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IS PH TESTING NECESSARY BEFORE ANTIREFLUX SURGERY IN PATIENTS WITH ESOPHAGITIS?
Katrin Schwameis1, Steven Siegal*2, Brenda Lin3, Jordan Roman3, Ketetha Olengue3, Steven R. DeMeester2
1Surgery, Medical University of Vienna, Vienna, Vienna, Austria; 2Surgery, Oregon Clinic, Portland, OR; 3Surgery, Keck, USC, Los Angeles, CA
Introduction: The relationship between the Los Angeles (LA) grade of esophagitis on endoscopy and the presence and severity of esophageal acid exposure by pH-monitoring is not well defined. The aim of this study was to correlate esophageal acid exposure by pH-testing in patients with various grades of endoscopic esophagitis using the LA grading system to determine at what grade of esophagitis a pH-test is not necessary to confirm the presence of abnormal esophageal acid exposure.
Methods: A retrospective review was performed of the records of all patients who underwent upper endoscopy and were found to have esophagitis and who also had pH-monitoring (24- or 48-hour) from 2014 to 2016. The upper endoscopy and pH-test were performed with patients off of all acid suppression medications. An abnormal pH-test was determined based on the DeMeester score, and for 48-hour Bravo pH-testing an abnormal score on either one or both days was considered an abnormal test.
Results: There were 66 patients with a median age of 57 years. Esophagitis was LA grade A in 23, B in 26, C in 15 and D in 2 patients. An abnormal pH-score was present in 56 patients (85%). All patients with LA C or D esophagitis had an abnormal pH-score and so these two groups were combined for further analysis. In contrast, an abnormal pH-score was present in 83% and 77% of patients with LA A and B esophagitis, respectively (p=0.111). Details of acid exposure on pH-testing are shown (Table). Patients with LA C and D esophagitis had significantly more esophageal acid exposure based on % time pH < 4 than did patients with LA A or B esophagitis. Further, among patients that had Bravo 48-hour pH-testing an abnormal score on both days was significantly more common in patients with LA C or D esophagitis.
Conclusions: The presence of LA C or D esophagitis was always associated with increased esophageal acid exposure on pH-testing and is adequate proof of reflux disease in patients being considered for antireflux surgery. In contrast, pH-testing off medications is recommended prior to antireflux surgery in patients with LA A or B esophagitis since approximately 20% of these patients had a normal score and non-reflux etiologies may be associated with these minor degrees of esophagitis in some patients.
Table 1: Acid exposure related to LA grade of esophagitis (LA C and D combined). (Numbers are medians)
Acid exposure related to LA grade of esophagitis (LA C and D combined)
| Total n=66 | LA A n=23 | LA B n=26 | LA C/D n=17 | p-value | | Median DeMeester score | 18 (IQR, 15-33) | 34 (IQR, 13-49) | 33 (IQR, 27-45) | 0.284 | | Number with abnormal score (%) | 19 (83) | 20 (77) | 17 (100) | 0.111 | | Bravo pH-test (%) | n=20 (87) | n=23 (88%) | n=15 (88) | 0.986 | | Abnormal pH-test 1 day only | 6 (30) | 5 (22) | 1 (7) | 0.238 | | Abnormal pH-test both days (%) | 10 (50) | 13 (57) | 14 (93) | 0.037 | | # of reflux episodes Day 1 | 65 (IQR, 46-92) | 76 (IQR, 29-117) | 117 (IQR, 73-149) | 0.132 | | # of reflux episodes Day 2 | 41 (IQR, 16-60) | 58 (IQR, 17-98) | 111 (IQR, 76-139) | 0.003 | | Fraction time pH <4 (%) Day 1 | 6.8 (IQR, 4-11) | 10.4 (IQR, 3-14) | 10.7 (IQR, 9-17) | 0.098 | | Fraction time pH < 4 (%) Day 2 | 6.8 (IQR, 3-10) | 8.7 (IQR, 2-16) | 12 (IQR, 8-17) | 0.208 |
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