The article by Shey et al.1 in the current issue evaluates the degree of symptomatic recurrence of gastroesophageal reflux disease (GERD) after the suspension of proton pump inhibitors (PPIs) and its correlation with symptoms during ambulatory pH monitoring with the Bravo® wireless capsule.
In this retrospective review, the authors showed that the patients with a shorter period of PPI suspension presented with greater symptomatology and the patients whose symptoms worsened during the pH monitoring study presented with greater acid exposure. A total of 55.1% of the patients experienced symptom worsening that was correlated with a percentage of time with pH under 4.
The authors called their test an inverse PPI trial and discussed its possible role in predicting the cases that could present with a positive ambulatory wireless pH monitoring study. The correlation was adequate, but just slightly over half of the patients presented with said worsening and only approximately 60% of the patients with symptom exacerbation had a pathologic pH study. PPI trial sensitivity varies from 75 to 92%, with specificities of 55-90%.2 Even though the sensitivity and specificity of the impact of PPI suspension and symptom worsening were not evaluated, the percentages reported by the authors suggest a lower impact for the detection of patients with GERD. In addition, the duration of PPI ingestion and the type of PPI described were not consistent. Different PPIs have a different impact on acid suppression, which could alter the outcome of this study. Morgan D et al. evaluated the symptomatic response with a double dose of different PPIs in patients with no response or a partial response to a single dose and observed that esomeprazole had greater symptomatic control.3
On the other hand, there was heterogeneity in the indication for performing the pH monitoring study, with a predominance of extraesophageal and dyspeptic symptoms. In subjects with typical symptoms, 56% presented with a worsening of symptoms after PPI suspension.
The concept dealt with in the present article is compelling and opens the door for new studies prospectively characterizing the time of PPI suspension, the type of PPI used, and the indication (extraesophageal symptoms versus esophageal symptoms) to identify which type of GERD patient has symptoms that can raise the suspicion of being true positives. Finally, the addition of impedance to the pH study may help identify patients that are not correctly assessed through pH monitoring, alone.
Financial disclosureNo financial support was received in relation to this article.
Conflict of interestThe authors declare that there is no conflict of interest.
Please cite this article as: Coss-Adame E. Recurrencia sintomática al descontinuar inhibidores de la bomba de protones durante la monitorización inalámbrica del pH esofágico Bravo® en pacientes con enfermedad por reflujo gastroesofágico. Revista de Gastroenterología de México. 2017;82:275–276.
See related content at DOI: http://dx.doi.org/10.1016/j.rgmxen.2017.07.002, Schey R, Alla SP, Midani D, Parkman HP. Gastroesophageal reflux disease-related symptom recurrence in patients discontinuing proton pump inhibitors for Bravo® wireless esophageal pH monitoring study. Revista de Gastroenterología de México. 2017;82:277–286.