Ambulatory Esophageal Monitoring.pptx

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    Esophageal Esophageal pH recordingprovides quantitative data on bothesophageal acid exposure and on the

    correlation between patient symptomsand reflux events.

    Ambulatory EsophagealMonitoring

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    1. To detect refractory reflux in members with chest pain aftercardiac evaluation using a symptom reflux association scheme,preferably the symptom association probability calculation (pHstudy done after a trial of proton pump inhibitor [PPI] therapy forat least 4 weeks)

    Indications

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    2. To document abnormal esophageal acid exposure in an

    endoscopy-negative member being considered for surgical anti-reflux repair (pH study done after withholding anti-secretorydrug regimen for more than 1 week)

    3. To document concomitant gastro-esophageal reflux disease(GERD) in an adult onset, non-allergic asthmatic suspected of having reflux-induced asthma (pH study done after withholdinganti-secretory drugs for more than 1 week). Note: a positive testdoes not prove causality

    4. To evaluate members after anti-reflux surgery who aresuspected to have ongoing abnormal reflux (pH study done afterwithholding anti-secretory drug regimen for more than 1 week)

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    Patients with known or suspecteddigestive tract malformation,gastrointestinal obstruction, perforation of

    digestive tract, strictures, or fistulas basedon the clinic picture or pre-proceduretesting and profile.

    Contraindications

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    * Patients with cardiac pacemaker or other implantableelectro-medical devices.

    * Patients with swallowing disorders.

    * Patients with various acute enteritis, serious ischemiadiseases, radioactive colonitis, such as season of bacillary

    dysentery action, acute stage ulcerative colitis, especiallypatients of fulminating form are forbidden to use.

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    *It is forbidden for patients who are sensitive to highmolecular material.

    *Psychopath should be treated cautiously.

    *Patients aged under 18 or above 70 should be treatedcautiously.

    *Pregnancy

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    * Detects episodes of reflux

    * Determines temporal association

    between acid GER and symptoms

    Advantages

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    * Cannot detect non-acidic reflux

    * inability to prove causality between

    symptoms and acid reflux

    Limitations

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    Nasal & Pharygeal DiscomfortRhinorrheaPatients may have limited activity

    Complications

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    GlovesAdhesive TapeEsophageal Probes

    The recording device (Acidogastrometer)A glass of water with drinking-straw

    Equipments

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    Esophageal ProbesA probe that measures pH, connected to an external MonitoringDevice

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    Acidogatrometer

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    Different Types of pH Monitoring

    Single sensor pHmonitoring using a pH

    catheter

    Dual sensor pHmonitoring using a pH

    catheter

    Wireless pH monitoring usingBravo pH capsule or OMOM pH

    monitoring capsule

    The duration of the test is 24 hours in the first and second techniques and 48 hours forthe Bravo capsule or more (96 hours) for OMOM capsule.

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    PreparationThe patient will be asked to refrain fromconsuming alcohol or smoking for at least 24hours before the test.

    The patient will be asked to refrain from eating ordrinking anything for at least 6 hours before thetest.

    The physician may give instructions that disallow

    consuming any antacid medication at least 24-36hours before the test.

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    PreparationStop medications used for treating reflux and fortreating stomach acid problems unless indicatedby the physician.

    Advice the patient to wear a shirt or blouse whichopens in the front so that it is easier to dress afterthe probe is placed.

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    In assessment of distal esophageal pH, the sensor isplaced 5 cm above upper border of the loweresophageal sphincter (LES) determined by esophageal

    manometry.

    The Procedure

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    To measure proximal esophageal acid exposure the

    second sensor is placed 1-5 below the lower border of the upper esophageal sphincter (UES).

    The Bravo pH capsule is placed either transnasally basedon manometric measurements, or following endoscopy.In transnasal placement the capsule is placed 5 cmabove upper border of the LES, and in endoscopicplacement 6 cm above gastroesophageal junction. Thesame applies to OMOM pH monitoring capsule.

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    Since the use of the aambulatory pHmonitoring, this evaluation tool is usedinfrequently.

    Performed to evaluate complaints of acid-related chest or epigastric pain.

    Bernstein Test

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    Procedure

    HCl is instilled through a small feedingtubepositioned in the esophagus. This isdone to elicit reported chest pain. Resultant

    signs and symptoms are compared with theusual symptoms the patient reports.

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    a: Dual-channel proximal and distal esophageal pH monitoring is used to monitorpatients with reflux symptoms off therapy. b: Dual channel distal esophageal andgastric pH monitoring is used to monitor patients with reflux symptoms on acid

    suppressive therapy.

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    A reflux episode is defined as esophageal pH drop below four.Esophageal pH monitoring is performed for 24 or 48 hoursand at the end of recording, patients tracing is analyzed andthe results are expressed using six standard components. Of these 6 parameters a pH score called Composite pH Score orDeMeester Score has been calculated, which is a globalmeasure of esophageal acid exposure. A JD score > 14.72indicates reflux.

    Components of esophageal pHMonitoring

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    Components of 24-h Esophageal pH

    MonitoringPercent total time pH < 4Percent Upright time pH < 4Percent Supine time pH < 4Number of reflux episodesNumber of reflux episodes 5 min Longest reflux episode (minutes)

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