Model to Select On-Therapy vs Off-Therapy Tests for Patients With Refractory Esophageal or Extraesophageal Symptoms.

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Adult; Antacids; Asthma; Cough; Esophageal pH Monitoring; Female; Gastroesophageal Reflux; Heartburn; Hoarseness; Humans; Hydrogen-Ion Concentration; Logistic Models; Male; Middle Aged; Point-of-Care Testing; Predictive Value of Tests; Prospective Studies; Proton Pump Inhibitors; Risk Factors; Symptom Assessment; Treatment Failure; Body Mass Index; Gastroesophageal Reflux Disease; Heartburn, Asthma, and BMI Extraesophageal Reflux (HAs-BEER); Proton Pump Inhibitor


BACKGROUND & AIMS: It is not clear whether we should test for reflux in patients with refractory heartburn or extraesophageal reflux (EER) symptoms, such as cough, hoarseness, or asthma. Guidelines recommend testing patients by pH monitoring when they are on or off acid-suppressive therapies based on pretest probability of reflux, determined by expert consensus. However, it is not clear what constitutes a low or high pretest probability of reflux in these patients. We aimed to develop a model that clinicians can use at bedside to estimate pretest probability of abnormal reflux.

METHODS: We performed a prospective study of 471 adult patients with refractory heartburn (n = 214) or suspected EER symptoms (n = 257) who underwent endoscopy with wireless pH monitoring while they were off acid-suppressive treatment and assigned them to groups based on symptoms at presentation (discovery cohort). Using data from the discovery cohort, we performed proportional odds ordinal logistic regression to select factors (easy to obtain demographic criteria and clinical symptoms such as heartburn, regurgitation, asthma, cough, and hoarseness) associated with esophageal exposure to acid. We validated our findings in a cohort of 118 patients with the same features from 2 separate tertiary care centers (62% women; median age 59 years; 62% with cough as presenting symptom).

RESULTS: Abnormal pH (>5.5% of time spent at pH25 kg/m

CONCLUSION: We developed a clinical model to estimate pretest probability of abnormal pH in patients who were failed by proton pump inhibitor therapy. This system can help guide clinicians at bedside in determining the most appropriate diagnostic test in this challenging group of patients.

Clinical Institute

Digestive Health