джахая Н.Л., Ивашкин В.Т. Нарушения пищеводного клиренса при гастроэзофагеальной рефлюксной болезни и возможности их коррекции. Рос журн гастроэнтерол гепатол колопроктол. 2012;22(2):14–21 [Storonova O.A., Trukhmanov A.S., Dzhahaya N.L., Ivashkin V.T. Disorders of esophageal clearance in gastroesophageal reflux disease and option of their treatment. Rus J Gastroenterol Hepatol Coloproctol. 2012;22(2):14–21 (In Rus.)].

19. Martinucci I., de Bortoli N., Savarino E., et al. Esophageal baseline impedance levels in patientswith pathophysiological characteristics of functional heartburn. Neurogastroenterol Motil. 2014;26:546–55.

20. Savarino E., Tutuian R., Zentilin P.,et al. Characteristics of reflux episodes and symptom association in patients with erosive esophagitis and nonerosive reflux disease: study using combined impedance- pH off therapy. Am J Gastroenterol. 2010;105:1053–61.

21. Meneghetti A., Tedesco P., Damani T., et al. Esophageal mucosal damage may promote dysmotility and worsen esophageal acid exposure. J Gastrointest Surg. 2005;9:1313–7.

22. Frazzoni M., Manta R., Mirante V., Conigliaro R., Frazzoni L., Melotti G. Esophageal chemical clearance is impaired in gastroesophageal reflux disease-a 24-h impedance-pH monitoring assessment. Neurogastroenterol Motil. 2013;25(399–406):e295.

23. Sifrim D., Castell D., Dent J., Kahrilas P. Gastro-oesophageal reflux monitoring: review and consensus report on detection and definitions of acid, non-acid, and gas reflux. Gut. 2004;53:1024–31.

24. Rhijn B., Kessing B., Smout A., Bredenoord A. Oesophageal baseline impedance values are decreased in patients with eosinophilic oesophagitis. United European Gastroenterol J. 2013;1:242–8.

25. Savarino E., Gemignani L., Pohl D., et al. Oesophageal motility and bolus transit abnormalities increase in parallel with the severity of gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2011;34:476–86.

26. Savarino E., Zentilin P., Frazzoni M., et al. Characteristics of gastro-esophageal reflux episodes in Barrett’s esophagus, erosive esophagitis and healthy volunteers. Neurogastroenterol Motil. 2010;22:1061–e1280.

27. Farré R., Blondeau K., Clement D., et al. Evaluation of oesophageal mucosa integrity by the intraluminal impedance technique. Gut. 2011;60:885–92.

28. Kessing B., Bredenoord A., Weijenborg P., Hemmink G., Loots C., Smout A. Esophageal acid exposure decreases intraluminal baseline impedance levels. Am J Gastroenterol. 2011;106:2093–7.

29. Matsumura T., Arai M., Ishigami H., Fujie M., Ishikawa K., Akizue N., Taida T., Ohta Y., Hamanaka S., Okimoto K., Saito K., Maruoka D., Nakagawa T., Kato N. Evaluation of Esophageal Mucosal Integrity in Patients with Gastroesophageal Reflux Disease. Digestion. 2018;97(1):31–7.

30. Hoeij F., Smout A., Bredenoord A. Predictive value of routine esophageal high-resolution manometry for gastroesophageal reflux disease. Neurogastroenterol Motil. 2015 Jul;27(7):963–70.

31. Rerych K., Kurek J., Klimacka-Nawrot E., BłońskaFajfrowska B. High-resolution Manometry in Patients with Gastroesophageal Reflux Disease Before and After Fundoplication. J Neurogastroenterol Motil. 2017 Jan 30;23(1):55–63.

32. Ho S., Chang C., Wu C., et al. Ineffective esophageal motility is a primary motility disorder in gastroesophageal reflux disease. Dig Dis Sci. 2002;47:652–6.

33. Sanagapalli S., Emmanuel A., Leong R., Kerr S., Lovat L., Haidry R, Banks M., Graham D., Raeburn A., Zarate-Lopez N., Sweis R. Impaired motility in Barrett’s esophagus: A study using high-resolution manometry with physiologic challenge. Neurogastroenterol Motil. 2018 Mar 15.

34. Porter R., Kumar N., Drapekin J., et al. Fragmented esophageal smooth muscle contraction segments on high resolution manometry: a marker of esophageal hypomotility. Neurogastroenterol Motil. 2012;24:763–8, e353.

35. Diener U., Patti M., Molena D., et al. Esophageal dysmotility and gastroesophageal reflux disease. J Gastrointest Surg. 2001;5:260–5.