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Does Reflux Height Matter? A Study of 1680 Patients
Guilherme M. Campos1, Fernando Herbella1, Ian Nipomnick1, Marco Patti1, Eric Vittinghoff2; 1Surgery, University of California, San Francisco, San Francisco, CA; 2Epidemiology, University of California, San Francisco., San Francisco, CA

Background: Dual-channel pH monitoring, which measures if gastric reflux reaches the proximal esophagus, is used mostly in patients with atypical symptoms of gastroesophageal reflux disease (GERD), but its value in clinical practice is undetermined. Aims: To study the clinical characteristics of proximal reflux in a large institutional sample of patients with GERD and evaluate the usefulness of dual-channel pH monitoring. Patients and Methods: We reviewed the records of all patients who underwent dual-channel esophageal pH monitoring between January 1990 and July 2005. Patients with named esophageal motility disorders and previous foregut surgery were excluded. Patients were grouped according to primary symptom [typical symptoms (heartburn, regurgitation or dysphagia) versus atypical symptoms [respiratory, chest pain, or ear, nose and throat (ENT)], and pH profile findings [combined reflux (CR) - abnormal distal reflux (composite score > 14.7) and abnormal proximal reflux (number of single reflux episodes > 18) or abnormal distal reflux only (ADRO)]. Group differences were analyzed with Chi-square or Mann-Whitney U Tests. Results: Of the 1,680 patients who underwent dual-channel pH monitoring, over 60% had CR; and abnormal proximal reflux prevalence was similar in the groups (Table 1). Patients with ENT symptoms had greater proximal esophageal exposure to acid than other groups. Proximal esophageal exposure to acid in all other groups was similar (Table 2). Conclusions: Greater proximal esophageal exposure to acid may cause ENT symptoms. Abnormal proximal reflux is not a distinctive feature of reflux induced respiratory and chest pain symptoms. Additional clinical information is needed to support the use of Dual-channel pH monitoring in clinical practice.
Table 1. Prevalence of ADRO and CR

Group

All (n=1680)

ADRO (n=596)

CR (n=1084)

p value

Typical Symptoms

1342 (79.9 %)

475 (35.4%)

867 (65.6%)

 

Atypical Symptoms

338 (20.1%)

121 (35.8%)

217 (64.2%)

0.9

Respiratory

174 (10.4%)

61 (35.1%)

113 (64.9%)

1.0

Chest pain

128 (7.6%)

50 (39.1%)

78 (60.9%)

0.4

ENT

36 (2.1%)

10 (27.8%)

26 (72.2%)

0.4


Values are expressed as number and percentages.
Table 2. Reflux Profile in Patients Groups divided by Primary Symptom

Group

Typical Sx.

Respiratory

Chest Pain

ENT

p value

# RE Distal

149 (100-225)

137 (100-208)

138 (89-215)

125 (100-187)

0.3

# RE Proximal

28 (13-55)

27 (11-55)

29 (9-59)

44 (14-76)

0.04

%TpH<4 Distal

10.5 (5-25.7)

8.6 (5-20)

8 (3.6-18.5)

12.7 (8-50)

0.08

%TpH<4 Proximal

1 (0-4)

1 (0.2-3)

1 (0-4)

3.1 (1.1-7.8)

0.01


Values are expressed as median (Interquartile range) and number (percentages); # RE = number of reflux episodes, %TpH<4 = percent time pH < 4


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