D0217 - Role of 24 Hours Ambulatory pH Impedance Study and High Resolution Manometry in Patients With PPI Refractory Non-Erosive Reflux Disease

Introduction: Refractory GERD is a common problem faced by a gastroenterologist. Understanding the cause of treatment refractory GERD helps in guiding the further course of treatment. We aim to study the physiological basis of patients with refractory non-erosive reflux disease and classify these patients based on findings of 24 hour ambulatory pH Impedance monitoring and high resolution manometry (HRM).

Methods: This is a single centre prospective study from March, 2019 to August, 2020 in which clinical profile and data of pH impedance studies and HRM was analysed in patients on PPI with refractory non-erosive GERD. Refractory GERD was defined as persistence of heartburn or regurgitation atleast once a week after receiving standard dose of PPI for atleast 8 weeks. Patients on NSAIDs, pregnant females, patients with organic disease of the upper digestive tract or previous upper digestive tract surgery, significant comorbidities like decompensated chronic liver disease, chronic kidney disease, poorly controlled diabetes mellitus or any malignancy were excluded.

Results: 151 patients with refractory GERD were analysed of which, 48 had abnormal esophagogastroduodenoscopy and 103 were non-erosive GERD. Amongst, non-erosive disease, acid reflux disease was found in 29.1%, non-acidic reflux disease in 21.4%, 30.1% patients had reflux hypersensitivity whereas, 19.4% patients had functional heartburn. On HRM, 8.74% had esophageal motility disorders, most commonly being IEM in 5.82% patients followed by EGJ obstruction in 1.94% and absent contractility in 0.97%. 25.2% had hiatus hernia; 20.4% patients had type II EGJ morphology, 2.9% had type IIIa and 1.9% had type IIIb EGJ morphology.

Discussion: True acid reflux disease was found in less than 1/3^rd refractory non-erosive GERD patients only and around 50% patients had functional esophageal disorder as found on pH impedance studies. Majority patients have normal esophageal motility but 1/4^th have abnormal EGJ morphology.