Esophageal pH Monitoring with Impedance & Wireless pH Monitoring

Gastroenterology Consultants is proud to announce that Esophageal pH Monitoring with Impedance is now offered at the Heartland Center for Motility, under the supervision of Dr. Ashok Attaluri, within Gastroenterology Consultants.  Dr. Attaluri is an expert in Motility Disorders of the gastrointestinal tract.  This is the only center in the Quad-Cities area with Esophageal pH Monitoring with Impedance.

 

What is esophageal pH monitoring?
Esophageal pH monitoring is a test used to evaluate for gastroesophageal reflux disease (GERD) and to determine the effectiveness of medications that prevent acid reflux. This test measures the amount of acid refluxing or backing up from the stomach into the esophagus (food pipe). 

Esophageal pH monitoring is used in several situations to assess for GERD.  The first is to evaluate typical symptoms of GERD such as heartburn and regurgitation that do not respond to treatment with medications. In this situation, there may be a question whether the patient has GERD or whether anti-acid medications are adequate to suppress the acid production. The second is when there are unusual symptoms of GERD such as chest pain, coughing, wheezing, hoarseness, and sore throat. In this situation, it is not clear if the symptoms are due to GERD. Occasionally, this test can be used to monitor the effectiveness of medications used to treat GERD. The test is often used as part of a pre-operative evaluation before anti-reflux surgery.

What is impedance?
Impedance allows for the simultaneous measurement of non-acid or weak acid reflux. Often patients with persistent reflux symptoms, despite the fact that patients is on acid suppression medications, is due to the fact that symptoms of these patients are the results of weak acid or non-acid reflux. Multichannel Intraluminal Impedance (MII) detects intraesophageal bolus transport. This method is based on measuring the resistance to alternating current (impedance) of the content of the esophagus. This can assist in the care of GERD patients who have persistent symptoms despite medical therapy.

Types of pH monitoring?
There are three types of pH monitoring. Your doctor will decide which one is better for your situation. Each type uses pH sensors that register the reflux of acid from the stomach into the esophagus. For each type of monitoring, you should try to perform your regular activities during the day, including the ones that may bring on your symptoms. Regular meals should be eaten during the test.

Catheter-based Esophageal pH monitoring
In order to determine the correct placement of the esophageal pH probe, it may be necessary to perform a short test called upper endoscopy (EGD) or esophageal manometry.

The nose is numbed for a short time. A thin wire-sized plastic catheter is passed into one nostril, down the back of the throat, and into the esophagus as the patient swallows. The tip of the catheter contains a sensor that senses acid. The sensor is positioned in the esophagus so that it is just above the lower esophageal sphincter, a specialized area of esophageal muscle that lies at the junction of the esophagus and stomach and prevents acid from refluxing back up into the esophagus. The probe has pH sensors to measure pH in the stomach and to measure pH in the upper esophagus. Placing the probe takes approximately 10 minutes. No sedation is necessary. The other end of the small catheter comes out the nose and is connected to a small battery-powered recorder that is worn on a strap over the shoulder. The patient is sent home with the catheter and recorder in place.

During the 24 hours that the catheter is in place, the patient goes about his/her usual activities, for example, eating, sleeping, and working. Meals, periods of sleep, and symptoms are recorded by the patient in a diary and by pushing buttons on the recorder.

The diary helps the doctor to interpret the results. The patient returns the next morning for removal of the catheter. After the catheter is removed, the recorder is attached to a computer so that the data recorded can be downloaded into the computer where it is then analyzed.

There may be mild discomfort in the back of the throat while the catheter is in place. The vast majority of patients have no difficulty eating, sleeping, or going about their daily activities.

 

Catheter-based Esophageal pH monitoring with impedance

Same as above with additional information obtained from a specialized catheter. 

How should I prepare for catheter-based esophageal pH monitoring?

An empty stomach allows for the best and safest examination, so do not eat or drink anything for 6 hours before the test. Your doctor may ask that you temporarily stop taking your acid reducing medication.

What can I expect after the test?

After the test, you may experience mild sore throat, stuffy nose, or a minor nosebleed; all typically improve within hours. Unless your physician has given you other instructions, you may resume normal meals, activities, and any interrupted medications.

What are the possible risks associated with catheter-based esophageal pH monitoring?

As with any medical procedure, there are certain risks. While serious side effects of this procedure are extremely rare, it is possible that you could experience irregular heartbeats, aspiration (when stomach contents flow back into the esophagus and are breathed into the lung), or perforation (a hole in the esophagus). During insertion, the tube may be misdirected into the windpipe before being repositioned. Precautions are taken to prevent such risks, and your physician believes the risks are outweighed by the benefits of this test.

What if the tube cannot be passed?

In some situations, correct placement of the tube may require passage through the mouth or passing the tube using endoscopy (a procedure that uses a thin, flexible lighted tube). Your physician will determine the best approach.

 

Wireless capsule esophageal pH monitoring

Monitoring esophageal pH can also be performed with Bravo pH monitoring which uses a capsule that is attached to the esophageal lining.

How is a Bravo pH-monitoring test performed?
The capsule is approximately the size of an eraser on a pencil. The capsule contains an acid sensing probe, a battery, and a transmitter. During an upper endoscopy (EGD), the capsule is introduced into the esophagus on a catheter through the nose or mouth and is attached to the lining of the esophagus with a clip. The catheter then is detached from the capsule and removed. The probe monitors the acid in the esophagus and transmits the information to a recorder that is worn by the patient on a belt.

With this method, there is no catheter protruding from the nose for the recording. For this test, the monitoring period is longer, 48 hours (2 days), which allows more symptom events to be captured.

During the recording, the patient goes about his or her usual activities, for example, eating, sleeping, and working. Meals, periods of sleep, and symptoms are recorded by the patient in a diary and by pushing buttons on the recorder.
The diary helps the doctor to interpret the results.

The patient returns 48 hours after placement and the recorder is attached to a computer so that the data recorded can be downloaded into the computer where it is then analyzed.

The capsule will eventually fall off the esophageal lining, usually after five to several days, and is passed in the stool. The capsule is not reusable.

The advantages of the capsule device are related to the absence of a catheter connecting the probe to the recorder and the longer duration of the study. There is greater comfort without a catheter in the back of the throat, and patients are more likely to go to work and do more normal activities. One disadvantage of the capsule is that it only measures the pH at one level since it cannot be used in the pharynx or the stomach.  Another disadvantage is the inability to measure impedance via the Bravo pH system.

How should I prepare for the test?
An empty stomach is essential for an accurate and safe examination, so you should have nothing to eat or drink, including water, for at least eight hours before the examination.

Can I take my current medications?
Most medications can be continued as usual.  Inform us about medications you're taking, particularly aspirin products, arthritis medications, anticoagulants (blood thinners), insulin or iron products.

What about Aspirin?
Do not stop aspirin, unless instructed to by your physician or our staff.  The latest research and guidelines tell us that it is safe to perform routine upper endoscopy and biopsy while patients continue their aspirin. You may have stopped aspirin before a previous upper endoscopy.  The latest data shows us that the risk of bleeding is very low and when compared with the risk of a stroke or other clotting event, bleeding is relatively easy to control.  Major clotting events, such as stroke can leave irreversible damage.

What about Plavix® (clopidogrel)?
Do not stop Plavix® (clopidogrel), unless instructed to by your physician or our staff.  The latest research and guidelines tell us that it is safe to perform routine upper endoscopy and biopsy while patients continue their Plavix® (clopidogrel). You may have stopped Plavix® (clopidogrel) before a previous upper endoscopy.  The latest data shows us that the risk of bleeding is very low and when compared with the risk of a stroke or other clotting event, bleeding is relatively easy to control.  Major clotting events, such as stroke can leave irreversible damage.

What about Coumadin®?
Do not stop Coumadin®.  The latest research and guidelines tell us that it is safe to perform routine upper endoscopy and biopsy while patients continue their Coumadin® as long as their INR is in the routine therapeutic range of between 2 and 3.  You may have stopped Coumadin® before a previous upper endoscopy.  The latest data shows us that the risk of bleeding is very low and when compared with the risk of a stroke or other clotting event, bleeding is relatively easy to control.  Major clotting events, such as stroke can leave irreversible damage. Your doctor will discuss with you if Coumadin® should be stopped.

What about Pradaxa® (dabigatran)?
Please STOP taking Pradaxa® (dabigatran) 36 hours before your upper endoscopy (EGD).  Pradaxa® (dabigatran) has an extremely short half-life, unlike Coumadin®, which means the blood thinning effect is gone after 24-36 hours after stopping the medication.

Will I feel the capsule?
The capsule device may cause a vague sensation in the chest or discomfort when swallowing. This may be due to food tugging on the capsule as the food passes, although discomfort occasionally can be felt when swallowing only saliva. In rare instances, the Bravo capsule can cause chest pain requiring removal of the capsule with an endoscopy.

Restrictions after Bravo pH monitoring?
Patients cannot have an MRI (Magnetic Resonance Imaging) during the test and for 30 days afterwards.

Some patients cannot have this type of monitoring. Patients with pacemakers, implantable defibrillators or neurostimulators cannot use Bravo. Patients with a history of bleeding diatheses, strictures, severe esophagitis, varices, obstruction, and prior esophageal resection are not candidates for Bravo pH monitoring.

What are the possible complications of Bravo pH monitoring?
Although complications are rare, bleeding can. If this occurs, it's usually minimal and rarely requires follow-up. Other potential risks include a reaction to the sedative used and a perforation (a tear in the gastrointestinal tract lining). It's important to recognize early signs of possible complications. If you have a fever after the test, trouble swallowing or increasing throat, chest or abdominal pain, contact us immediately.