Revista de Gastroenterología de México Revista de Gastroenterología de México
DOI: 10.1016/j.rgmxen.2017.07.019
Editorial
Symptomatic recurrence upon proton pump inhibitor discontinuation correlated with results of Bravo® wireless esophageal pH monitoring in patients with gastroesophageal reflux disease
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
Enrique Coss-Adamea,b,,
a Departamento de Gastroenterología, Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
b Curso de Motilidad Gastrointestinal, Universidad Nacional Autónoma de México, Mexico City, Mexico

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 disclosure

No financial support was received in relation to this article.

Conflict of interest

The authors declare that there is no conflict of interest.

References
1
R. Schey,S.P. Alla,D. Midani
Recurrencia sintomática relacionada con la enfermedad por reflujo gastroesofágico en pacientes que descontinúan los inhibidores de la bomba de protones durante el estudio inalámbrico de monitorización de pH esofágico Bravo
Rev Gastroenterol Mex, 83 (2017), pp. 276-285
2
R. Tutuian
Update in the diagnosis of gastroesophageal reflux disease
J Gastrointestin Liver Dis, 15 (2006), pp. 243-247
3
D. Morgan,J. Pandolfino,P.O. Katz
Clinical trial: Gastric acid suppression in Hispanic adults with symptomatic gastro-oesophageal reflux disease - comparator study of esomeprazole, lansoprazole and pantoprazole
Aliment Pharmacol Ther, 32 (2010), pp. 200-208 http://dx.doi.org/10.1111/j.1365-2036.2010.04335.x

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. http://dx.doi.org/10.1016/j.rgmx.2017.07.002

Enrique Coss-Adame. Vasco de Quiroga 15, Col. Sección XVI, Tlalpan, Mexico City, C.P. 14080, Mexico. (Enrique Coss-Adame enriquecossmd@gmail.com)
Copyright © 2017. Asociación Mexicana de Gastroenterología
DOI: 10.1016/j.rgmxen.2017.07.019