Tag Archives: pH-impedance

#5000: Simple Rule for Deciding When pH Impedance Testing Should Be Done While on Therapy

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Editor’s note: This is the 5000th post on this blog! The first post was on December 7th, 2011.

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CP Gyawali et al. Clin Gastroenterol Hepatol 2025; 23: 2459-2467. Open Access! pH Impedance Monitoring on Proton Pump Inhibitor Therapy Impacts Management Decisions in Proven GERD but Not in Unproven GERD

Methods: Prospective 2-center study enrolled adult patients (n=79) with typical reflux symptoms with incomplete PPI response; they were studied both off PPI (wireless pH monitoring) and on PPI (pH-impedance monitoring)

Key findings:

  •  In 60 patients with proven GERD off-PPI, 56.7% had no ongoing GERD on PPI (despite reflux symptoms)
  • In unproven GERD, pH-impedance monitoring on acid suppressive therapy is unable to differentiate non-GERD symptoms from controlled GERD in the majority of patients, or identify patients who could benefit from discontinuation of acid suppression

Discussion points:

  • “Only a small proportion of PPI nonresponders have true GERD, and most have either no GERD or overlap between inconclusive GERD and a non-GERD process such as an esophageal disorder of gut-brain interaction (E-DGBI).10,11“
  • “On-therapy pH-impedance monitoring can identify refractory GERD in patients with previously proven GERD.”
  • “Definitive GERD evidence and persisting symptoms despite optimized PPI therapy is an indication for escalation of management.20… potassium competitive acid blockers provide better healing of advanced grade esophagitis21 as well as faster symptom response in nonerosive reflux disease,22,23 and could be an option”

My take:

  1. Simple rule: Only perform on-therapy pH-impedance monitoring in patients with proven GERD
  2. Many patients with GERD symptoms do not have GERD (see posts below)
  3. In patients with documented GERD, on therapy pH monitoring can be helpful in proving refractory GERD which may benefit from alternative treatments

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Does Reflux Really Worsen After Gastrostomy Placement in Children?

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A recent prospective longitudinal cohort study (J Franken et al. JPGN 2020; 70: e41-47) examined the development of gastroesophageal reflux (GER) in 50 children  who underwent gastrostomy tube (GT) placement between 2012-2014.

Key findings:

  • GER symptoms were present before and after GT placement: in 44% and 40% respectively.

Among the 25 who underwent pre- and post-operative impedance-pH analysis

  • there was not a significant change in acid exposure: 6.2% vs. 6.1%
  • there was not a significant change in reflux episodes
  • Prior to GT placement, 18 of 25 (72%) had pathologic reflux.  Afterwards, 18 of 25 (72%) had pathologic reflux –though this included 4 with new onset reflux and 4 with resolved reflux

My take: This study shows that reflux symptoms and documented reflux are commonplace in children undergoing GT placement.  Based on this limited sample size, it appears that GER does not appreciably change following GT placement.

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How helpful is a pH-Impedance Study in Identifying Reflux-Induced Symptoms?

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In both kids and adults, individuals presenting with complaints of reflux more often have other problems like functional heartburn or reflux hypersensitivity (see posts below).  A recent prospective, cross-sectional study (LB Mahoney et al. JPGN 2020; 70: 31-36) provides data that further shows that abnormal pH-impedance (pH-MII) testing does NOT predict reduced quality of life (QOL) in children with reflux symptoms (n=82).

Key findings:

  • 38% had abnormal pH-MII testing; however, there were no significant differences in QOL scores on any of the tested questionairres between those with normal or abnormal pH-MII studies.
  • Subjects with gross esophagitis on EGD reported significantly worse QOL scores. Microscopic esophagitis was not associate with differences in QOL scores.

The implication of this study is that reflux without esophagitis is NOT a driver of abnormal QOL parameters; instead, functional GI disorders are likely more important.

My take: This study makes it clear that gross endoscopic findings are much more consequential than abnormal pH-MII studies.

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