Chapters Transcript Video Clinical Applications of Impedance/pH Monitoring Presented by John E. Pandolfino MD, MSCI, Fienberg School of Medicine, Northwestern Memorial Hospital, Chicago, IL good day to everyone. On behalf of Sandhill Scientific, I would like to welcome you to our reflects webinar entitled Clinical applications of impedance pH monitoring. Before we begin, I would like to talk about a few organizational items. This event is being recorded in anyone that would like to listen to it a second time or suggest the webinar toe one of your colleagues. You're welcome to do so. You'll be able to find the recording of the event at the Sandhill scientific website www dot sand hillside dot com. All participants are presently muted for sound control reasons. We're going to present to you three case studies, and we very much encourage everyone to actively participate in the discussion. As we present the fundamentals of the case studies, you can come in to make comments or to ask questions by either raising your hand. You will see in the lower right hand corner of your control screen a small icon, which allows you to raise your hand, and we will go to each of you in order and give you a live mike and you'll be able to ask your questions or make comments. Alternatively, you have a chat icon on your screen. You compress the chat icon and you can type your question and we will read it during the event. So without further ado, I would like to introduce our, uh, faculty. We have online Gina Osborne RN, who has developed the case, studies that we're going to be using for the discussion. Wendy O. Connor, the sandhill scientific nurse training coordinator, is online. Windy will be the sound coordinator. She'll be helping you with asking your questions and be sure ing that you have access to Dr Panel Fino. And finally, we also have Dr Matt readily online a Denver gastroenterologist. And he will act as physician commentator T Hope out Dr Panel Fino. And finally, I would like to introduce our guest speaker, Dr John Panel Fino, the chief of G I and Hepatology at Northwestern University in Chicago. And Hans Popper, professor of medicine Dr. Panel Fino. Well, thank you very much, Jerry E think this is gonna be a very interesting and one of the first times I think I've ever done live interpretations of ph impedance over a webinar with an interactive audience. So forgive me if it's a little clunky This is my first time doing this in totality, but I think it's a really nice opportunity because I think that impedance pH Monitoring is something that, you know we take for granted sometimes is being very, uh, simplistic in many ways. But we all know that there's a ton of data that's in these particular studies, and it's important for us to kind of look at these in greater detail. And I think many people like to Dio and Jean put together today a very nice set of way go Ah, very nice set of patient cases that I think, uh, gonna be very helpful for us to illustrate a couple of concepts off where Ph impedance is really gonna help us. And that's really gonna be focused on, you know, assessing not only whether or not someone has reflux, but the mechanisms looking at proximal extent and also assessing patients have non acid reflux. So these are very nice cases. We're gonna jump right into it. So case one isa patient with chronic nighttime cough for two years. Patient wakes up during the night with cough, regurgitation, nausea and sometimes vomiting. Does have symptoms of throat clearing and Harper mostly believed by premise, FBI B but has some right upper quadrant of Donald Payne 4 to 5 times per week does not always correspond to eating and then has a history of non insulin dependent diabetes and is gonna be tested on P B I in this particular instance. So obviously, if you're gonna test someone on a p b I unless very, very small indications, um, most people who are being assessed on PP I therapy should be assessed with ph impedance because otherwise you're really not getting the most of your efforts. So I'm not gonna go directly into this. I'll swing over, get into Oh, sorry, the actual study. So this is a study for case one. And immediately when I look at these studies and how I interpret this is I always spend the first part of the study looking at the overall acid exposure and when you're looking now and I hope everybody can see my point, there here changes a little bit, but it should be here on the bottom. I'm actually looking at the red line here at the bottom, the second, the last line on the bottom, and that's the pH in the esophagus placed in the distal esophagus. And then the orange line here is the gastric pH. And the first thing that you assesses just get a good sense is toe what the overall acid burdens. And this is just like a typical PH. Study. And I'm looking at this particular study right now, and what I consent is is at least during the majority of the upright time, you can see that the pH is way above four. In fact, for the most of the study just giving my rough assessment of what I would typically say here, this patient has pretty normal acid burden throughout the upright, a period during the day. Now, what you're actually seeing here at night is also pretty stable. Baseline, there is this one episode right about here in the middle of the night time period and you guys buy All appreciate. On the top bar here, you can see recumbent regurgitation, proximal probe Adept. They're all these little landmarks you can see during this long recumbent phase, which is obviously the night time period when these patients probably sleeping through the night. There's this one little area where there's a drop in pH. But this may be a little bit of artifact because you can tell this I actually the fact that there's a lot of air in this particular area here, so this might just be a little bit of a shift in the catheter, but nothing I'm too worried about. So in this particular patient, if I was on Lee relying on Ph. You know, this looks like a pretty normal study. It looks like the assets depression in the stomach is okay. I mean, you could see that the majority of time, the Ph is above four. So if I were to look at this, I would say just based on pH. That that there's really not much going on here. However, when you look at this particular study and you start to assess what's going on throughout the day, you can clearly see that there is a lot of activity while this patient is away. Now, not on Lee. Does this patient have a lot of events such as cough regurgitation? But you can also see that at night. Ah, lot of this calms now. So just by looking at this global aspect of the entire I believe this is, you know, the 24 hour screen, but this is 23.6 hours. You can clearly see a lot of activity during the day when the patient is upright, moving around when the patient goes to sleep at night. Certainly there is a lot of kind of baseline less noise, less activity, less evidence of reflux. So typically, that's what I do when I first opened Stun, um immediately after that, I usually go to about an hour to two hour window based on what I see. If there's not a lot of activity on just the first bio view analysis, then I'll go to two hours. But if there's a lot of activity, I'll look at this in two in in one hour increments, and when I try to always do in the beginning is I try to just look generically at a couple of decent swallows here. So here's a nice swallow. So I get a good sense as to what the swallow pattern is for this particular patient. So once again, I use the magnification key here access magnified tool, and then I'll just scroll across a couple of these swallows here and now I can kind of get a sense as to what these swallows look like, and I'll also look at what they look like with the color contour change. And I think the color contour changes a very nice tool. When you're looking at this in a little bit more detail, because then you can really see the proximal extent you can see the combination of the air and the liquid and this particular patient you can clearly see. They don't swallow a lot of air during this follows. And that's also an important part of this analysis. So when I scroll through here, I can clearly see that there's an event here. There's a deep event, and there are a few other events here that happened during the meal. But what I'm actually senior is an event that looks like there's a little bit of a drop. So we'll take a little bit more detailed view of this particular event and this is a really nice event, because what we see here and once again, if I auto correct and change the baseline, find what we see here is a nice air event and then after this There's definitely a drop in impedance, and you can clearly see that. So we were using the tool here. You can see that the 50% mark. This is a retrograde movement all the way up there by a little bit of a swallow attempt there. But this is all proceeded by a little bit of air. Once again, you can clearly see that by looking at the color scale, you can see this beautiful full air reflux event, which some people may call a belch, and you can also see that that occurs. And then this beautiful reflex event, probably a couple and eliciting a little bit of a swallow. Also with them. You see that a lot. When the events get to the proximal area, you will see a swallow, just like when you throat clear and you cough. There's usually a swallow left after that. So it's a very nice example of, ah, good reflex event and looking to scroll through. So I'm getting a sense here that this patient is having some reflects on. What I can also see is acting, and I think this is important is that during the meal period of time, the patient does swallow a lot of air. So if you would actually look at this, you would clearly see that there's a lot of air swallowing in this first part here and then a little postprandial refunds. Now what's interesting is as we get to this more postprandial phase after that little meal, you can start to see that this patient is having certainly postprandial reflux. Now I want to go back and forth and toggle here because I think this is a very important point in terms of when you now analyze this. When I look at this globally, I get a sense that there's something going on. I trust the computer that it's showing me where the yellow highlight is that there's reflux. But it's not that easy to appreciate the retrograde, er anti great movement of the bullets. But when you actually put together that with the color contour now, I can certainly appreciate We're gonna We're gonna look at this in a little bit more detail that there is now movement here, right in the middle, beautiful, retrograde movement with some proximal extent here. Another beautiful, and you can get a sense now that these air actually reflux events as opposed to swallows or swallows associate ID with poor Bullis transport. So once again, we look at this night event right here in the middle, and you can clearly see beautiful proximal extent, another event all the way up. There's a little bit of a swallowed air once again, another reflux events. So you can clearly see that this patient does have significant postprandial reflux which, if someone came to me with a complaint of postprandial cough, this would typically be the pattern that I would sit now I'm for the intents and purposes of this presentation, I can't spend the normal 20 to 30 minutes that I would typically spend on the study. But I just want to kind of keep scrolling through and highlighting these beautiful events. And this is really a very nice study where the patient has a minimal drop in there. PH. But certainly these beautiful, proximal extent reflux events. And then here you can actually see an encroachment after another little meal of Samarra events. I'm gonna take a little closer. Look, these guys here and once again you can see beautiful reflux event here some reflux here, and it's always important to realize that you know, the esophagus is filled with air and liquid, and one of the things that you'll see is a liquid reflexive bank. And then you'll see some activity of air here, and once again you may see air swallowing. You may see super gas and belching coupled with reflux event, and it goes back to the point that these mechanisms they're not just uniforms. They're usually very heterogeneous. So the flavor of this particular study is really a study of what appears to be pretty significant reflux events that occur in the postprandial event, not with a significant drop in pH. Now, once again, here is another couple episodes of cough that we're seeing now. The cough here, you can clearly see, is not associate ID with a major reflex of interior. There's a little some activity, but nothing that meets criteria. And you may be attempted to figure out that maybe this was a cough that was associate with this event, but the patient just forgot about it. But unfortunately, that's the problem with Cough and Symptom Association is that it is sometimes very difficult to actually correlate these. Here's another episode of a cough, but the reflex event actually happens after the car. So once again, this is something that you know, in terms of timing, you need to be careful. Now, if you look at this in terms of the Color Contour, you might be tempted to think that this waas a little bit of a reflux event. But you could clearly see that there's a swallow and then maybe a reflux induced or a swallow induced reflux event. Um, that could be someone picked up here. Can't even see that. Maybe this was even elicited by a little bit of more distant reflex associated with a swallowing some poor bowls transit. So you could maybe implicate this event with this particular cough. So as I mentioned for the intensive purposes of time was grow through that. That's once again the recumbent area that's that short reflective. And I'm gonna go back to the beginning so you can see where we are right now. So right now we're kind of right in the middle smack there, and I just want to kind of take a look at a few of these regurgitation episodes. Um, and here is a couple of regurgitation episodes and you're seeing this patient here and you know, it doesn't really miss, but right smack in the middle and you can see that maybe the timing is not perfect. But these air these air pretty good, reflexive banks. So let's go back to the presentation at can you put together for us here? And as you can see, when it actually looks at the acid exposure data, it looks pretty minimal. And as you mentioned once again, just my my my global assessment and my just just looking at the study ph wise, which is the same as I would in a regular PH. Study. You could pretty much get a pretty good assessment that this is basically normal acid exposure, Mr Scores, probably zero. And then when you actually look at the number of reflux events, look at all of these reflux events. And then if you look at them, you know how many are upright, how many recumbent? You can clearly see that this patient is being dominated by upright reflux. And then if you actually look at the proximal migration, you can clearly see that there is significant proximal migration to so here we have an instance where this patient not only has a significant number of reflux events, they have a significant number of proximal reflux events. So this is someone who certainly if they were complaining about regurgitation postprandial cough, this particular pattern in terms of overall burden and buying would certainly fit that Now. It's interesting, however, is that when you actually look at the symptom index for cough, heartburn and regurgitation, what you find is that the symptom index looking at cough is around 59% for all reflux, 53% for non asset. And if you look at regurgitation 60% you can see that the heartburn, which was only one symptoms. So you gotta take that with a grain of salt. But you can clearly see that the symptom indices were actually pretty good. Now, that being said, when you look at the Symptom Association probability, which has a threshold value of 95% you can clearly see that that does not hit the threshold 63% 72% now. This is an important distinction here because in this particular study, it really highlights the difference between symptom index and escape the SYMPTOM Index gives you a sense as to how strong the relationship is when I say that, you know, if half of the reflux event or half of the symptoms or associate with reflux, that's a lot stronger relationship, then if only one out of 10 books, alright, so it gives you kind of a strength of the relationship. What the SAP shows you is whether or not there is a high likelihood that that relationship occurred by chance, right? So it's essentially reverse of API bound. So if your SAP is 95% for that particular relationship, there's less than a one in 20 chance or around the one in 20 chance that those results were actually found because of random chance so highly unlikely that that's random chance. Now, in this particular example, you see values of 63% and 72%. So can I be comfortable and confident that this relationship, which is a pretty strong relationship, is not just occurring by chance? No, I cannot. I cannot, at a p value of 0.5 level, be confident. However, that being said, I think with the global volume of the number of reflux events, that's probably driving down the sap. So in this particular example, I would still be very concerned that this patient is non acid reflux and that they are having a relationship. But I'm not 100% confident or 95% confident that this is not just related to change. So a very interesting study. Ah, very nice study to interpret because of the overall buyem of that particular patient. All right, so I don't know if there were any questions. If you want to go around to see if anyone wants to raise their hand. Jerry, I have a question for John Matt Ridley in Colon John. In this case, one of the other historical clues was Type two diabetes. We don't know duration. Would you would. An evaluation of gastro Parisse has come into your thought process when you look at this tracing and if you were thinking surgery as opposed to medical therapy going forward. Oh, certainly, uh, if there is any question or even a hint about I think with patients who have refractory reflux, I think you always especially we're gonna go send someone for surgery, always assess their gas and empty the main reason is. You know, we know that there's a high prevalence of gastric emptying out of formalities and patients with reflux and people with refractory flux. But it's it's more important for the surgeon to know that because of gas block the potential for gas bloat on Do you know, you certainly wanna wanna keep that in mind. There's always the chance that you might knock out the vagus nerve with the funding location. But certainly you also want to know if there's Baseline Gas or Parisse is because if you discovered that afterwards, medical legally, it's also a good idea to do that. So, yeah, certainly with that history, you know. And it's interesting because when we do see, patients were pretty surprised at how often people have some clinical gastro polices is a confounding factor with this particular pattern. So this is someone who's got non acid reflux, you controlling the acid very well, um, someone who's reflecting a tremendous amount, and it would not be surprising to me that if you fix this particular problem, you could potentially make this patient feel a lot better in my practice. What I probably start off within this patient is I would probably not send the patient right for surgery. Given the fact that their overall acid burden wasn't extremely high, I'd probably start with reflux inhibitor. Um, specifically, it seems like cough is driving this and back often does have, ah, very nice effect in some of the cop patients. And if that didn't work, I probably try some Neurontin, particularly because of the cough. And we've had some decent success. We usually started very low doses, but we have had people go upto, you know, 600 mg t i d within Iran and have a good effect. Thank you. Wendy. Did you have some participants with questions? I do not have any hands raised at this time. We just had a little operational question, but nothing for Dr Panda Fino so far. All right, well, let's keep moving on then. So now, in case to I'm gonna scroll through the entire case, and then we're gonna go through the actual study just so we can kind of go in reverse. Um, this is a 68 year old male patient. Long history of chest pain, heartburn and regurgitation worsening over the past year. Right. So this is you know this is a pretty good story. For, you know, we flocked patients 68 you know, long history of heartburn regurgitation. But something happened over the last year. Next year relief symptoms at first, but stopped working now taking excellent. And, you know, this is a common scenario that we see Can't really explain it all that much. You know, people believe sometimes they get resistant to these medicines. But these medicines is supposed to not have any form of tacking Phil Axis. And and typically, if you look at the data, they tend to last their their effect for many people last for many years. So so But we do see this, um, normal endoscopy one month ago had a small high it'll hernia and was scheduled for surgery in a month and was tested on the P. P I. Once again, if you're gonna test people on medicine, you need to use Ph impedance, especially when you're trying to figure out why the p. P. I is not working. Right. So if you're going to study someone on medicine, make sure you have impedance combined with PDS. The only few indications where that's not the case is If you have someone who has severe esophagitis, you know, then you are more focused on pH. So you could do Ph alone. But for the most part, the best bang for your buck is doing ph Penis when you're studying people on mets. So we're gonna look at the gastric pH in this particular patient in the savage pH. And once again what you see here and at least in the gastric pH and the esophageal pH, you can clearly see that the p p. I is working no big surprise PP eyes air really effective for them for the majority of people at suppressing acid. In fact, when we look at people who are on single and double those peopie I very effective in suppressing esophageal acid exposure. And of course, you know, the main reason we get P p I is obviously to raise the gastric creates about four. It doesn't do that for everybody to this particular level, I mean, but certainly this particular patient has pretty profound acid suppression. Whenever I see as a suppression like this, I wonder if the patient is a trophy, gastritis or body predominant h. Pylori, because they certainly have a very high level and no evidence of nocturnal break for. So in this particular patient, the number of reflux episodes were 35 non acid, obviously no acid reflux events because the gastric pH is about for the entire time. And you can see that the majority of these particular events in the upright position have a proximal migration. I'm not going to go too much into, um into the case further than this, but one of the things that I just want to show you this is a very nice example off where you have a significant amount of confidence in the SYMPTOM Index and the Symptom association probability. A lot of people talk poorly about symptom reflux correlation. But if you get a scenario like this where the patient has of 50% to 100% symptom index and then you look at the sap and the sap is 100% you're feeling very confident that this is related. So in this particular patient, the heartburn and regurgitation with a symptom index of 100% and the sap of 100% I'm pretty confident that the symptom relationship Israel now once again the chest pain episodes, unfortunately, was only two, um, symptoms. So obviously one attitude, 50% and it's gonna be hard to show that that's a positive step when you have such a small number of symptoms. Eso Once again, that's where the symptom reflux correlation stuff comes apart a little bit. But it shouldn't be a big surprise, because if you only have a few events, obviously, it's gonna be hard to not say that this is just a relationship by chance. So let's look at the actual study. Open the sky up. So remembering that I usually typically get a very nice view of the entire global picture here. And once again you see something that's very similar to the last patient. See a lot of activity while they're awake, a lot of swallows and then while the patient is sleeping, not a lot of activity. There's a little bit of bullets, transport reflux and four bowls. Transit here associate with a little bit of air movement, But you can clearly see that even during the night time period, there is no evidence of nocturnal breakthrough. So this is, as we saw with the blown up images of the gastric and esophageal pH. This is a patient that actually, um, you know, has pretty profound acid suppression. Maybe getting a little bit of help from a trophic, gastritis or even a body predominant needs by Lord. So assessment we've already talked about with the acid exposure. So now I'm going. I'll take a nice look at my our blocks here, and kinda as I mentioned. I always like to get a nice flavor for what a couple of typical swallows look like. And I could see this patient maybe swallows a little bit of air here down here. And you can clearly see maybe just a little bit of air when they first swallow. But dissipates quickly, not a big deal. So once again, I get a nice flavor for what I'm looking at here. And I can clearly see that there is no major reflux events here. There's a small event here that will take a look at and use the magnification tool. And then here you see once again, very nice. Beautiful air reflux event. Starting it off. Go back here Mhm. And you can see this kind of peeking up here and I'm gonna blow this up a little bit more for everybody to see, so you can clearly see that this starts from below and heads up. Beautiful air event. Yeah, with not really a lot of liquid coming up. Auto correct here. And I think you know the bio view. I feel the bio view system when I'm looking at impedance. It's very it's very intuitive, and it's very straightforward in terms of how you go through the analysis and how the commands and how the tools work. I mean, it's it's really works very well. It's seamless in terms of how you go through the magnification and how you use the the analysis tool. So once again, I think it's a very important aspect of this particular system is that it does very user friendly. It makes sense in terms of when you see stuff in your hands and you're going back and forth with particular studies. So now, because I don't see any symptoms here, I still like to get a general sense is to what the reflux events are looking at like and once again you see a little bit of air here, maybe pushing out some air, but a nice little reflux event here. And if I wasn't convinced and I wanted a little help, and I use our analysis tool there to show me where these guys air flying up and you can clearly see once again starts with a little bit of air. Um, and once again, nice little reflux event on auto. Correct here so you can see it a little bit better. So once again, boom, boom, boom. And, you know, it gets almost up to where you're in. But a little bit of that air of the patient might be perceiving, and this might be a little bit of remnant of that. So once again, I'd like to get a little a bit of a flavor of the reflux events. You have been the short guy here. You see a lot of air proceeding. This very important because that gives you a better idea of plan to back laughing. I'd like to see a lot of air lead the reflex event when I'm gonna start a reflection. See this and Jean Really? Yeah, the the I think especially teaching people. I think it's really helpful. Uh, but once again, I I tend toe just old school that looking at the tree because that's what I was brought up on. But, sir, certainly, uh, it isn't very helpful. Tool. So now let's roll through and let's see if we can find a few symptoms. So here's that one heartburn, um, and actually here. So you can clearly see here. Beautiful reflux event Growing up, we could see our heartburn event right in the middle of that. This is a beautiful non acid reflux event, a little bit of air moving more of the proximal air because remembering someone sitting up there's a little bit of air above our movie. Yeah, but certainly certainly a beautiful reflux event cleared here very nicely with a swallow eso another one a little bit further down. Oh, there it is so very similar patterns. You can see two very nice episodes of heartburn that are associating reflux events and let's see if we can find a couple of years. And here's the chest pain. There is one of the chest pain events. It's not associated with overall reflux event, but this one's a little tough. I'll tell you, be a little bit nervous about not saying anything about this because There is a little bit of activity here, and sometimes, you know, you just need to kind of look at it a little bit closer and you can see that there certainly is a swallow here, but it does appear that there could be a little bit of a swallowing use reflux event. But once again, it doesn't fit criterias that we don't count it. Let's see if we see a nice with vegetation episode here is one. You can see that the air moves all the way out and I would have auto correct this guy. So here's another nice little vegetation and you see, the air goes all the way up until the to the throat here and you can see the swallow. You're a little bit so these are all stimulating. A little bit of this reflux here. I'm gonna go back and here, obviously a couple more nice heartburn events and regurgitation events. This is a very deep reflux with some poor clearance. Let's see what this looks like when we look at a little bit more clothes. Good. You can see the baseline here. Yeah, so this is very here, and it's finally clearing so this is pretty good bullets contact. So you can imagine that even if there, even though the pH is normal if this is filled with Peps in and bile, you know it's not gonna be a pleasant thing for the mucosa to see, although this particular instance not a significant amount of Symptom Atala. Gee, there's a meal bases following a lot of hair scrolling through. And I think a lot of people do like to look at the color when they're scrolling through to. And I just kind of get through this Neil here, supine period. And then you could see it during that period of time. What that looks like here, a little bit of Bullis transport. And you know, it's interesting because I think a lot of times when you see these patients here, you know that this person probably woke up and just didn't hit the this button to tell them that that there are. But, you know, people tend to wake up a little roll around in bed, and that could cause some of that activity. So, going back to this particular study, I think we see a pretty good scenario where we see some decent reflux, but a lot of air movement with this, and you can see that the patients not gonna have ah, overwhelming, you know, burden of liquid reflux that acidic in this particular patient, Given the fact that there their overall pH has been pretty good. So this is someone who once again, that if I was looking at based on the fact that a lot of the reflux events are shorter events going proximal, almost like being led by a belch, this is also someone who reflux inhibition, um, could be very helpful. I'd be a little nervous, though. I would probably tell the surgeon, you know, that this is someone who's belching a lot, you know, make sure that they're not swallowing a lot of air. Um, you know that this is someone who, uh you know, when when you actually look at them. You know, I if I were a surgeon and I was gonna do a fund implication on them, I would definitely be a little bit nervous. Um, you know that that they were gonna retain a lot of hair, and they may They may have a lot of fleet, its and gas bloat afterwards. so, but just something to kind of keep in the back of my mind. But I think this is someone once again that I would approach with something like that, or potentially even an endoscopic therapy first, um, any hands raise any questions we need? Do you have any questions? There is one question. There was a request to review the S A. P and the symptom index going to go back to that. Can everybody see it? So So once again, the way I like to look at it is the symptom index tells you how strong the relationship is, right? And the sack tells you how likely that relationship is to be occurring just by random chance. So I would like to use a betting analogy. So if the SAP was 90% that would mean even though it's not 95% that would mean that I'm pretty certain, like, nine out of 10 times that this this result Israel. So in 95% probability means that 19 out of 20 times if I was gonna bet I'd be right 19 out of 20 times that this is a true relationship, you know? So So they're they're different, They're different metrics. And they really shouldn't be used, you know, as a single metric alone. Because once again, you saw the previous example the patient may have, you know, had a pretty significant relationship on symptom Index. But when you actually look at this happened, there could have been some chance there. I think that when you actually look at, you know, sorry, I went back to this one. So this is the patient, you know, that we just talked about They have a pretty good relationship based on symptom index, but the saps not great. But if you look at this particular instance especially for heartburn regurgitation, the symptom index is strong, and there's essentially no no chance that this is just random association. It would be very low likelihood that this is just random association. So that's how you kind of think of one tells you strength. The other one tells you how likely that relationship is just occurring by random chance. And if it's occurring by random chance, then you downplay the effect or the impact of that particular scenario. Yes, or good windy. I believe you have another question. I do the question is which endoscopic therapy is promising, in your opinion. So which endoscopic therapy is promising? My opinion? Well, I think that the endoscopic therapy that appears to be best studied, um, in terms and have a result is the sa fix. Um, you know, if you look at the respect trial, if you're dealing with someone who's suffering from regurgitation, I think that study showed very nicely, um that you can improve regurgitation and people who are PP I non responders, you know, people are continue tohave regurgitation. Straight up, I think, is a very nice tool in my mind to use in people who have reflux sensitivity or a short reflux events. Um, that maybe tell us our trigger, too. So I think that they're they're promising. I don't think we have a huge amount of data, but you know, once again, you know, those studies air very difficult to do. And, you know, one thing I can tell you is that when people get stranded, they do feel better. Um, you know, regardless of what the functional stuff looks like in terms of the acid exposure, And I do think that you know, patients who get a suffix do feel better. Um, you know, and it basically functions in a way where you reduce the reflux, burn or reduce the number of reflux events. So, you know, I do think the links procedure is also extremely promising, especially for patients who have normal anatomy. But we are doing them now. And even in patients with hernia, I think it's a very nice way to avoid the rap, which I think is the part that causes a lot of the problems in patients who have fun applications. I see a lot of people post on application complications, and the rap component is usually what's causing the problem. Um, and it's very rare that I see a Heidel hernia repair that's way too tight. It's typically the rap is either Hurney there's a Carassava Geul component, or it's just it's just way too tight function. So and Wendy, I believe you have one person with their hand raised. Um, let's see, I do have some other printed questions I don't see a hand raised. But on a related question, what type of endoscopic therapy would use from case to that you just presented? Well, I think if I was gonna look at this person. I think I would probably with the Tellus, are in the belching reflects. I might I might try this strata on this person once again have no data to support that. But really, I think the strait of probably would have its best effect in the rial. TVs are mediated, you know, events just based on, you know, my my thought process because the overall change in the anatomy is not all that significant. I think patients who have significant regurgitation a zehr primary complaints and there's not a lot of air. If there's a lot of liquid reflux, proximal liquid reflux, then that particular patient I'd probably use Theus optics. Um, I think that would probably be a little bit better option, because you're probably really altering the anatomy. But once again, I mean, I don't have a lot of data. There's nothing to help me predict that that's just a feel for what both devices kind of do and where I probably see them working, but they can be used interchangeably, e. I think. Obviously, the most important thing always is whether or not you have experience using them. The more experience you have using them better off the patient will be right. Another question here. Is there a way to differentiate between gastric and Supergrass? Trick belching by looking at the impedance. Certainly there is. Um in fact, I think we may see some arrow Feige in a little bit. But if we don't, I do have a power point that I can pull up rapidly to show you the difference. But essentially what you do you see is in Arafeh Asia. You see air coming in. So you see, basically this big. You know this this sharp rise in impedance in an integrated fashion. And you see that same sharp rise? Leave the esophagus in an integrated fashion with a super gastric belt. You see that sharp rise coming in an integrated fashion and leaving in a retrograde fashion with a gastric belt? You see that sharp price going retrograde and retrograde. And I do have a nice image if we don't have any good examples in the last case, Um Thio kind of show. Everybody Okay, Another question is, do you manage upright reflux differently from recumbent reflex? Um, do I manage them differently? Yes, because they they're very different. Upright reflux is typically tell us are mediated when you see by positional reflux that typically means the patient does have pretty significant anatomical distortion of the anti reflux barrier. So I always say that you know it. Z not that out. I'll never send anyone with upright for a fund application on. I only send some you know, people with by positional, but I tend to think that everything is a spectrum, so by positional it's pretty much dominated by by anatomy. Upright is dominated by TVs are, but there's always somewhere in the middle where people are, you know they can have both. They connect Eleazar, Mediate and, you know, significant in the upright and then and then also have laptop distortion Tonight. The one thing is, is that at night you don't have Telia songs. Essentially, when you're sleeping a zoo long as you are sleeping, when you're in that work coming phase, curious are they're not driving back, so I do treat them differently. I focus on anatomy more with, you know, hernia repair. If they have a hernia with the by positional and if it's just upright, I tend to start with more conservative stuff like the reflux inhibitor. I think it's probably a reasonable approach and, you know, also, lifestyle modifications. How they eat. Andi, you know, obviously, uh, you know, looking for triggers and stuff like that weight loss. I think it's also important. Very good. I'm for timing reasons. I think we should move three. Yep, All right. Of career history. So this is a 58 year old female with long history of Harper, an anti reflux medication produces little symptom. Only developed a chronic cough and throat clearing in July. Um, recently states. The cough usually occurs later in the day, probably after she's using a voice a lot. She's been on pan toppers all be I d with Benedettini at bedtime to maybe help a little bit the nocturnal acid breakthrough state that you often forgets the second dose of the PP I not a big surprise. As you know, 50% of people are not compliant Now. This is an interesting case, because in this case, you know you're getting a sense here. Anti reflux medication doesn't help the patient at all. With little reflux with little relief, she's on pretty high doses. You know what the pan topics all be I d and the rigidity and, you know, it doesn't really matter. So this particular patient, you may be saying yourself, You know what? I just want to see this patient has any evidence of reflux whatsoever, you know, because this is someone who you may say, you know, if they have no evidence but we need to steer this patient in a different direction. So when you look at the acid exposure data on this particular patient in the upright on bond, you know, recumbent position, you could see that this patient does have a significant number of acid reflux. Event 27. If you look at the overall minutes and the percent time, though, he's not all that abnormal. So here's someone who's, you know, 3.5%. You know, you might have caught her on a good day where she's not reflecting all that much. Um, you know, maybe tomorrow she'd be 4.5%. But, you know, not horrible. Um, acid reflux and really know recumbent reflux. Now, what happens when you look at the non acid reflux events? And on top of that, a lot of non acid reflux in this particular patient. You know, if you look at the overall number, I mean and look at the comparison to Asset this patients being dominant And a lot of these reflux events are associated approximate migration. This will be a nice example where we'll use a color or a little bit more just to kind of show that. So here we have someone who's kind of pretty significant number of proximal reflux events. So this is also something but, you know, borderline acid. You know, I'm not not significant. Certainly nothing that anyone would ever call abnormal. I'm sure that Mr Score was probably around nine or 10. So when we go back and look at our symptom index on this particular patient, the cough is about 50% regurgitation. No big surprise with all those proximal extent reflux events, Um, 100% for all reflux, half of the acid and half of the non acid. But remember, one of the things that PP ice do is they actually just convert um acid to non acid reflux events. So I'm sure if you put this patient back on their p p I most of these events would be non acid reflux disease, and you see that symptom in that sees would certainly hold up. Throat clearing is a little bit interesting because throat clearing it's kind of like a mild call. You know it's instead of like, you know, like you know, it's just one kind of, uh, you know, epoch as we call them. And so, But when you look at this, I think that once again the fact that there's only two coughs during the entire period of time, you know you're not going to get a symptom association probability above, you know, 95% in those particular patients because it could just be by random chance. But if you look at regurgitation and throat clearing, clearly see that that's not just chance. So that relationship, which appears to be strong for regurgitation and throat clearing, does appear to be highly unlikely, highly unlikely to be associating with just random chance. So there probably is a real effect here that we need to kind of keep in the back of our mind. So let's look at the actual study for study number today, and we should have time to look at Study number four, which does have some swallowing shoes in terms of the area. His face second here, there we go. So once again, my gestalt looking at this and you know, I can see that patient does have a lot of events. But once again look what happens at night Really very minimal stuff. She throat clears here, so obviously she's not sleeping because she wouldn't say that she's having symptoms if she was sleeping. I think it's very important to look at the diary and what people are saying when they eat. She does a good job of not eating before she goes to sleep, so that probably helps her out to, um, she's look at this. I mean, she's last meal was, you know, hours before she actually went to sleep, so that probably helps her out. Maybe if she ate right before she went to sleep, she would have by positional reflux. And then I would just tell her not to do that. Um, eso looking at the acid exposure, the red line here, you could see she does have significant reflux, at least reflux events that occurred during the meals. But when she's not eating, you know, not too bad. In fact, here. You know, all of the drops here are associated with meals, and she's got a few little reflux events that will look at it a little bit more cautious. Now, this particular patient is off PP I there. But you could see that she has areas where times during day where she drops her pH pretty significant levels in terms of the overall acid burden. And you can clearly see at night this particular patient at night has very low pH in the stomach, which is what we call nocturnal acid breakthrough. If the patient is on P B I. But there is a nocturnal surge of acid, or at least a created acid environment at night because we know, obviously we're not benefiting from the buffering of the meal during the day. All right, so let's look at this particular study in a little closer. Sure, here. And then we're gonna use a little bit of color, and you can clearly see here once again a couple of events here. And maybe I'll just look at this just to show you guys what someone swallows look like. And as I mentioned, I always get just a little sense you could see the swallows here are a little bit more blunted. Onda, let's take a look at this particular event right here. So this is event that is associate with a little bit of air movement. See the little air here? You blow this up, you're a little bit and you see a little bit of air. Lose it there. Maybe. Let's look at this guy a little bit closer here so you can see this person. Probably This might be a little bit of swallowed air, but you can see that this right here, it's coming up. And maybe this is actually the extent event. So there is a little bit of an error. Doesn't quite hit the threshold, but they're definitely air movement. Maybe miss this a little bit because there's a little liquid blunting it. But certainly there is a little bit of a reflux event there. Mostly got it by the air. You can see here another nice little reflux around. You can see how the color really highlights the fact that this is there and I'll see between tracings coming back here, you know? And then obviously here there's a nice drop. Doesn't clear for quite a while. The patient has a couple of swallows. But let's look at the more interesting part of this study a little bit later on during here, and we'll look at a few of these more reflux events here. So I'm gonna take a look at these guys just right here in the middle. And you could see if I look at the color here. It's a very short, reflexive and nothing major. And then we'll look at this guy. Uh huh. It's like there's a little bit of a drop here. Once again, you can see and you know, if you don't you having trouble discerning and you're not really sure that's when we use our friendly tool here. You can clearly see if this coming up. I probably would say that this has moved over a little bit. Um, that's just my personal where I put it. But certainly there is movement here. Um, and you can see that the reflux event occurs up. There might be a little bit of swallowed air here as the patient is reflecting. It's very common for patients to swallow air. Um, when a reflex or having a super gas we belts during the reflux event. Uh, we're gonna look a couple more interesting images here. True, the throat clear. Let's take a look at this throat clear and here you can see it. If you look at the overall time window here, it's a little bit off. Here's your reflux event. Mhm. Oh, kind of See the drop here. And even it might even be another re reflux event there in the distal area. Associate with throat clear here. And you can see this is definitely within a t least this particular point of two minute window. Um, so here's another throat clear right after a meal. She's not in common. Here's a night. Another nice, beautiful reflux event. See the this and then you'll see this kind of. So let's look at the relationship between the air, air and liquid interface, and you can kind of see here that this is reflux event. And then, if you look really close here, this might even be a little bit of a super gastric belt associate with that liquid reflux event. And it's interesting because sometimes that super gastric belt actually augments theatrical reflux events, or, you see, comes in and then almost creates this negative pressure window when it comes out. So it comes in and then shoots out and trails and almost drags the liquid up with it. So here's a nice example of that. Just show that again. So I really appreciate it. Here's the link reflux event to the tracings on that there's a super gas and belt, or at least in air swallow and release associate with a little bit more liquid, many flux coming up here. So these events, you know they're not. They're they're complicated. They're not straightforward. They have a lot of nuance to them. I'm Here's another nice throat clear on a couple of them with color. Beautiful reflects around approximate extent you see the patient here, uh, tryingto muster up a little something feeling sensing that, um, another nice Once again, it's nice pattern here that the patient has, um, go here. I looked at a couple more car clears. So and then here's another throat clear that if you look at it, let's take a look in here. There's definitely something going on, but there's probably just a little bit of a a slow So yeah, my Swallow associate with classes patient. I obviously throat probably clear their throat over here and then swallowed, but there was no activity. And of course, you know, if you have something that's causing repetitive irritation there, you're probably gonna throat clear even without having an overt reflux event. Um, this is a beautiful episode. You should take a closer look at this guy. So, yeah, so here's another deep associate with nice here and here. You can kind of see a little bit of something coming up, but once again, the patient does have a hair movement up here, and it's important to realize that that do you. Upper Airway reacts to a lot of things that are occurring in terms of reflux, and that's really by most of these things are associating with upper airway stuff, reflects mediated. So scrolling through here and he's a meal and do stroke clear. Let's look at the meal for a second. Just cause e think it's sometimes it's very helpful because you can kind of see the liquid swallows now coming down makes you appreciate how much easier it is to see that. So these air liquid swallows coming down. Thanks. Oh, go back to our sunny and then you can clearly see here and now let's look at what happened at night when this patient had a couple of reef throat clear. So here's a throat clear. Doesn't really look like it's associate with much, probably more of a throat clear and then swallow, which is something. As I mentioned, you typically see what about over here? Anything here patient woke up, had a little bit of a throat clear and then a cough. Clearly see, nothing hits criteria for pretty, for reflexive, so you can see the computer is pretty adept at discerning whether or not this is really or not. So you have to events, you know, And really, the computer did not, you know, didn't fall for anything here, I would say so did a really nice job picking up the fact that those or not real reflux events. So this is somebody, as we saw who is off PP I but having non acid reflux does have some liquid acid reflux, but not to the point where we reach a threshold value. This is another great example of someone who worked really hard on, um, you know, reflects inhibition You know, I probably looked to see you How she looks on PP I therapy. Um, I think that would be very helpful. Um, you know, once again, because I do think that there is an opportunity to improve this, although we know throat clearing and regurgitation Ah, are not to, uh, symptoms that do respond to P p I very well. I will also council this patient on voice utilization and see if we can get her to relax a voice to eso Any questions? E You have some questions. There's a question about how to interpret Bullis clearance. So is it s o. It's interesting because the bullets contact time, you know, and and going through it I think this this was a nice You will see that one swallow here again. It was a reflex event. Get out. Right there it is. Alright. Don't need to use out. She's this. Yeah, So it's a very simple and I think maybe this is a little makes it look a little simple here, but you can clearly see Here's your drop. Oh, use our analysis tour Here. You can see there is a reflex advantage. You could see the peaks. I mean, the impedance has dropped significantly, almost a baseline. Here, you get this highlight a little bit more. So here's your reflexive and three is a little bit of air movement in the middle. But you can clearly see that this impedance level is very low on. I'm gonna blow this up to just kind of capture the entire section here. But then you could see eventually, even though there might have been a little bit temple of a swallow here. Peters doesn't get back to baseline 50% baseline until later on in the swallow here. And this is probably led by a little bit of a swallow. And you can see now this is so It's hard to say what this is a primary swallow on Ben this. But regardless of whether it's primary or secondary post office, I would probably say that this is probably primary swallow here. Swallows a little bit of saliva, causes a nice Paris trophic effect, and you can see that the balls now return. So that's the timing. You know, it's interesting. I don't know necessarily that that we're at the point now where we can really use bullets. Contact time in any clinical way. But I will tell you that when you see these nice, beautiful, deep reflux events that lasts for a while, you're likely more significant than the ones that are short Eso we don't really count. You know long what we call long bullets contact time. As much as we look at proximal extent, I think Procter extends a lot more predictive than than the actual bullets contact time. But there are a couple of more recent studies that are looking at that. They're also looking at the ability of the once you do actually, uh, having reflux event, how often you see a swallow afterwards. Onda ratio back to look at how how well you will clear the Bullis on. That might be important. People have kind of microscopic injury and increased permeability in the esophagus. Wendy, I believe you have some more. Yes, um, it says, what back 11 dose do you start with? And that's a good question. So the back levendos that I typically start with, um is usually 5 mg t idea and what I usually tell them on the first day just take breakfast and dinner. Don't take breakfast, lunch and dinner. And I typically, um, go through. Uh huh. E can't really go through a little bit of scenario. Tell them they're gonna feel lightheaded. Maybe a little weak, and then I'll have them go get up to 10. You know, eventually, but the first week is really 5 mg t I do. And if they have no response, then I'll go up to 10, Um, t i d. And I'll have them do 10 in the morning 500 lunch, 10 at night on that first day just to make sure they don't feel really weird. And then I'll have them go That for me? If they don't get better on 10 t i d. Over a two week period of time. I usually aboard on the reflux in the mission because I don't know that it's really gonna work. I'm actually gonna try to pull up a quick study while I'm answering that question. Um, regarding the Arafat Asia. Since I have that you do. In that case, you wanna ask another question why I try to find this? Uh, yes. And dr Panel, if you know, it should be under case for in the study that I gave you. I just want to pull out that figure of the arrow Freesia. Yes. Pull that up. And then as I do that, I'll get that. But when do you want your next question? Yeah, The next next question relates to what is the reflux index for different age groups in pediatrics? Yeah. So, you know, we don't really have very good data for that. I have to kind of maybe defer to Jerry if there's you knows of anybody doing some more work in the pediatric literature, but, you know, Yeah. I mean, I think once again, we tend to We tend to use, you know, our adult numbers. And I think certainly, you know, when when when a child gets to the point where you know their their their their weight is close to, you know, 80 pounds. And that's kind of what we use here in Northwestern when we're actually bring them over the adult hospital do stuff. You know, we tend to just use the adult values, but, you know, you're looking mawr at the symptom reflux correlation. I think that's really where you know where most focused. Um, you know, in in using ph impedance right now. I mean, obviously, you know, someone has abnormal abnormal events. Uh, just turns color here. Um, it's kind of see globally. Uh, then then you know I don't, but I don't really have a good answer for that. I have to admit, and obviously, the challenge there is always It's not possible for ethical reasons to do normal values on Children's. Uh, there there is ah, group in Europe That's called E P I G. European pediatric, uh, impedance group on. What they're doing is they're harvesting data on a Siris of pediatric patients that are otherwise, uh, normal and sort of backing into normal values, if you will not an ideal situation, but it should be better than nothing. Uh, when you had your next question, I do This one relates to the back life in question. It says, Would you try neuron if back often fails Now, rockin has really only been shown to be helpful in and cough. Um, it's not really a reflux inhibitor, but Neurontin could be helpful in people with reflux sensitivity. Um, you know, I think that that's certainly something that, you know, I would try, but but But not for, you know, not for anything outside of cough right now, right? Yeah. And, Wendy, we have time for one or two more questions If you can pick out your, uh, right now, they're they're still relating to the pediatric values. Um, let's see the another pediatric question. What is the what are the medical agents used in Children for non acid reflux in the United States? So yeah, so once again, you know, extrapolating back from adults I mean, none of this stuff is FDA approved. It's all off label. And, you know, one of the things that we have to tell all of these patients is that, you know, this is certainly off label. Um, here's I just wanted to pull this up because I was trying to find this because it's a beautiful image I took from our Ian Brennan or a really highlight the difference between non acid and acid reflux. E mean, uh, super gastric belching and gas resulting in an oaf asia. Um, yeah. So I mean, a lot of this is is off label. Um, you know, even for adults. So it would be off label for Children, you know, back laughin obviously is not gonna be something Children are gonna like. It's gonna be sedating. It's gonna make them feel weird. So reflex inhibition. You know, in terms of that, I mean, we're really at a loss in terms of our pediatric population. But certainly a lot of people try these medicines. Yeah, so let me just break here for a second. Can everybody during can you guys see this year? So yeah. So this is what I was saying about you. See this rapid rise and impedance on and you can see it going in the basically the retrograde way, and then you'll see the rapid rise leaving the retrograde. This is a gastric belt. This is a super gastric belt where you actually see the rapid rise come in in the anti great fashion and out in the retrograde fashion. And here is a Roaf Asia where you see it actually coming in the anti great fashion. And then it actually leaves the esophagus in the anti great fashion and getting to this particular study here, we'll take a quick peek care because you can kind of see it. I think the colors will actually do it much more justice. When you come in here this you'll see that this is actually a lot of arrow Feige, and you can see the air coming in and in the integrated way the patient's swallowing it over and over here. So another example. So So I took me a little bit of time to find that you'll see that the air is coming in. The patient is actually following this air, and this is really just an opportunity to see what that looks like. Um, but you you you can always tell it when you see the kind of study here and you. You see, a lot of this is kind of packed color here. Even when you auto correct, you can get a sense that there's probably a lot of Arafat Asia there, So that's kind of the difference. So on. And then we went over a little bit. Um, I don't know if we have any more questions. I think that we have a last one. Wendy, please go ahead. Okay, last one in patients being evaluated for lung transplant, do you study them pre transplant with ph or with pH impedance? Oh, absolutely. Have to study lung transplant patients with PHP dense. Um, it's not enough to just look at the pH. You have to look at the overall burden because we've we've shown in in other other people, you know that That that's an important component. Uh, non acid reflux, you know, especially proximal extent is a very high risk. In fact, I there are studies now being done in these patients that were suggesting, and maybe even just doing fund applications on these patients. Um, just across the board is the right thing to do. And and I wouldn't be surprised if that turned out to be the case, but certainly if you're gonna be evaluating lung transplant patients, you need to do Ph impedance together. Very good. Thank you. Dr. Panel Fino, we're five minutes over, so I would like to close it there and thank all of the participants for joining us today. For those of you that would like to listen to this again or would like to recommend this to your colleagues for review, please go to sandhill you. Or you can go to the sandhill scientific website www sand hillside dot com and just follow the link to sandhill you. Thank you to everyone and thank you, Dr Panel Fino. Thank you very much. It was fun Created by Related Presenters John Pandolfino, MD Chief of Gastroenterology and Hepatology in the Department of MedicineHans Popper ProfessorProfessor of Medicine (Gastroenterology and Hepatology) View full profile
