Role of Intraluminal Esophageal Impedance Baseline in the Diagnosis of Esophagitis in Children

Abstract

Introduction Low values of esophageal impedance baseline (EIB) have been related to esophagitis. The aim of this study was to evaluate the diagnostic performance of EIB for erosive esophagitis (ErE) and histological esophagitis (HiE) in children studied for gastroesophageal reflux.

Material and Methods Children who underwent esophageal multichannel intraluminal impedance-pH monitoring (MII-pH) and upper-endoscopy with esophageal biopsies were studied retrospectively. EIB values were obtained by MII-pH. ErE was assessed by endoscopy following the Hetzel-Dent classification; HiE was defined by basal zone hyperplasia, papillary lengthening, or inflammatory infiltration. EIB was compared between groups. Receiver operating characteristic (ROC) curves were obtained to calculate the global diagnostic performance of EIB and to find cut-off values for sensitivity and specificity. Logistic regression was used for age adjustment.

Results Fifty-one patients were studied: 11 had ErE and 23 had HiE. EIB median values were 1,159 in ErE versus 2,583 in non-ErE (U = 80, p < 0.01). The adjusted ROC curve analysis for ErE was 0.85 (95% CI = 0.74–0.96); the EIB cut-off value = 2,379 determined sensitivity = 100% and specificity = 52.6% in children < 4 years old. and sensitivity = 100% and specificity = 63.2% in children > 4 years old. EIB median values were 1,666 in HiE versus 2,669 in non-HiE (U = 80, p < 0.01). The adjusted ROC curve analysis for HiE was 0.75 (95% CI = 0.59–0.90); the EIB cut-off value = 2,296 determined sensitivity = 71.2% and specificity = 83.1% in children < 4 years old, and sensitivity = 75.1% and specificity = 80.1% in children > 4 years old.

Conclusion EIB provides statistically significant diagnostic performances for ErE and HiE. It could become a useful tool, especially to discriminate between ErE and non-ErE, avoiding other invasive tests.

Keywords

child - esophageal impedance baseline - esophagitis - gastroesophageal reflux - multichannel intraluminal impedance

• References

• 1 Vandenplas Y, Rudolph CD, Di Lorenzo C , et al; North American Society for Pediatric Gastroenterology Hepatology and Nutrition; European Society for Pediatric Gastroenterology Hepatology and Nutrition. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49 (4) 498-547
• 2 van Wijk MP, Benninga MA, Omari TI. Role of the multichannel intraluminal impedance technique in infants and children. J Pediatr Gastroenterol Nutr 2009; 48 (1) 2-12
• 3 Vandenplas Y, Salvatore S, Vieira MC, Hauser B. Will esophageal impedance replace pH monitoring?. Pediatrics 2007; 119 (1) 118-122
• 4 Bredenoord AJ, Tutuian R, Smout AJPM, Castell DO. Technology review: esophageal impedance monitoring. Am J Gastroenterol 2007; 102 (1) 187-194
• 5 López-Alonso M, Moya MJ, Cabo JA , et al. Twenty-four-hour esophageal impedance-pH monitoring in healthy preterm neonates: rate and characteristics of acid, weakly acidic, and weakly alkaline gastroesophageal reflux. Pediatrics 2006; 118 (2) e299-e308
• 6 Wenzl TG, Benninga MA, Loots CM, Salvatore S, Vandenplas Y ; ESPGHAN EURO-PIG Working Group. Indications, methodology, and interpretation of combined esophageal impedance-pH monitoring in children: ESPGHAN EURO-PIG standard protocol. J Pediatr Gastroenterol Nutr 2012; 55 (2) 230-234
• 7 Francavilla R, Magistà AM, Bucci N , et al. Comparison of esophageal pH and multichannel intraluminal impedance testing in pediatric patients with suspected gastroesophageal reflux. J Pediatr Gastroenterol Nutr 2010; 50 (2) 154-160
• 8 Mousa HM, Rosen R, Woodley FW , et al. Esophageal impedance monitoring for gastroesophageal reflux. J Pediatr Gastroenterol Nutr 2011; 52 (2) 129-139
• 9 Farré R, Blondeau K, Clement D , et al. Evaluation of oesophageal mucosa integrity by the intraluminal impedance technique. Gut 2011; 60 (7) 885-892
• 10 Kessing BF, Bredenoord AJ, Weijenborg PW, Hemmink GJM, Loots CM, Smout AJPM. Esophageal acid exposure decreases intraluminal baseline impedance levels. Am J Gastroenterol 2011; 106 (12) 2093-2097
• 11 Loots CM, Wijnakker R, van Wijk MP, Davidson G, Benninga MA, Omari TI. Esophageal impedance baselines in infants before and after placebo and proton pump inhibitor therapy. Neurogastroenterol Motil 2012; 24 (8) 758-762 , e351–e352
• 12 Salvatore S, Salvatoni A, Van Steen K, Ummarino D, Hauser B, Vandenplas Y. Behind the (impedance) baseline in children. Dis Esophagus 2014; 27 (8) 726-731
• 13 Ummarino D, Salvatore S, Hauser B, Staiano A, Vandenplas Y. Baseline esophageal impedance according to different time intervals. Dis Esophagus 2013; 26 (6) 582-586
• 14 Hetzel DJ, Dent J, Reed WD , et al. Healing and relapse of severe peptic esophagitis after treatment with omeprazole. Gastroenterology 1988; 95 (4) 903-912
• 15 Black DD, Haggitt RC, Orenstein SR, Whitington PF. Esophagitis in infants. Morphometric histological diagnosis and correlation with measures of gastroesophageal reflux. Gastroenterology 1990; 98 (6) 1408-1414
• 16 Vandenplas Y. Reflux esophagitis in infants and children: a report from the Working Group on Gastro-Oesophageal Reflux Disease of the European Society of Paediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 1994; 18 (4) 413-422
• 17 Ummarino D, Salvatore S, Hauser B, Staiano A, Vandenplas Y. Esophageal impedance baseline according to different time intervals. Eur J Med Res 2012; 17: 18
• 18 Zhong C, Duan L, Wang K , et al. Esophageal intraluminal baseline impedance is associated with severity of acid reflux and epithelial structural abnormalities in patients with gastroesophageal reflux disease. J Gastroenterol 2013; 48 (5) 601-610
• 19 Borrelli O, Salvatore S, Mancini V , et al. Relationship between baseline impedance levels and esophageal mucosal integrity in children with erosive and non-erosive reflux disease. Neurogastroenterol Motil 2012; 24 (9) 828-e394
• 20 Salvatore S, Salvatoni A, Ummarino D , et al. Low mean impedance in 24-hour tracings and esophagitis in children: a strong connection. Dis Esophagus 2016; 29 (1) 10-14
• 21 Dent J. Microscopic esophageal mucosal injury in nonerosive reflux disease. Clin Gastroenterol Hepatol 2007; 5 (1) 4-16
• 22 Sackett DL, Haynes RB. The architecture of diagnostic research. In: Knottnerus JA, ed. The evidence base of clinical diagnosis. London: BMJ Books; 2002: 19-38
• 23 Burgueño MJ, García-Bastos JL, González-Buitrago JM. ROC curves in the evaluation of diagnostic tests [in Spanish]. Med Clin (Barc) 1995; 104 (17) 661-670
• 24 Knottnerus JA, Muris JW. Assessment of the accuracy of diagnostic tests: the cross-sectional study. In: Knottnerus JA, ed. The evidence base of clinical diagnosis. London: BMJ Books; 2002: 39-59