DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Esophageal manometric study and a 48 hour Bravo pH study.
INDICATIONS FOR PROCEDURE: The patient has poorly controlled esophageal heartburn-type symptomatology and studies are being done to try and determine how much acid the patient gets. The patient ran out of Prilosec, omeprazole about 4 days prior to coming in for placement of the Bravo capsule so the initial part of the evaluation was done off of medication.
PROCEDURE FINDINGS: Motility was performed first with no sedation. The lower esophageal sphincter area was in the 42 to 50 cm range and was a fairly quick high pressure zone. The lower esophageal sphincter appeared to relax close to 100% and was in the range of 10 to 14 mmHg. This was seen well on 2 of 3 electrodes. The peristalsis in the body and upper esophagus were evaluated also. Interestingly, on the studies where the lower esophageal sphincter was looked at, the peristalsis did appear to be normal in amplitude and in waveform. This would be the most distal part of the esophagus and was well seen on 2 of the 3 tracings. It did appear to be peristaltic; although, there were occasional simultaneous waves and occasionally some low amplitude contractions too. In the body of the esophagus, one peristalsis was studied directly. There are some peristaltic waves, which are normal amplitude, being about 50 to 60 mmHg and peristaltic. However, most of the waves seem to be fairly low amplitude in the range of about 15 mmHg, but again generally peristaltic. Some of these occurred with dry swallows and some of them were low amplitude with wet swallows, but the patient clearly does have the ability to generate some waves, which are adequate and deepen in the range of 150 mmHg with some normal waveforms with wet swallows. We suspect that in general the peristalsis is probably okay. Reviewing the tracings in the body, the patient does not really get up to 150 mmHg, but there are some tracings where the patient does get up close to 100. For the most part, however, the amplitude is fairly low.
The Bravo capsule study was done with the patient partly on 20 mg b.i.d. of the omeprazole; although, the patient started this after the Bravo was placed and was certainly off it in the beginning.
On day 1, the patient’s DeMeester score was 62 with a normal of less than 14.7. There were multiple episodes of reflux, 115 in fact, and the longest duration was 21 minutes. This occluded some significant areas, time frames when his pH was less than 4 at nighttime. There were episodes of heartburn recorded and these in general correlated pretty well with the pH less than 4; although, there were occasional times when the pH was above 4 and he still complained of heartburn.
On day 2, the DeMeester score was 56 so really not that of an improvement. He had 115 episodes of reflux with the longest duration being 7 minutes at that point. Again, there was fairly good correlation with heartburn and decreased pH below 4 and he had regurgitation, which generally tended to correlate fairly well too with the pH less than 4.
The patient clearly has significant reflux off medications and whether it improves much on medications is unclear from the study. Motility study does not reveal any gross abnormalities. There is some decreased peristaltic intensity in the mid part of the esophagus, but the patient is able to generate fairly good peristaltic waves and lower esophageal sphincter seems to work normally, so it does appear as though in general, the patient’s esophagus probably works okay.
