By Jim Dryden
November 2, 2001
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University gastroenterologists at Barnes-Jewish Hospital have become one of five groups in the country now using a novel means of testing for one of the most common digestive-tract problems in the United States: gastroesophageal reflux.
Known as the Bravo pH System, the test measures the amount of stomach acid reaching the esophagus over 24 hours in patients who may have reflux but have never been officially diagnosed with the problem.
Reflux occurs when the valve between the esophagus and stomach weakens, and gastric fluids flow back up into the esophagus and the throat. The condition can cause symptoms ranging from heartburn to chest pain that mimics heart disease. Some people become hoarse and have difficulty speaking, and chronic reflux is thought to increase the risk of esophageal cancer in some people.
"All of us reflux from time to time, but people with a serious problem will have symptoms almost every time they eat, or every time they lie down or engage in other activities that trigger the symptoms," said Ray E. Clouse, M.D., professor of medicine and of psychiatry at the School of Medicine and director of the Digestive Disease Clinical Center at Barnes-Jewish Hospital.
The most common way to diagnose reflux is to put a patient on treatment, such as antacids or other drugs, and follow the patient to see if symptoms improve or go away entirely. But even years later, symptoms may return, and many patients then opt for minimally invasive surgery to strengthen the valve between the stomach and the esophagus.
"We don't want to send someone into something as serious as surgery unless we are sure the symptoms really are caused by gastroesophageal reflux, and we need more than a successful record of treatment to diagnose the problem," Clouse said.
Sometimes, it is possible to diagnose reflux by examining a patient with an endoscope, a rubber tube with a camera at the end that is slipped into the esophagus of a sedated patient.
"But endoscopic exams can only identify areas that have been damaged by gastric acids," Clouse said. "If a patient has been treated successfully for years, there may be no damaged tissue."
The other option is 24-hour pH testing to monitor acid levels in the esophagus. Until now, 24-hour pH testing involved running a catheter up the patient's nose and down the back of the throat into the esophagus. The patient then returned home for 24 hours with the catheter hooked to a monitor that records acid levels.
The Bravo system dispenses with the catheter entirely. Instead, it uses a small capsule about the size of a coffee bean that doctors attach to the wall of the esophagus near the junction with the stomach. The capsule transmits electrical signals to a pager-like device that is worn on the belt or kept on a nightstand next to a bed.
"There are two primary advantages," Clouse said. "First, patients don't like having a catheter running from their nose to a monitor for a day. Secondly, the tubing interferes with normal activities, so many patients go home and simply sit in a chair for 24 hours.
"We'd rather have them free to spend a more typical day, so we can get more accurate measures of their reflux problems and see when reflux is most likely to occur. If it happens after meals, the new system tells us that. If it happens while lying down or gardening or walking in the mall, we'll know that, too."
After about a week, the capsule falls away from the wall of the esophagus and passes naturally out of the system. Not all patients are candidates for this type of pH monitoring, but it does provide a new option for some people.
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