Digestive Diseases and Sciences,Vol.50,No.1(January2005),pp.100–102(C 2005)
DOI:10.1007/s10620-005-1285-x
Dynamic Position Testing for the Detection of Esophageal Acid Reflux Disease
CARL G.SCHOWENGERDT,MD
Currently the most widely accepted study for the detection of significant esophageal reflux disease
is the24-hr pH study.It is a problematic study,however.The data obtained from that study have to
126性
be analyzed by comparison to a normal tested population,revalued through a weighted scale,then
judged against recorded symptoms in order to obtain a valid interpretation.Dynamic position acid
reflux testing has recently been described as a better alternative.In this comparative study between
dynamic position and24-hr pH testing in64patients,the dynamic position study was found to be
more definitive,more informative,and more efficient in the detection of significant esophageal acid
reflux disease.
KEY WORDS:esophageal acid reflux disease;dynamic position acid reflux testing;24-hour pH testing.
Dynamic position testing has been described as an effi-cient method of evaluating patients for the presence of significant esophageal acid reflux disease.Questions re-main as to the accuracy and specificity of this test for this disease.The most widely used and accepted study for this disease has been24-hr pH testing.In a preliminary com-parative study of these two techniques,dynamic position testing appeared to be as accurate as24-hr pH testing, as well as providing more information on which to base clinical decisions.Additional comparative study was in-dicated to determine which of these two studies appears to be the most reliable and useful for the detection of signifi-cant esophageal acid reflux disease in patients who present with uncontrolled reflux symptomatology.
METHODS
A total of64patients who presented with uncontrolled esophageal acid reflux symptoms underwent esophageal manometry combined with dynamic position acid reflux test-ing and,on a separate date,also had24-hr pH testing performed. Manuscript received November20,2003;accepted Februar
y28,2004. From Genesis HealthCare Systems,Zanesville,Ohio,USA. Address for reprint requests:Carl G.Schowengerdt,MD,1246 Ashland Avenue,Zanesville,Ohio43701,USA;schowe@msmisp.The techniques of dynamic position testing(1,2)and24-hr pH testing(3,4)have been described previously.The manometry ap-paratus was a Sandhill Scientific system with Bioview software, using four channels for pressure recording and one for pH de-termination.The manometry catheter was a Sandhill Scientific solid-state probe with four pressure transducers,the distal two of which were circumferential,with a pH probe at the tip(model P34B2412C17).Twenty-four-hour pH studies were done using a Sandhill Scientific GERDcheck system(Model B96-1100) and a Comfort tech plus cather(Model PHI10).The manom-etry,dynamic position and24-hr studies were recorded and correlated.
RESULTS
俘虏兵下载Dynamic position testing demonstrated negativefind-ings for significant acid reflux disease in38patients, and positivefindings for significant acid reflux disease in26patients.In17of those26patients the tests were strongly positive,indicating severe reflux disease;in9pa-tients the tests were weakly positive for significant acid reflux disease.In those9patients a hiatus hernia was iden-tified with constant acidity in the hiatus hernia.There were no patients in whom the results were equivocal. Twenty-four-hour pH testing demonstrated negative findings for significant esophageal acid reflux disease in 37patients and positivefindings for significant esophageal
100Digestive Diseases and Sciences,Vol.50,No.1(January2005)
0163-2116/05/0100-0100/0C 2005Springer Science+Business Media,Inc.
DYNAMIC POSITION TESTING FOR ACID REFLUX
reflux disease in11patients.There were16patients in whom the24-hr studies were equivocal and unreliable for use in clinical decisions.Twenty-four-hour tests were con-sidered negative if the composite score was less than22or greater than22but the symptom index was less than25%. They were considered positive if the composite score was greater than22and the symptom index more than75%. Tests were considered unreliable if the composite score was greater than22but the symptom index between25 and75%(5).
There was complete agreement between the two studies in38patients.Both demonstrated the presence of signif-icant esophageal acid reflux in7patients and both found no evidence of significant esophageal acid reflux in31pa-tients.There was disagreement between the two methods of testing in
10patients.In16patients,the24-hr tests were equivocal and not of value in treatment determinations or comparisons.
The10patients in whom there was disagreement be-tween the two tests were examined more closely.In four of those patients the dynamic position study was highly positive,with refluxate easily reaching the neck.On that basis,the positive dynamic position study appeared to be more reliable than the negative24-hr study.In three patients,the dynamic position study was weakly positive and the24-hr study negative.In each of these three patients there was evidence of esophagitis by endoscopic study. The dynamic position study appeared to be more reliable in these three patients for that reason.In three patients the dynamic study was negative and the24-hr study positive; in all of them,endoscopy showed no evidence of esophagi-tis.One of these three drank tea throughout the24-hr study, was being treated for psychosis,and had a variable his-tory;one showed severe dysmotility on manometry.The validity of the symptom index in these two patients was questionable.In one remaining patient,the dynamic study was negative and the24-hr study highly positive.Treat-ment was given in this one patient on the basis of the positive24-hr study.
DISCUSSION
Dynamc position testing is a brief study done over a short period of time,usually less than1hr.As such,its validity can be questioned in a disease which is dynamic over a long period of time.There is a great deal to be said, however,for a study of acid reflux disease which is fully controlled and observed.If one can demonstrate repeti-tively acid reflux in the esophagus with position changes, there is no doubt that the potential for reflux disease is high.A directly observed and recorded study has much more chance for accuracy than a test which is unobserved and depends on an erratic diary of activity to determine its validity.
童年的发现教案In dynamic position testing,the validity of accepting constant acidity in a hiatus hernia as a positive study can be questioned.There is ample evidence in other literature, however,that the presence of a hiatus hernia significantly increases the risk of acid reflux disease,that risk increasing with the size of the hiatus hernia(6,7).If one is able to demonstrate that there is constant acidity in a hiatus hernia, the statistical chance that there will be frequent acid reflux is high.The logical conclusion should be that this is a valid indicator of significant acid reflux. The number of patients in this study who had an equiv-ocal or unreliable24-hr pH test is nearly identical to that described in other studies(5).It appears that,in anyone’s hands,properly interpreted24-hr studies will contain a 25%group that has an indeterminate study on the ba-sis of the
symptom index alone.This does not even ad-dress the question whether the normal population chosen for comparison is accurate(8),the weighted scale accu-rate(9),or a paucity of recorded symptoms meaningful (5).Patients simply do not fully record smoking,bending, chasing a child,lifting a laundry basket,sneezing,cough-ing,eating chocolate,drinking coffee,tea,or alcohol,hav-ing bowel movements,and multiple other activities,all of which bear significantly on the interpretation of that test (10–12).Twenty-four-hour testing is an unobserved and, for the most part,poorly recorded study,other than acid readings.
This comparative study indicates that dynamic position testing is the most useful study for the detection of signif-icant esophageal acid reflux disease.It is more definitive than24-hr pH testing and provides information on low-level acid reflux and upper esophageal acid reflux which is not available with24-hr testing.It is more efficient,al-lowing,when combined with esophageal manometry and esophagogastroduodenoscopy(1,2,13),all necessary test-ing for the diagnosis and treatment of esophageal acid reflux disease to be performed within a few hours.
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102Digestive Diseases and Sciences,Vol.50,No.1(January2005)
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