Discounting the duration of bolus exposure in impedance testing underestimates acid reflux

Background: Combined impedance-pH testing (MII) allows for detection of reflux episodes regardless of pH. However impedance-based diagnosis of reflux may not routinely account for duration of the reflux episode. We hypothesize that impedance testing may be less sensitive than pH-testing in detecting acid reflux off therapy as a result of discounting duration of exposure. Methods: Baseline characteristics and reflux parameters of MII studies performed off-anti-secretory medications were analyzed. Studies on acid suppressive medication and those with recording times less than 20h or low baseline impedance were excluded. Results: A total of 73consecutive MII studies were analyzed of which 31 MII studies had elevated acid exposure while 16 were abnormal by impedance criteria. MII testing off-therapy was more likely to be abnormal by pH criteria (percent time pH<4) than impedance criteria (total reflux):[42 vs 22% (p =0.02)]. Acid exposure (percent time pH<4) identified more studies as abnormal than MII-detected acid reflux episodes [42 vs 34% (p<0.01)]. Mean acid clearance time (pH-detected) was significantly longer than median bolus clearance time (impedance-detected) in the total [98.7s vs 12.6s (p<0.01)], upright [58.6s vs 13.1s (p<0.01)], and recumbent positions [136.7s vs 14.2s (p<0.01)] with the greatest difference seen in the recumbent position. The mean ratio of mean acid clearance time (pH-detected) and the median bolus clearance time (impedance-detected) was significantly higher in the recumbent position compared to the upright position [11. vs 5.3 (p=0.01)]. Conclusion: Ambulatory impedance testing underestimates acid reflux compared to esophageal acid exposure by discounting the prolonged period of mucosal contact with each acid reflux episode, particularly in the recumbent position.