Postprandial High-Resolution Impedance Manometry Identifies Mechanisms of Nonresponse to Proton Pump Inhibitors

Abstract

Background & aims: Recognition of rumination and supragastric belching is often delayed as symptoms may be mistakenly attributed to gastroesophageal reflux disease. However, distinct from gastroesophageal reflux disease, rumination and supragastric belching are more responsive to behavioral interventions than to acid-suppressive and antireflux therapies. Postprandial high-resolution impedance manometry (PP-HRIM) is an efficient method to identify rumination and belches. We investigated the distribution of postprandial profiles determined by PP-HRIM, and identified patient features associated with postprandial profiles among patients with nonresponse to proton pump inhibitors (PPIs).

Methods: We performed a retrospective analysis of PP-HRIM studies performed on 94 adults (mean age, 50.6 y; 62% female) evaluated for PPI nonresponsiveness at an esophageal referral center, from January 2010 through May 2016. Following a standard esophageal manometry protocol, patients ingested a solid refluxogenic test meal (identified by patients as one that induces symptoms) with postprandial monitoring up to 90 minutes (median, 50 min). Patients were assigned to 1 of 4 postprandial profiles: normal; reflux only (>6 transient lower esophageal sphincter relaxations (TLESRs)/h); supragastric belch (>2 supragastric belches/h), with or without TLESR; or rumination (≥1 rumination episode/h) with or without TLESR and supragastric belching. The primary outcome was postprandial profile.

Results: Of the study participants, 24% had a normal postprandial profile, 14% had a reflux-only profile, 42% had a supragastric belch profile, and 20% had a rumination profile. In multinomial regression analysis, the rumination group most frequently presented with regurgitation, the supragastric belch and rumination groups were younger in age, and the reflux-only group had a lower esophagogastric junction contractile integral. The number of weakly acidic reflux events measured by impedance-pH monitoring in patients receiving PPI therapy was significantly associated with frequency of rumination episodes and supragastric belches.

Conclusions: In a retrospective analysis of 94 nonresponders to PPI therapy evaluated by PP-HRIM, we detected an abnormal postprandial pattern in 76% of cases: 42% of these were characterized as supragastric belching, 20% as rumination, and 14% as reflux only. Age, esophagogastric junction contractility, impedance-pH profiles, and symptom presentation differed significantly among groups. PP-HRIM can be used in the clinic to evaluate mechanisms of PPI nonresponse.

Keywords: Belching; EGJ; Functional Heartburn; GERD.

Figure 1

Post-prandial events on high-resolution impedance manometry. A) Example of a transient lower esophageal sphincter with inhibition of the crural diaphragm and LES relaxation lasting for > 10 seconds, associated with a reflux episode (retrograde movement of gastric contents proximal to the LES). B) Example of a rumination episode with (1) rise in intragastric pressure > 30mmHg above baseline followed by (2) retrograde flow of gastric contents to the UES, with (3) increased esophageal pressure, and (4) UES relaxation. C) Example of a supragastric belch with (1) EGJ contraction, (2) negative intra-thoracic pressure, (3) UES relaxation, and (4) aboral flow of air as demonstrated by rise in impedance, and (5) retrograde movement and expulsion of air. Figure used with permission from the Esophageal Center at Northwestern’s Digestive Health Center.

Figure 1

Post-prandial events on high-resolution impedance manometry. A) Example of a transient lower esophageal sphincter with inhibition of the crural diaphragm and LES relaxation lasting for > 10 seconds, associated with a reflux episode (retrograde movement of gastric contents proximal to the LES). B) Example of a rumination episode with (1) rise in intragastric pressure > 30mmHg above baseline followed by (2) retrograde flow of gastric contents to the UES, with (3) increased esophageal pressure, and (4) UES relaxation. C) Example of a supragastric belch with (1) EGJ contraction, (2) negative intra-thoracic pressure, (3) UES relaxation, and (4) aboral flow of air as demonstrated by rise in impedance, and (5) retrograde movement and expulsion of air. Figure used with permission from the Esophageal Center at Northwestern’s Digestive Health Center.

Figure 1

Post-prandial events on high-resolution impedance manometry. A) Example of a transient lower esophageal sphincter with inhibition of the crural diaphragm and LES relaxation lasting for > 10 seconds, associated with a reflux episode (retrograde movement of gastric contents proximal to the LES). B) Example of a rumination episode with (1) rise in intragastric pressure > 30mmHg above baseline followed by (2) retrograde flow of gastric contents to the UES, with (3) increased esophageal pressure, and (4) UES relaxation. C) Example of a supragastric belch with (1) EGJ contraction, (2) negative intra-thoracic pressure, (3) UES relaxation, and (4) aboral flow of air as demonstrated by rise in impedance, and (5) retrograde movement and expulsion of air. Figure used with permission from the Esophageal Center at Northwestern’s Digestive Health Center.