Dual Ambulatory pH Monitoring in Patients with Gastroesophageal Reflux Rendered Asymptomatic with Proton Pump Inhibitor Therapy

Studies have suggested that proton pump inhibitor (PPI) therapy in gastroesophageal reflux disease (GERD) achieves high rates of esophageal acid normalization.

Our aims were to investigate the adequacy of esophageal and gastric acid suppression in reflux patients rendered asymptomatic on optimized PPI therapy.

We retrospectively analyzed outcomes of dual-sensor, ambulatory 24-h pH monitoring in referred persistent reflux patients rendered asymptomatic on PPI therapy. After optimization, we analyzed esophageal and gastric pH profiles to assess acid suppression and examine differences between PPIs. In patients with repeat studies, comparisons between different PPI doses were made.

Of 172 asymptomatic GERD patients, 75 (43.6 %) achieved symptomatic remission with once-daily dosing PPI, and 97 (56.4 %) patients required twice-daily dosing. Of the entire cohort, 93 (54.1 %) had abnormal and 79 (45.9 %) had normal esophageal pH profiles, with mean percent time pH < 4.0 of 14.3 and 2.4, respectively (p < 0.0001). The percent time esophageal pH was abnormal did not correlate with the percent time gastric pH was abnormal (p = 0.17). Different PPI formulations demonstrated differences in gastric—not esophageal—pH times, with esomeprazole exhibiting superior gastric pH suppression (p < 0.0001). Overall, gastric pH control remained suboptimal, with pH < 4.0 ranging between 30 and 50 %. Among patients with sequential pH studies, those with higher PPI dose had improved esophageal pH profiles (p < 0.01).

In GERD patients rendered asymptomatic on PPI therapy, most continue to experience abnormal esophageal and gastric acid exposure. The efficacy of acid suppression therapy, in certain patients, may be much lower than previously thought.