A 20-year-old lady presented with heartburn, belching and persistent hiccups. High resolution manometry and 24-hour pH/impedance reflux monitoring were carried out.
High Resolution Manometry
HRM results were as follows:
- The upper oesophageal sphincter was normotensive and showed complete relaxation on wet-swallows.
- The oesophagus showed normal peristalsis.
- The lower oesophageal sphincter was normotensive and showed complete relaxation on wet-swallows.
- There was no evidence of a hiatus hernia.
These results based on the Chicago Classification showed that the patient exhibited normal oesophageal motility.
24-hour pH-Impedance Reflux Monitoring Off PPI
The pH-impedance reflux monitoring gave the following results:
- Proximal oesophagus: total of three episodes; normal <31 (impedance).
- Distal oesophagus: total: 2.8%, normal <4.2%; upright: 0.2%, normal <6.3%; supine: 5.2%, normal <1.2%; DeMeester score: 13.9, normal <14.72; number of reflux events (impedance): total 29, normal <73 (off PPI).
- Reflux symptom correlations: belching 79 episodes, SI & SAP not analysed; positive SI >50%, positive SAP >95%.
Interpretation
- The patient was experiencing pathological acid/non-acid reflux when off PPIs during the night.
- There was a positive reflux symptom association for belching which indicated that the majority of reflux events were indeed triggered by a belch episode.
- Although nocturnal reflux was not directly triggered by belching, it occurred within a few minutes after the patient had a little food/drink at around 1.30am.
- 79 belching episodes were reported and was a mix of real gastric and supragastric belching.
Next Steps
For the true gastric belching, a hydrogen and methane breath test may be considered to exclude small intestinal bacterial overgrowth (SIBO). The patient may benefit from oesophageal biofeedback therapy.
