Abstract
Gastroesophageal reflux disease (GERD) is the most common esophageal disorder and perhaps among the most prevalent conditions seen in the primary care setting. The clinical manifestations of GERD, typical or atypical, such as noncardiac chest pain, respiratory or ear, nose, and throat symptoms, result from the reflux of gastric contents into the esophagus. Thus the clinical spectrum is wide and requires accurate diagnosis. Ambulatory 24-hr esophageal pH monitoring is not useful in all patients suspected to have GERD. This review describes the technique of ambulatory 24-hr esophageal pH monitoring, the interpretation of findings, and clinical applications of this test.
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REFERENCES
Sontag SJ: Rolling review: Gastroesophageal reflux diseasee. Aliment Pharmacol Ther 7:293–312, 1993
Spechler SJ: Epidemiology and natural history of gastroesophageal reflux disease. Digestion 51(Suppl 1):24–29, 1992
Spencer J: Prolonged pH recording in the study of gastrooesophageal reflux. Br J Surg 56:9–12, 1969
Johnson LF, DeMeester TF: Twenty-four hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol 62:325–332, 1974
Emde C, Garner A, Blum L: Technical aspects of intraluminal pH-metry in man: Current status and recommendations. Gut 28:1177–1188, 1987
McLauchlan G, Rawlings IM, Lucas ML, McCloy BF, Crean GP, McColl KEL: Electrodes for 24 hour pH monitoring—a comparative study. Gut 28:935–939, 1987
Duroux P, Emde C, Bauerfeind P, Francis C, Grisel A, Thybaud L, Arstrong D, Depeursinge C, Blum AL: The ion sensitive field effect transistor (ISFET) pH electrode: A new sensor for long term ambulatory pH monitoring. Gut 32:240–245, 1991
Weusten BL, Akkermans LM, van Berge-Henegouwen GP, Smout AJ: Spatiotemporal characteristics of physiological gastroesophageal reflux. Am J Physiol 266:G357–G362, 1994
DeMeester TR, Johnson LF, Joseph GJ, Toscano MS, Hall AW, Skinner DB: Patterns of gastroesophageal reflux in health and disease. Ann Surg 184:459–470, 1976
DeMeester TR, Wang CI, Wernly JA, Pellegrini CA, Little AG, Klementschitsch P, Bermudez G, Johnson LF, Skinner DB: Technique, indications, and clinical use of 24 hour esophageal pH monitoring. J Thorac Cardiovasc Surg 79:656–670, 1980
Branicki FJ, Evans DF, Ogilvie AL, Atkinson M, Hardcastle JD: Ambulatory monitoring of oesophageal pH in reflux oesophagitis using a portable radiotelemetry system. Gut 23:992–998, 1982
Evans DF: Twenty four hour ambulatory oesophageal pH monitoring. An update. Br J Surg 74:157–161, 1987
Klauser AG, Schindlbeck NE, Muller-Lissner SA: Esophageal 24-hour pH monitoring: Is prior manometry necessary for correct positioning of the electrode? Am J Gastroenterol 85:1463–1467, 1990
Mattox HE, Richter JE, Sinclair JW, Price JE, Case LD: Gastroesophageal pH step-up inaccurately locates proximal border of lower esophageal sphincter. Dig Dis Sci 37:1185–1191, 1992
Singh S, Price JE, Richter JE: The LES locator: Accurate placement of an electrode for 24-hour pH measurement with a combined solid state pressure transducer. Am J Gastroenterol 87:967–970, 1992
Klingler PJ, Hinder RA, Wetscher GJ, Davis DM, Achem SR, Seelig MH, O'Brien P, DeVault KR: Accurate placement of the esophageal pH electrode for 24-hour pH monitoring using a combined pH/manometry probe. Am J Gastroenterol 95:906–909, 2000
DeCaestecker JS, Blackwell JN, Pryde A, Heading RC: Daytime gastro-oesophageal reflux is important in oesophagitis. Gut 28:519–526, 1987
Schofield PM, Bennett DH, Whorwell PJ, Brooks NH, Bray CL, Ward C, Jones PE: Exertional gastro-oesophageal reflux: A mechanism for symptoms in patients with angina pectoris and normal coronary angiograms. Br Med J 294:1459–1461, 1987
Fass R, Hell R, Sampliner RE, Pulliam G, Graver E, Hartz V, Johnson C, Jaffe P: Effect of 24-hour esophageal pH monitoring on reflux-provoking activities. Dig Dis Sci 44:2263–2269, 1999
Galmiche JP, Scarpignato C: Esophageal pH monitoring. Functional evaluation in esosphageal disease. Front Gastrointest Res 22:71–108, 1994
Saraswat VA, Dhiman RK, Mishra A, Naik SR: Correlation of 24-hr esophageal pH patterns with clinical features and endoscopy in gastroesophageal reflux disease. Dig Dis Sci 39:199–205, 1994
Vitale GC, Cheadle WG, Sedek S, Michel ME, Cuschieri A: Computerized 24-hour ambulatory esophageal pH monitoring and esophagastroduodenoscopy in the reflux patient. Ann Surg 20:724–728, 1984
Johnsson F, Joelsson B, Isberg PE: Ambulatory 24-hour intraesophageal pH-monitoring in the diagnosis of gastroesophageal reflux disease. Gut 28:1145–1150, 1987
Schindlbeck NE, Heinrich C, Konig A, Dendorfer A, Pace F, Stefan A, Muller Lessner SA: Optimal thresholds, sensitivity and specificity of long-term pH-metry for the detection of gastroesosphageal reflux disease. Gastroenterology 93:85–90, 1987
Johnsson F, Joelsson B: Reproducibility of ambulatory oesophageal pH monitoring. Gut 29:886–889, 1988
Fink SM, McCallum RW: The role of prolonged esophageal pH monitoring in the diagnosis of gastroesophageal reflux. JAMA 252:1160–1164, 1984
Grande L, Pujol A, Ros E, Garcia-Valdecasas JC, Fuster J, Visa J, Pera C: Intraesophageal pH monitoring after breakfast + lunch in gastroesosphageal reflux. J Clin Gastroenterol 10:373–376, 1988
Galmiche JP, Guillard JF, Denis P, Boussakr K, Lefrancois R, Colin R: Etude du pH oesophagien en periode postprandiale chez le sufet normal et au course du syndrome de reflux gastro-oesophagien: Interet diagnostique d'un score de reflux acide. Gastroenterol Clin Biol 4:531–539, 1980.
Jorgensen F, Elsborg L, Hesse B: The diagnostic value of computerized short-term esophageal pH monitoring in suspected gastroesophageal reflux. Scand J Gastroenterol 23:363–368, 1988
Ottington Y, Ampelas M, Voigt JJ, Classigneul J, Pascal JP: Comparison de trois methodes d'enregistrement du pH oesophagien dans le diagnostique du reflux gastro-oesophagien acide. Gastroenterol Clin Biol 8:609–615, 1984
Bianchi Porro G, Pace P: Comparison of three methods of intraesophageal pH recordings in the diagnosis of gastroesophageal reflux. Scand J Gastroenterol 23:743–750, 1988
Dhiman RK, Saraswat VA, Mishra A, Naik SR: Inclusion of supine period of short-duration pH monitoring is essential in diagnosis of gastroesophageal reflux disease. Dig Dis Sci 41:764–772, 1996
Cheadle WG, Vitale GC, Sadek SA, Cuschieri A: Computerized ambulatory esophageal pH monitoring in 50 asymptomatic volunteer subjects: Results and clinical implications. Am J Surg 155:503–508, 1988
Branicki FJ, Evans DF, Jones JA, Ogilvie AL, Atkinson M, Hardcastle JD: A frequency duration index (FDI) for the evaluation of ambulatory recordings of gastro-oesophageal reflux. Br J Surg 71:425–430, 1984
Weiner GJ, Morgan TM, Cooper JB, Wu WC, Castell DO, Sinclair JW, Richter JE: Ambulatory 24-hour esophageal pH monitoring. Reproducibility and variability of pH parameters. Dig Dis Sci 33:1127–1133, 1988
Dinelli M, Passaretti S, Di Francia I, Fossati D, Tittobello A: Area under pH 4: A more sensitive parameter for the quantitative analysis of esophageal acid exposure in adults. Am J Gastroenterol 94:3139–3144, 1999
Ghillebert G, Demeyere AM, Janssens J, Vantrapeen G: How well can quantitative 24-hour intraesophageal pH monitoring distinguish various degrees of reflux disease? Dig Dis Sci 40:1317–1324, 1995
Dent J, Holoway RM, Toouli J, Dodds WJ: Mechanism of lower oesophageal sphincter incompetence in patients with symptomatic gastroesophageal reflux. Gut 29:1020–1028, 1988
Orr WC, Allen ML, Robinson M: The pattern of nocturnal and diurnal esophageal acid exposure in the pathogenesis of erosive mucosal damage. Am J Gastroenterol 89:509–512, 1994
Kjellen G, Tibbling L: Influence of body position, dry and water swallos, smoking and alcohol on esophageal acid clearance. Scand J Gastroenterol 13:51–57, 1978
Orr WC, Johnson LLF, Robinson MG: Effect of sleep on swalloing, oesophageal paristasis and acid clearance. Gastroenterology 86:814–819, 1984
Sonnenburg A, Steinkamp U, Weise A, Berges W, Weinbeck M, Rohner HG, Peter P: Salivary secretion in reflux esophagitis. Gastroenterology 83:889–895, 1982
Weiner GJ, Richter JE, Copper JB, Wu WC, Castell DO: The symptom index: A clinically important parameter of ambulatory 24-hour esophageal pH monitoring. Am J Gastroenterol 38:358–361, 1988
Breumelhof R, Smout AJPM: The symptom sensitivity index: A valuable additional parameter in 24-hour esophageal pH recording. Am J Gastroenterol 86:160–164, 1991
Weusten BLAM, Roelofs JMM, Akkermans LMA, van Berge-Henegouwen GP, Smout AJPM: The symptom association probability: An improved method for symptom analysis of 24-hour esophageal pH data. Gastroenterology 107:1741–1745, 1994
Shi G, des Verannes SB, Scarpignato C. Le Rhun M, Galmiche JP: Reflux related symptoms in patients with normal oesophageal exposure to acid. Gut 37:457–464, 1995
Euler AR, Byrne WJ: Twenty-four hour esophageal intraluminal pH probe tersting: A comparative analysis. Gastroenterology 80:957–961, 1981
Jamieson JR, Stein HJ, DeMeester TR, Bonavina L, Schwizer W, Hinder RA, Albertucci M: Ambulatory 24-H esophageal pH monitoring: Normal values, optimal thresholds, specificity, sensitivity, and reproducibility. Am J Gastroenterol 87:1102–1111, 1992
Mattioli S, Pilotti V, Spangaro M, Grigioni WF, Zannoli R, Felice V, Conci A, Gozzetti G: Reliability of 24-hour home esophageal pH monitoring in diagnosis of gastroesophageal reflux. Dig Dis Sci 34:71–78, 1989
Masclee AAM, De Best ACAM, De Graaf R, Cluysenaer OJJ, Jansen JBMU: Ambulatory 24-hour pH-metry in the diagnosis of gastroesophageal reflux disease. Scand J Gastroenterol 25:225–230, 1990
Schindlbeck NE, Wiebecke B, Klauser AG, Voderholzer WA, Muller-Lissner SA: Diagnostic value of histology in nonerosive gastro-oesophageal reflux disease. Gut 39:151–154, 1996
Ghillebert G, Demeyere AM, Janssens J, Vantrappen G: How well can quantitative 24-hour intraesophageal pH monitoring distinguish various degrees of reflux disease? Dig Dis Sci 40:1317–1324, 1995
Kahrilas PJ, Quigley EMM: Clinical esophageal pH recording: A technical review for practice guideline development. Gastroenterology 110:1982–1996, 1996
Klauser AG, Heinrich C, Schindlbeck NE, Muller-Lissner SA: Is long-term esophageal pH monitoring of clinical value? Am J Gastroenterol 84:362–366, 1989
Olden K, Triadafilopoulos G: Failure of initial 24-hour esophageal pH monitoring to predict refractoriness and intractability in reflux esophagitis. Am J Gastroenterol 86:1141–1146, 1991
Quigley EMM: 24-hour pH monitoring for gastroesophageal reflux disease: Already standard but not yet gold? Am J Gastroenterol 87:1071–1075, 1992
Johnsson F, Joelsson B: Reproductibility of ambulatory oesophageal pH monitoring. Gut 29:886–889, 1988
Wiener GJ, Morgan TM, Copper JB, Castell DO, Sinclair JW, Richter JE: Ambulatory 24-hour esophageal pH monitoring: reproducibility and variability of pH parameters. Dig Dis Sci 33:1127–1133, 1988
Eckardt VF, Dilling B, Bernhard G: The impact of open access 24-h pH-metry on the diagnosis and management of esophageal reflux disease. Am J Gastroenterol 94:616–621, 1999
Kahrilas PJ: Treatment versus management of gastroesophageal reflux disease. Am J Gastroenterol 92:1959–1960, 1997
Schenk BE, Kuipers EJ, Klinkenberg-Knoll EC, Festen HPM, Jansen EH, Tuynman HARE, Schrizver M, Dieleman LA, Meuwissen SGM: Omeprazole as a diagnostic tool in gastroesophageal reflux disease. Am J Gastroenterol 92:1997–2000, 1997
Schindlbeck NE, Klauser AG, Voderholzer WA, Muller-Lissner SA: Empiric therapy for gastroesophageal reflux disease. Arch Intern Med 155:1808–1812, 1995
Johnsson F, Solhaug WJ-H, Hernqvist H, Bengtsson L: Oneweek omeprazole treatment in the diagnosis of gastroesophageal reflux disease. Scand J Gastroenterol 33:15–30, 1998
Fass R, Ofman JJ, Gralnek IM, Johnson C, Camargo E, Sampliner RE, Fennerty MB: Clinical and economic assessment of the omeprazole test in patients with symptoms suggestive of gastroesophageal reflux disease. Arch Intern Med 159:2161–2168, 1999
Fass R, Fennerty MB, Ofman JJ, Gralnek IM, Johnson C, Camargo E, Sampliner RE: The clinical and economic value of a short course of omeprazole in patients with noncardiac chest pain. Gastroenterology 115:42–49, 1998
Ofman JJ, Gralnek IM, Udani J, Fennerty MB, Fass R: The cost-effectiveness of the omeprazole test in patients with noncardiac chest pain. Am J Med 107:219–227, 1999
Bate CM, Riley SA, Chapman RW, Durnin AT, Taylor MD: Evaluation of omeprazole as a cost-effective diagnostic test for gastro-oesophageal reflux disease. Aliment Pharmacol Ther 13:59–66, 1999
Richter JE: Cost-effectiveness of testing for gastroesophageal reflux disease: What do patients, physicians, and health insurers want? (Editorial). Am J Med 107:288–289, 1999
Castell DO: Aggressive acid control: minimizing progression of Barrett's esophagus. Am J Manag Care 7:S15–S188, 2001.
Fass R, Sampliner RE, Malagon IB, Hayden CW, Camargo L, Wendel CS, Garewal HS: Failure of oesophageal acid control in candidates for Barrett's oesophagus reversal on a very high dose of proton pump inhibitor. Aliment Pharmacol Ther 14:597–602, 2000
Ortiz A, Martinez de Haro LF, Parrilla P, Molina J, Bermejo J, Munitiz V: 24-h pH monitoring is necessary to assess acid reflux suppression in patients with Barrett's oesophagus undergoing treatment with proton pump inhibitors. Br J Surg 86:1472–1474, 1999
Hewson EG, Dalton CB, Richter JE: Comparison of esophageal manometry, provocative testing and ambulatory monitoring in patients with unexplained chest pain. Dig Dis Sci 35:302–309, 1990
Hewson EG, Sinclair JW, Dalton CB, Richter JE: Twenty four hour esophageal pH monitoring: The most useful test for evaluating noncardiac chest pain. Am J Med 90:576–583, 1991
Janssen J, Vantrappen G, Ghillibert A: 24-hour recording of esophageal pressure and pH in patients with noncardiac chest pain. Gastroenterology 90:1978–1984, 1986
Paterson WG, Abdollah H, Beck IT, Da Costa LR: Ambulatory esophageal manometry, pH metry and Holter ECG monitoring in patients with atypical chest pain. Dig Dis Sci 38:795–802, 1993
Soffer EE, Scalabrini P, Wingate DL: Spontaneous noncardiac chest pain: Value of ambulatory esophageal pH and motility monitoring. Dig Dis Sci 34:1651–1655, 1989
DeCaestaker JS, Blackwell JN, Brown J, Heading LC: The oesophagus as a cause of recurrent chest pain: which patients should be investigated and which tests should be used? Lancet 2:1143–1146, 1985
Singh S, Richter JE, Hdusson EG, Sinclair JW, Hackshaw BT: The contribution of gastroesophageal reflux to chest pain in patients with coronary artery disease. Ann Intern Med 117:824–830, 1992
Achlem SR, Kolts BE, MacMath T, Richter JE, Mohr D, Burton L, Castell DO: Effects of omeprazole vs placebo in treatment of noncardiac chest pain and gastroesophageal reflux. Dig Dis Sci 42:2138–2145, 1997
Ghillebert G, Janssen J, Vantrappen G, Nevens F, Piessens J: Ambulatory 24-hour intraesophageal pH and pressure recordings vs provocative tests in the diagnosis of chest pain of oesophageal origin. Gut 31:738–744, 1990
Richter JE: Ambulatory esophageal pH monitoring. Am J Med 103(5A):130S–134S, 1997
Sontag SJ, Schnell TG, Miller TQ, Khandelwal S, O'Connell S, Chejfec G, Greenlee H, Seidel UJ, Brand L: Prevalence of oesophagitis in asthmatics. Gut 33:872–876, 1992
Sontag SJ, O'Connell S, Khandelwal S, Miller T. Nemchausky B, Schnell TG, Serlovsky R: Effect of positions, eating, and bronchodilators on gastroesophageal reflux in asthmatics. Dig Dis Sci 35:849–856, 1990
Ekstrom T, Tibbling L: Esophageal acid perfusion, airway function, and symptoms in asthmatic patients with marked bronchial hyperreactivity. Chest 96:995–998, 1989
Harding SM, Guzzo MR, Richter JE: 24-h esophageal pH tsting in asthmatics. Respiratory symptom correlation with esophageal acid events. Chest 115:654–659, 1999
Harding SM, Richter JE: The role of gastroesophageal reflux in chronic cough and asthma. Chest 111:1389–1402, 1997
Harding SM, Richter JE, Guzzo MR, Schan CA, Alexander RW, Bradley LA: Asthma and gastroesophageal reflux: acid suppressive therapy improves asthma outcome. Am J Med 100:395–405, 1996
Kiljander TO, Salomaa ERM, Hietanen EK, Terho EO: Gastroesophageal reflux in asthmatics. A double-blind, placebocontrolled crossover study with omeprazole. Chest 116:1257–1264, 1999
O'Connor JFB. Singer ME, Richter JE: The cost-effectiveness of strategies to assess gastroesophageal reflux as an exacerbating factor in asthma. Am J Gastroenterol 94:1472–1480, 1999
McNally MPR, Maydonovitch CL, Prosek RA, Collette CRP, Wong CRKH: Evaluation of gastroesophageal reflux as a cause of idiopathic hoarseness. Dig Dis Sci 34:1900–1904, 1989
Weiner GJ, Kaufman JA, Wu WC, Cooper JB, Richter JE, Castell DO: Chronic hoarseness secondary to gastroesophageal reflux disease: Documentation with 24-hour ambulatory pH monitoring. Am J Gastroenterol 84:1503–1508, 1989
Koufman JA: The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): A clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 101(suppl 53):1–78, 1991
Timon C, O'Dwyer T, Cagney D, Walsh M: A globus pharyngeus: Long-term follow-up and prognostic factors. Ann Otol Rhinol Laryngol 100:351–354, 1991
WO JM, Grist WJ, Gussack G, Delgaudio JM, Waring JP: Empiric trial of high-dose omepraole in patients with posterior laryngitis: A prospective study. Am J Gastroenterol 92:2160–2165, 1997
Irwin RS, Madison JM: Anatomical diagnostic protocol in evaluating chronic cough with specific reference to gastroesophageal reflux disease. Am J Med 108(suppl 4a): 126S–130S, 2000
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Dhiman, R.K., Saraswat, V.A. & Naik, S.R. REVIEW: Ambulatory Esophageal pH Monitoring: Technique, Interpretations, and Clinical Indications. Dig Dis Sci 47, 241–250 (2002). https://doi.org/10.1023/A:1013763616262
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DOI: https://doi.org/10.1023/A:1013763616262