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The role of advanced technology in the assessment of oesophageal function in health and disease

Introduction In the absence of disease on endoscopy and failure to respond to empirical therapy, guidelines recommend manometry and reflux studies; however these investigations often fail to establish the physiological basis of oesophageal symptoms or guide therapy. Advances in technology may help provide insight into oesophageal function in health and disease and in turn direct management. The aim of this thesis was to explore the impact of introducing novel techniques and methodology through High Resolution Manometry (HRM) and prolonged wireless pH monitoring (Bravo). Methods: Bravo Study 1: 110 patients who successfully completed standard catheter-based pH monitoring (C-pH) were compared with 134 patients who failed the study and progressed to 48 hour Bravo. The total reflux time (TR; total % time pH drops below 4) was used as the diagnostic marker of reflux disease. Visceral sensitivity was assessed by Symptom Index (SI) and tolerability was measured with a questionnaire. Study 2: 38 patients who continued to have symptoms of reflux despite negative results with C-pH progressed to prolonged Bravo. ‘Worst day’ and ‘Average cumulative’ 24, 48, 72 and 96 hour Bravo measurements were compared to standard 24 hour C-pH. High Resolution Manometry (HRM) 23 asymptomatic volunteers who underwent HRM were compared to 18 patients presenting with oesophageal symptoms. Measurements of swallow responses were collected by varying workload on the oesophagus (changing bolus volume, consistency and patient position). Normative values from healthy subjects were formulated and were used to investigate patients. A novel dysmotility-symptom association parameter (Dysfunction Symptom Index; D-SI) was formulated. Clinical outcome and final diagnosis were documented at 2 years. Results Bravo Study 1: 76% of patients had a pathological TR on day 1 or 2 compared to 49% of C-pH (p<0.01). There was no difference in SI (p=0.28). A questionnaire demonstrated a preference for Bravo with reduced restriction, discomfort and dysphagia. Study 2: Using ‘Average’ and ‘Worst-day’ analysis, 61% and 76% patients were diagnosed with reflux disease based on either pathological acid exposure or reflux-symptom association at 96 hours. Of 12 patients who underwent anti-reflux surgery, 10 (83%) reported a good outcome at 2 years. HRM In health contractility and coordination improved with increased workload; from upright to supine and single liquid to solid swallows. Inter-observer agreement was high and normal values were formulated. Compared to healthy subjects, meal consumption was associated with more ineffective swallows in patients (28% vs. 51%; p<0.001). No symptoms occurred with single water swallows. With the test meal 50% of patients exhibited symptoms and 75% of these had a pathological D-SI. Furthermore, compared to water alone, 67% patients had a manometric change in diagnosis during the test meal. 2 year follow-up studies suggest that these techniques may help guide management Conclusion Bravo Tolerance, satisfaction and diagnostic yield was high in those who underwent Bravo. Prolonged pH measurement also increased the diagnostic yield in patients in whom an initial catheter study was negative. HRM The introduction of novel metrics and a protocol that mimics normal eating and drinking was more likely to identify the culprit dysmotility and associate these with symptoms. In summary, these studies advance the utility of modern technology in oesophageal testing and appear to guide clinical management.
Date January 2013
CreatorsSweis, Rami
PublisherKing's College London (University of London)
Source SetsEthos UK
Detected LanguageEnglish
TypeElectronic Thesis or Dissertation

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