P1347 - Diagnostic Accuracy of the Proton Pump Inhibitor Test in Patients With Gastroesophageal Reflux Disease and Non-Cardiac Chest Pain: A Systematic Review and Meta-Analysis

Monday, October 25, 2021

10:30 AM – 4:15 PM PT

Location: Shoreline Exhibit Hall

Presenting Author(s)

Sara Ghoneim, MD

University of Nebraska Medical Center
Omaha, NE, United States

Sara Ghoneim, MD¹, Nabil El Hage Chehade, MD², Jiasheng Wang, MD², Stephen Ganocy, PhD³, Ehsan Chitsaz, MD², Ronnie Fass, MD⁴
¹University of Nebraska Medical Center, Omaha, NE; ²MetroHealth Medical Center, Cleveland, OH; ³University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH; ⁴Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH

Introduction: Symptomatic response to PPIs remains a popular approach to diagnosing gastroesophageal reflux disease (GERD). Meta-analyses of the “PPI test” diagnostic performance are limited and out-of-date. We conducted a comprehensive systematic review and meta-analysis to examine the diagnostic accuracy of the PPI test in GERD and non-cardiac chest pain (NCCP).

Methods: Web of Science, Cochrane Controlled Register of Trials [CENTRAL] and MEDLINE were searched for studies reporting the diagnostic accuracy of the PPI test in adult patients with typical GERD and NCCP who underwent evaluation using an accepted reference standard from January 1^st, 1950 through February 1^st, 2021. Subgroup analyses were performed based on study design. Summary estimates of sensitivity, specificity, diagnostic odds (DOR), positive and negative likelihood ratios (LR) for the PPI test were determined using bivariate random effects model. All tests were two sided; P< 0.05 was considered statistically significant. The area under the receiver operating characteristic curve (AUC) was calculated. Heterogeneity was assessed by the Paule-Mandel tau square (τ²), I²index, and Cochran’s Q test. Risk of bias assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

Results: Nineteen studies (GERD= 11, NCCP= 8) were included involving 1,691 patients. In GERD, the PPI test had 79% pooled sensitivity (95% CI, 72.4%-84%; I²= 59%, P= 0.14), and 45% pooled specificity (95% CI, 40%-49%; I²= 0%). Overall DOR, positive LR and negative LR were 2.30 (95% CI, 1.78-3.0, I²= 0), 1.36 (95% CI, 1.15-1.60), and 0.54 (95% CI, 0.4-0.74), respectively. In NCCP, the pooled sensitivity and specificity were 79% (95% CI, 69%-86%; I²= 29%, P= 0.23) and 79% (95% CI, 69%-86%; I²= 22% P= 0.28), respectively. Overall DOR, positive LR, and negative LR were: 17.27 (95% CI, 8.84-33.71; I²=0%), 3.91 (95% CI, 2.60-5.89) and 0.26 (95% CI, 0.17-0.39), respectively. The AUC was 0.62 and 0.85 in GERD and NCCP, respectively.

Discussion: The PPI test was highly accurate in GERD-related NCCP, sensitive in typical GERD but with suboptimal specificity.

Figure: Figure 1. Forest plots of PPI test pooled estimates of (A) sensitivity and (B) specificity in GERD and NCCP. Abbreviations: PPI, proton pump inhibitor; GERD, gastroesophageal reflux disease; NCCP, non-cardiac chest pain; CI, confidence interval; RCT, randomized clinical trials.

Study	Country	No. Centers	Date of study	Sample Size for analysis	Average age (Years)	Gender distribution (M/F)	Reference standard	PPI dose	Indication	Duration
Randomized Controlled Trial
Schenk et al. 1997	Netherlands	Multi-center	July 1993-July 1994	85	Omeprazole: 49 Placebo: 49	33/52	pH-metry Endoscopy	Omeprazole 40 mg daily	GERD	2 weeks
Johnsson et al. 1998	Denmark Norway Sweden	Multi-center	NA	159	N/A	N/A	pH-metry Endoscopy	Omeprazole 20 mg BID	GERD	2 weeks
Fass et al. 1998	United States	Single center	January 1996- December 1996	39	GERD: 58.2 Non-GERD: 61.6	38/1	pH-metry Endoscopy	Omeprazole 40 mg AM 20 mg before dinner	NCCP	1 week
Fass et al. 1999	United States	Single center	January 1^st, 1996- December 31^st 1996	42	GERD: 55 Non-GERD: 56.4	32/10	pH-metry Endoscopy	Omeprazole 40 mg AM 20 mg before dinner	GERD	1 week
Juul-Hansen et al. 2001	Norway	Single center	NA	64	54	20/44	pH-metry Endoscopy	Lansoprazole 60 mg daily	GERD	5 days
Pandak et al. 2002	United States	Single center	May 1997- August 1999	37	NA	NA	pH-metry Endoscopy	Omeprazole 40 BID	NCCP	2 weeks
Xia et al. 2003	China	Single center	November 1998- February 2000	68	Lansoprazole: 59.6 Placebo: 56.6	26/42	pH-metry	Lansoprazole 30 mg daily	NCCP	4 weeks
Bautista et al. 2004	United States	Single center	NA	40	GERD: 52.1 Non-GERD: 56.3	31/9	pH-metry Endoscopy	Lansoprazole 60 mg AM 30 mg at bedtime	NCCP	1 week
Dickman et al. 2005	United States	Single center	NA	35	GERD: 55 Non-GERD: 55	23/12	pH-metry Endoscopy	Rabeprazole 20 mg BID	NCCP	1 week
De Varannes et al. 2006	France	Multi-center	NA	72	Rabeprazole: 49.1 Placebo: 47.1	29/43	pH-metry Endoscopy	Rabeprazole 20 mg BID	GERD	1 week
Open label Trials
Bate et al. 1999	United Kingdom	Multi-center	NA	69	47.4	38/31	pH-metry Endoscopy	Omeprazole 40 daily	GERD	1 week
Fass et al. 2000	United States	Single center	NA	35	55	33/2	pH-metry Endoscopy	Omeprazole 40 mg AM 20 mg before dinner	GERD	1 week
Hauman et al. 2004	Spain	Single center	October 2011- September 2012	30	GERD: 50 Non-GERD: 45	17/13	pH-metry Endoscopy	Pantoprazole 40 mg BID	NCCP	4 weeks
Troche et al. 2005	Mexico	Single center	NA	64	39.3	17/47	pH-metry Endoscopy	Rabeprazole 20 mg BID	GERD	1 week
Aanen et al. 2006	Netherlands	Single center	2003-2005	74	NA	NA	pH-metry	Esomeprazole 40 mg daily	GERD	2 weeks
Zheng et al. 2008	China	Single center	April 2007-October 2007	27	GERD: 57 Non-GERD: 57	8/19	pH-metry Endoscopy	Esomeprazole 20 mg BID	NCCP	2 weeks
Kim et al. 2009	Korea	Single center	January 2005-December 2006	42	GERD: 53.8 Non-GERD: 53.9	24/18	pH-metry Endoscopy	Rabeprazole 20 mg BID	NCCP	2 weeks
Cho et al. 2010	Korea	Single center	NA	73	47	40/37	pH-metry Endoscopy	Lansoprazole 30 mg BID	GERD	2 weeks
Zhou et al. 2010	China	Single center	2011-2012	636	49.3	371/265	pH-metry Endoscopy	Esomeprazole 20 mg BID	GERD	2 weeks

Table: Characteristics of Included Studies. Abbreviations: GERD, gastroesophageal reflux disease; NCCP: non-cardiac chest pain; BID, twice daily; NA, not available; PPI, proton pump inhibitor.

Disclosures:
Sara Ghoneim indicated no relevant financial relationships.
Nabil El Hage Chehade indicated no relevant financial relationships.
Jiasheng Wang indicated no relevant financial relationships.
Stephen Ganocy indicated no relevant financial relationships.
Ehsan Chitsaz indicated no relevant financial relationships.
Ronnie Fass indicated no relevant financial relationships.

Sara Ghoneim, MD¹, Nabil El Hage Chehade, MD², Jiasheng Wang, MD², Stephen Ganocy, PhD³, Ehsan Chitsaz, MD², Ronnie Fass, MD⁴. P1347 - Diagnostic Accuracy of the Proton Pump Inhibitor Test in Patients With Gastroesophageal Reflux Disease and Non-Cardiac Chest Pain: A Systematic Review and Meta-Analysis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.