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Background: Oesophageal manometry is the gold standard for accurate positioning of multichannel intraluminal impedance pH (MII-pH) monitoring. The pH step-up method is not as accurate as oesophageal manometry and needs patients to be off proton pump inhibitor (PPI) therapy., Objective: This study aimed to evaluate the feasibility of the impedance step-up method for lower oesophageal sphincter (LOS) localisation., Methods: A total of 100 patients who underwent 24-hour MII-pH monitoring were enrolled. High-resolution manometry (HRM) was performed before MII-pH monitoring in order to locate the LOS by a different operator. The impedance step-up was defined as an increase of ≥50% with respect to gastric baseline. Lin's concordance correlation coefficient ( ρ c ) with 95% Bland-Altman limits of agreement (LOA) and Spearman's rho correlation coefficient were used when appropriate., Results: The median impedance step-up was on average 0.8 cm caudal to the manometric upper border of the LOS. Agreement between two step-up impedance performances and inter-observer agreement were excellent ( ρ c  = 0.98 and 0.95), although the LOA ranges were wide (-2.4 to 4.0 cm). Impedance step-up performances were similar between patients off and on PPI., Conclusions: We have described an alternative new method for pH impedance probe positioning using impedance step-up. Although less accurate than HRM in locating the LOS, it has excellent intra- and inter-observer agreement., (© Author(s) 2019.)

Standard tests in clinical practice commonly fail to demonstrate a clear esophageal etiology for symptoms such as heartburn, dysphagia, or chest pain. Over the years, various provocative measures have been developed to provide a better understanding of the origins of such symptoms. Some measures, such as esophageal acid infusion or changing bolus consistency, can be easily incorporated into clinical practice. Others, such as multimodal stimulation systems, are more technically demanding. They have contributed to a better understanding of esophageal physiology in health and disease. Their role in clinical decision making is still evolving. This focused review provides a summary of the esophageal nociceptive pathways and how provocative testing can be used to interrogate their integrity., (© 2016 New York Academy of Sciences.)

Background: Patients with chronic autoimmune atrophic gastritis (CAAG) often refer digestive symptoms and are prescribed antisecretory medications. Aims were to investigate: (i) gastro-esophageal reflux (GER), (ii) psychopathological profile, (iii) frequency of use and clinical benefit of antisecretory drugs., Methods: Prospective observational study on 41 CAAG patients who underwent: 24 h multichannel intra-luminal impedance-pH (MII-pH) monitoring off-therapy, standardized medical interview and psychological questionnaire (i.e., SCL-90R). The medical interview was repeated at least 1 month after MII-pH in patients who were using antisecretory drugs. Statistical analysis was performed calculating median (10th-90th percentiles) and risk ratios (RR) with 95% confidence interval., Key Results: Median intra-gastric pH was 6.2 (4.6-7.0). One patient had acid reflux (AC) associated with symptoms, five had increased total reflux number and four had symptoms associated to non-acid reflux (NA) (patients referred as 'GER positive'). Using patients 'GER negative' with normal SCL-90R as reference, the RR of being symptomatic in patients GER positive was 2.1 (1.1-4.1) if SCL-90R was normal and 0.9 (0.5-1.7) if it was altered (difference in RR significant being p = 0.04). Seventeen/28 (61%) symptomatic patients were on antisecretory drugs, which were stopped in 16 of them according to results of MII-pH and clinical evaluation after 574 days (48-796) showed that symptoms were unchanged., Conclusions & Inferences: In patients with CAAG (i) AC reflux rarely occurred whereas increased NA reflux was not infrequent both being related to symptoms in some patients, (ii) psychopathological profile has a role in symptoms' occurrence, (iii) antisecretory drugs were generally inappropriately used and clinically ineffective., (© 2015 John Wiley & Sons Ltd.)

Abstract: Background: Multiple rapid swallows (MRS) is a provocative test for assessment of contraction reserve, however reproducibility on repetitive MRS is incompletely understood. Our aim was to determine the optimal number of MRS sequences for consistent assessment of contraction reserve. Methods: One hundred and fifty‐nine consecutive patients (79 IEM and 80 normal motility) who underwent high‐resolution manometers were enrolled. Ten single swallows (SS) and 10 MRS were performed. Gold standard for evaluation of the contraction reserve was the ratio between the mean DCI of 10 MRS and the mean DCI of 10 SS (MRS/SS DCI ratio). Rates of false negatives and false positives were calculated for increasing numbers of MRS sequences, using either mean DCI or the MRS with the highest DCI. Key Results: According to the gold standard, 50 IEM and 50 normal motility patients had contraction reserve. With progressively increasing numbers of MRS sequences, contraction reserve was detected using mean MRS DCI within three and four MRS sequences in IEM and normal motility respectively, whereas two and three MRS sequences were needed using the MRS sequence with the highest DCI. False positives were much higher with highest DCI method compared with mean DCI, (22% vs 9% respectively in IEM; 24% vs 9% in normal motility) when three MRS sequences were considered. Conclusions & Inferences: At least three MRS are needed to reliably assess contraction reserve. The mean DCI of the three MRS sequences is the best variable to utilize as evidence of contraction reserve. [ABSTRACT FROM AUTHOR]