Sa1301 Prolonged pH Monitoring With BRAVO Capsule for 96hrs Off/On PPIs Identifies Patients That Could Benefit From More Aggressive Treatment With Acid Suppression

Background: High-resolution manometry (HRM) utilizes peristaltic sequences from 10 wet swallows to assess distal contractile integral (DCI) for the motor diagnosis of ineffective esophageal motility (IEM).EGJ contractile integral (EGJ-CI) is a novel metric assessing EGJ barrier function.While both IEM and low EGJ-CI are recognized factors predicting esophageal reflux burden, the precise interrelationship between the two remains unclear.Methods: HRM and ambulatory pH monitoring performed off antisecretory therapy were reviewed from 188 patients (55.2 ±0.9 yr, 64% F) undergoing evaluation for persisting reflux symptoms (53.2% heartburn, 12.2% chest pain, 5.9% regurgitation).DCI values were recorded for individual swallows; EGJ-CI (mmHg.cm)was also measured using standard technique.Diagnosis of IEM required ‡50% swallows with DCI<450 mmHg.cm.s (Chicago Classification v3.0).Univariate and multivariate analyses were performed to assess the utility of IEM and low EGJ-CI (<46.2mmHg.cm),both separately and in conjunction, in predicting elevation in esophageal acid exposure time (AET).Results: Of the study cohort, 47 (25.0%) had IEM by CC 3.0 definition, 24 (51.1%) of whom had an abnormal total AET ( ‡4.0%).IEM as defined did not segregate patients with abnormal total AET (6.4 ±1.2% with IEM, 5.0 ± 0.4% without IEM, p=0.2), even at 100% ineffective sequences (mean AET 9.4±2.8%with 100% ineffective sequences, 5.0±0.4% without, p=0.15).EGJ-CI could segregate those with abnormal total and supine AET using a threshold value of 46.2 mmHg.cm,but performance characteristics were modest (sensitivity 68.9%, specificity 55.1%).When EGJ-CI and proportion of ineffective sequences were combined, the discriminative value improved substantially.Mean total AET increased as proportions of ineffective sequences increased (Table ); proportions with abnormal AET ranged 46-56% (Table ).Even at 30% ineffective sequences, odds ratio (OR) for abnormal AET was 2.6 (95% CI 1.2-5.8,p=0.02).At 50% ineffective sequences (IEM), OR was 2.5 (95% CI 1.1-5.9,p=0.03) with improved specificity (75.4%) albeit low sensitivity (45.0%).The impact of combined low EGJ-CI and ineffective sequences was most profound for supine AET assessment.Proportions with elevated supine AET steadily increased as proportions of ineffective sequences increased (range 37-60%, Table ).At 30% ineffective sequences, OR for abnormal supine AET was 2.7 (95% CI 1.1-6.6,p=0.03), which increased to OR 7.4 (95% CI 1.8-29.9,p=0.005) at 100% ineffective sequences.Conclusions: Low EGJ-CI and increasing proportions of ineffective esophageal body contraction sequences together predict abnormal esophageal acid burden better than either metric alone.Prediction of abnormal supine AET was significantly better than total AET, consistent with the role of a disrupted EGJ barrier in abnormal supine reflux burden.Ineffective Esophageal Body Peristalsis in Conjunction with Low EGJ-CI (<46.2 mmHg.cm)