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accuratelydetects

AmJPhysiolGastrointestLiverPhysiol283:

G376-G383,2002.

Multichannelintraluminalimpedanceaccuratelydetectsfasting,recumbentrefluxeventsandtheirclearing

StevenS.Shay,StevenBomeli,andJoelRichter

GastroenterologyService,ClevelandClinicFoundation,Cleveland,Ohio44195

ABSTRACT

Multichannelintraluminalimpedance（MII）isanewdiagnostictestforgastroesophagealrefluxdisease（GERD）.TheobjectiveofthisreportistodeterminetheaccuracyofMIIindetectingindividualrefluxevents（REs）identifiedbypHprobeandmanometry,aswellastheirclearinginpatientswithsevereGERDcomparedwithnormalvolunteers.TensevereGERDpatientsand10 normalvolunteersunderwentsimultaneousmanometry[7sites:

gastric,loweresophagealsphincter,esophagus（4）,pharynx],pH,andMII（6 sitesinesophagus）for15 minintheleftandrightrecumbentposturewhilefasting.Wefoundthatpatientshad30-foldmoreREsthannormalvolunteers（41 ± 11 vs.1.3 ± 0.4）,and95%ofallREsweredetectedbyMII.Anaverage15-foldfallinimpedancewithliquidandfivefoldrisewithgasmadeREsandtheircompositioneasytodetectwithMII.Intherightrecumbentposture,nearlyallREsdetectedbyMIIwereliquid（98%,98/100）.Incontrast,all283 REsdetectedbyMIIintheleftrecumbentpostureweregas.NearlyallREsdetectedbyMIIwerecleared（98%,368/374）.Meanacidclearingtimewasthreefoldlonger（47 s）thanclearingtimebyeithermanometry（15 s）orMII（13 s）,primarilyduetoacidrereflux,i.e.,additionalacidREsduringacidclearing.WeconcludethatMIIisaccurateindetectingREsidentifiedbymanometryand/orpHprobe,theircomposition,andtheirclearing.

pHmonitoring;commoncavities;gastroesophagealrefluxdisease

INTRODUCTION

MULTICHANNELINTRALUMINALimpedance（MII）isanewmethodforgastroesophagealrefluxdisease（GERD）patientsthatassessestransitbasedonchangesinresistancetocurrentflowbetweenadjacentelectrodeswhenaboluspassesbetweenthem

（2）.MIIdetectsgastroesophagealrefluxevents（REs）whenaboralflowoccursacrosstwoormoredistalelectrodesintheesophagus,andMIIcanalsoassesswhetherthecompositionoftherefluxedgastriccontentsisgas,liquid,ormixed.

Threerecentreports（6,7,9）examinedthepromisingroleofMIIcombinedwithpHindetectingacidandnonacidREs.TworeportscomparedGERDpatientswithnormals,oneutilizingpostprandialsimultaneousmanometry,pH,andMIIintheuprightposture,andtheotherambulatory24-hMII-pH.BothreportsfoundthattotalREsweresimilarinnormalsandGERDpatients,althoughacidREsmadeupagreaterproportionofREsinGERDpatients.Inaddition,mixedREsweremorecommonthanliquid-onlyREs（6,7）.InanotherreportofcombinedMII-pHafterarefluxogenicmealinGERDpatients,omeprazoledecreasedacidREs;however,totalREswereunchanged,becausenonacidREsincreased（9）.Inthesereports,meanREfrequencywas10.5/hr（6）and10/hr（9）intheshort-termstudiesbutonly46 per24 hinthe24-hstudy（7）.

Presentrefluxtestshavefundamentaldifferencesinthemeasurementparameteranalyzed.ThepHprobemeasuresacidconcentrationinavolumeofunknownamount.ThuswhengastriccontentswithapHof2 refluxesintotheesophagus,agallonofrefluxantwithpH2 looksthesametothepHprobeasanounceofrefluxantwithpH2. Conversely,thecommoncavity（detectedbymanometry）can'tassessconcentrationofanychemicalcomponent,especiallyacid.Instead,thecommoncavitydetectswhenenoughvolumeofgastriccontentsenterstheesophagustoraiseintraesophagealpressuretothatofintragastricpressure.However,thatthresholdvolumeandthefinalrefluxedvolumeisunknown.MeasurementcharacteristicsofREsdetectedbyimpedanceareunknown.

Thepurposeofthisreportisfourfold:

1）tovalidatetheaccuracyofMIIindetectingindividualREsinthemostchallengingsituation,whichismaximizingREfrequencybystudyingonlypatientswithsevereGERDandmaximizingREdetectionbycombiningmanometryandpHmonitoring;2）tocompareclearingofREsbypH,MII,andmanometry;3）tocomparerefluxantcompositionindifferentpostures;and4）toassessthemeasurementcharacteristicsofimpedance.

MATERIALSANDMETHODS

StudyPopulation

Tensymptomaticpatients（age53 ± 4;5 males,5 females）withsevereGERDwereselectedonthebasisoftwocriteria:

1）moderateorsevereGERDbyendoscopy[thinerosions（n = 4）;confluentulcerations（n = 2）;long-segmentBarrett'sesophagus（n = 4）];and2）

10commoncavitiesdetectedduringstandardesophagealmanometry.OtherfindingsofsevereGERDwerepresentonbariumesophagram（7/7withbothrefluxandhiatalhernia）and24-hpH（8/8withabnormalacidexposure;%timepH4/timemonitored:

total = 25 ± 8%;upright = 21 ± 7%;recumbent = 30 ± 11%）.Tennormalvolunteers（age35 ± 4;6 males,4 females）werestudiedforcomparison.

StudyDesign

Allsubjectsunderwentsimultaneousmanometry,pH,andMIIinthefastingleftandrightrecumbentpostures.SomesevereGERDpatientswerealsomonitoredafteranonrefluxogenicmeal.Subjectswerestudiedinaccordancewithprotocol3565, whichwasapprovedbytheInstitutionalReviewBoardoftheClevelandClinicFoundationonMarch15, 2000. Writteninformedconsentwasobtained.

Simultaneousesophagealmanometry,MII,andpHmonitoring.Amultichannelesophagealmanometrycatheterwitha7-cmdistalsleeve（DentSleeve）waspassedthroughthenoseandintotheesophagussothatitstraddledtheloweresophagealsphincter（LES）.A2.13-mmMII-pHcatheter（modelZ-TC;Sandhill）waspassedadjacenttothemanometrycathetersuchthattheperfusedsideportsandMIIsiteshadtheconfigurationshowninFig.1.Swallowswererecordedbyanair-perfusedhypopharyngealport.AlldatawererecordedsimultaneouslybytheSandhillInsightdata-acquisitionsystemforsubsequentanalysis.

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Fig.1. Catheterconfiguration,aswellaslocationsofperfusionportsformanometry,electrodepairsitesformultichannelintraluminalimpedance（MII）,andpHprobe.LES,loweresophagealsphincter.

Continuousfastingrecordingswereobtainedfor15 minontheleftandthentherightrecumbentpostures.SevereGERDpatientswithfewerthanfiveliquidREsintherightrecumbentposturebyMIIwerethengiven8 ozofyogurt（Dannon;lemonflavor）and8 ozofwater,andmonitoredforanadditional15 minontheirrightside.

DefinitionofREsandclearing.ThepHprobedefinedaREtraditionally（pH-RE）;i.e.,afallinpHfrom>4to<4,andacidclearingtime（ACT）ofsecondsuntilpH4 wasagainachieved.ManometrydefinedaREaswhenacommoncavityoccurred.Acommoncavitywasdefinedasanincreaseinintraesophagealpressurefromgastroesophagealpressureequilibrationthatwasnotassociatedwithincreasedintraesophagealpressurefromaswallow,dysmotility,ormovement.Itsdurationwassecondsuntiltheperistalticcontractiondecreasedintraesophagealpressuretobaseline.AcidrerefluxwasdefinedasacommoncavitywhilepHwasalready<4,i.e.,rerefluxofacidifiedgastriccontentsintotheesophagusbeforesuccessfulacidclearingafteratraditionalpH-RE（Figs.2,3,and4）.

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Fig.2. FourepisodesofacidrerefluxoveralowbasalLESpressure（LESp）areshown（seeverticallines1-4）duringsimultaneousmanometry,pH,andMII.Tensecondsintothetracing,apHfallof1 unitoccurs,whereaspHis<4fromaprevioustraditionalacidrefluxevent（RE）.ThereissimultaneousdetectionbybothMIIandmanometry:

1）thedistal3 MIIchannelsshowretrogradeliquidrefluxasimpedancefalls>50%frombaseline（to0 in2 leads）;and2）acommoncavityoccurssimultaneouslywiththeonsetoftheMII-RE.Acidrerefluxsimilartoaboveoccurson3 otheroccasions,although2 haveapHfall<1unit（lines3 and4）,andone（line2）occursinthevulnerableperiod2-3safteraswallow.Thefirst3 MII-REsandcommoncavitiesclearconcurrentlytotheiroriginalbaselinesdenotingclearanceafterasecondary（n = 2）orprimary（n = 1）esophagealcontraction,althoughthe4thisnotclearedbecausethetracingends.However,acidclearingtopH4 isneverachieved.

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Fig.3. Fiveepisodesofgas-onlyrefluxoveralowbasalLESpareshown（seeverticallines1-5）duringsimultaneousmanometry,pH,andMII.Threesecondsintothetracing,thefirstgas-onlyREissimultaneouslydetectedbybothMIIandmanometry:

1）intheMIIsites,thedistal5 showgasrefluxasimpedanceincreases>50%frombaselinesimultaneously,reaching7,000 

 sometimeduringtheREinallsites;and2）inthemanometryports,acommoncavityisdetectedbytheincreaseinintraesophagealpressure.EsophagealpHis>6duringtheRE.Theother4 gas-onlyREsaresimilar,althoughthe2nddoesnotextendtotheproximalimpedancesite.AllMII-REsandcommoncavitiesclearconcurrentlytotheiroriginalbaselinesdenotingsimultaneousclearanceafterasecondary（n = 4）orprimary（n = 1）esophagealcontraction.

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Fig.4. The4 mostcommonREtypesbasedonchangesinpHandcompositionofrefluxedgastriccontents:

traditionalacidREliquidbyimpedance,acidrerefluxliquidbyimpedance,nonacidrefluxgasbyimpedance,andnonacidrefluxliquidbyimpedance.MeanvaluesaredisplayedforchangesinpH,ohms,andmmHgforallREsintheREtypeshown.Acidrerefluxisrefluxofacidifiedliq