P1374 - Impact of Porto Consensus on Ambulatory Reflux Testing on Acid Suppression

Monday, October 25, 2021

10:30 AM – 4:15 PM PT

Location: Shoreline Exhibit Hall

Has Audio

Presenting Author(s)

Sitharthan Sekar, MD

Duke University Medical Center
Durham, NC, United States

Sitharthan Sekar, MD¹, Shai Posner, MD¹, Claire Dorsey, MD¹, David Leiman, MD, MSHP²
¹Duke University Medical Center, Durham, NC; ²Duke Clinical Research Institute, Durham, NC

Introduction: Many patients with gastroesophageal reflux disease (GERD) symptoms that do not respond to therapy with proton pump inhibitors (PPIs) undergo formal esophageal testing. According to the 2017 Porto consensus recommendations, patients lacking a previous GERD diagnosis should undergo ambulatory reflux testing off PPI therapy to increase diagnostic yield. We aimed to determine the frequency with which multichannel intraluminal impedance pH (MII-pH) testing is performed concordant with these recommendations and to examine factors associated with discordant ordering patterns.

Methods: A retrospective study of consecutive patients who underwent ambulatory MII-pH testing between 2016-2018 was performed. Patients with major motility disorders per Chicago Classification 3.0 or prior anti-reflux surgery were excluded. Clinicodemographic data were extracted from the electronic health record. Appropriate statistical tests were used to assess for clinical factors affecting concordance of studies with the Porto consensus.

Results: There were 596 patients with MII-pH testing during the study period, including 433 subsequent to the Porto consensus publication. Of patients undergoing testing after the Porto consensus, 134 (30.9%) were on PPI. The average age of patients tested after Porto publication, i.e., between 2017 and 2018, was 56 and most (60%) were women. Among these, 84% were performed outside of Porto recommendations with no documented GERD diagnosis. Surprisingly, the overall proportion of tests performed on PPI in patients without a prior diagnosis of GERD increased after the publication of Porto (Figure 1). Between patients who had Porto concordant and discordant testing, there was no significant difference in patient clinical characteristics (Table 1), practitioner type (p = 0.21), or total acid exposure time (AET) (2.1% and 1.7% respectively, p=0.61). Of those tested on PPI discordant with Porto, 85% had physiologic AET on testing yet 80% were continued on their current therapy.

Discussion: Ambulatory reflux testing should be performed on PPI therapy only if a GERD diagnosis is established. However, most patients appear to undergo MII-pH on therapy outside consensus recommendations, which results in limited clinical modifications as a result of testing.

Figure: Figure 1. Percentage of multichannel intraluminal impedance pH testing performed on proton pump inhibitor (PPI) therapy without a prior diagnosis of gastroesophageal reflux disease (GERD) before and after the Porto consensus in 2017. n for each year represents total tests performed on PPI at a tertiary academic medical center. Proportions were compared with a chi-square test of multiple proportions (chi-square= 2.83, df = 2, p=0.27).

	Concordant with Porto (n = 22, 16.4%)	Discordant with Porto (n = 112, 83.6%)	p-value
Baseline Characteristics
Age, mean ± SD	56.1 ± 13.1	55.9 ± 14.1	0.95
BMI, mean ± SD	31.3 ± 5.9	30.2 ± 8.1	0.55
Male, n (%)	10 (45.5%)	44 (41.5%)	0.73
Hiatal hernia present, n (%)	8 (36.4%)	43 (40.6%)	0.71
PPI dosing BID, n (%)	12 (54.6%)	81 (72.3%)	0.14

pH-Impedance Results
Elevated AET ( >6%), n (%)	2 (9.1%)	11 (9.8%)	0.91
Borderline AET (4-6%), n (%)	1 (4.5%)	6 (5.4%)	0.87
Physiologic AET (< 4%), n (%)	19 (86.4%)	95 (84.8%)	0.85
SI Positive ( >50%), n (%)	3 (13.6%)	24 (21.4%)	0.41
Reflux episodes, mean ± SD	30.1± 27.2	26.0± 20.8	0.43
DeMeester Score, mean ± SD	10.3± 21.0	9.4 ± 19.7	0.84
Total AET, mean ± SD	2.1± 4.1	1.7± 3.2	0.61
Upright AET, mean ± SD	1.8 ± 3.8	1.6± 3.2	0.79
Supine AET, mean ± SD	2.4± 5.7	1.9± 5.7	0.71

Management Approach
Taken off therapy, n (%)	4 (18.1%)	10 (8.9%)	0.14
Continued current therapy, n (%)	14 (63.6%)	89 (79.5%)	0.11
Increased acid suppression, n (%)	1 (4.5%)	5 (4.5%)	0.98
PPI brand changed, n (%)	3 (13.6%)	8 (7.1%)	0.31
Referred for ARS, n (%)	5 (22.7%)	10 (8.9%)	0.06
Trialed on neuromodulator, n (%)	5 (22.7%)	13 (11.6%)	0.16

Table: Table 1. Clinicodemographic data and testing results for multichannel intraluminal impedance pH testing performed on proton pump therapy with (concordant) versus without (disconcordant) a prior diagnosis of gastroesophageal reflux disease (GERD) after publication of Porto consensus recommendations from 2017-2018. Means and proportions were compared with a two-tailed two sample t test.

AET: acid exposure time; SI: symptom index
ARS: anti-reflux surgery
PPI: proton pump inhibitor
SD: Standard Deviation
BMI: Body Mass Index
BID dosing compared to once daily PPI dosing

Disclosures:

Sitharthan Sekar indicated no relevant financial relationships.

Shai Posner indicated no relevant financial relationships.

Claire Dorsey indicated no relevant financial relationships.

David Leiman: Medtronic – Consultant.

Sitharthan Sekar, MD¹, Shai Posner, MD¹, Claire Dorsey, MD¹, David Leiman, MD, MSHP². P1374 - Impact of Porto Consensus on Ambulatory Reflux Testing on Acid Suppression, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.