heartburn refractory to PPIs, as FH is over-diagnosed with 24hrs monitoring. Up to 35%of patients with initial diagnosis of FH at 24hrs monitoring could be reclassified as NERDafter a prolonged pH measurement period.

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Distal and Proximal Esophageal Impedance Basal Values in Patients With Non-Erosive Reflux Disease and Functional HeartburnNicola de Bortoli, Irene Martinucci, Edoardo Savarino, Radu Tutuian, Riccardo Franchi,Lorenzo Bertani, Salvatore Russo, Manuele Furnari, Massimo Bellini, Vincenzo Savarino,Santino Marchi

Background and aim: Several studies have shown that proximal extent of reflux episodesplays an important role in gastro-esophageal reflux symptom perception. The relative hyper-sensitivity of the proximal esophagus is most evident in patients with non-erosive refluxdisease (NERD). Recent studies demonstrated that low distal basal impedance values mayreflect impaired mucosal integrity and increased acid sensitivity. The aim was to comparedistal and proximal basal impedance values in patients with NERD and functional heartburn(FH). Methods: According to impedance and pH (MII-pH) monitoring off-therapy, weselected patients with NERD (i.e. pathological acid exposure time, AET) and FH (i.e. normalAET and reflux number; negative symptom association). FH patients did not show anysymptom relief after acid suppression therapy. For each patient, we evaluated basal impedancevalues at the distal (3 cm) and proximal (17 cm) channel, during the overnight rest, at threedifferent times: 1, 2, 3 am. Results: Male/female ratio was 23/23 in NERD and 13/33 in FHpatients. Mean age was 52.3±13.2 in NERD and 49.2±11.3 in FH. Mean AET was higherin NERD (6.1%±3.8%) than in FH (0.6%±0.7%) (p<0.05). NERD group recorded highertotal reflux number (67.8±18.2) than FH group (23.7±9.4) (p<0.05). Basal impedance valueswere significantly (p<0.05) lower in NERD than in FH, both at the distal (1294.3±529.9Ohm vs 3502.1±809.2 Ohm) and proximal (3480.7 ±1322.6 Ohm vs 4344.9±976.2 Ohm)channels. Distal basal values were significantly lower than proximal basal values, both inNERD and FH group (p<0.05). Moreover, in NERD group, 24/46 patients (52.2%) had anabnormal number of proximal refluxes. These NERD patients with pathological proximalrefluxes did not show lower basal impedance values than NERD patients with normal numberof proximal refluxes even if distal (1226.7±453 vs 1243.1±497.1; P=0.5239) or proximalchannels (2670.8±1163.4 vs 2849.2±1434.2; p=0.5046) were compared. Summary andconclusion: Patients with NERD showed lower basal impedance values both at the distaland proximal esophagus. Consistently with the concept that low basal impedance mayreflect impaired mucosal integrity, our results might be helpful to better investigate thepathophysiological role of proximal refluxes.

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Evaluation of Sleep Disruptions by Means of Impedance-pH Monitoring inPatients With NERDNicola de Bortoli, Irene Martinucci, Edoardo Savarino, Radu Tutuian, Lorenzo Bertani,Riccardo Franchi, Manuele Furnari, Salvatore Russo, Massimo Bellini, Vincenzo Savarino,Santino Marchi

Introduction & Aim: Gastroesophageal reflux disease (GERD) adversely impacts on sleep,representing a major cause of disrupted sleep mainly due to reflux symptoms. This maylead to a impaired quality of life. Impedance and pH monitoring (MII-pH) is the goldstandard technique for GERD diagnosis. During the sleep period, impedance values remainstable unless the occurrence of arousals. We aimed to evaluate sleep disruptions in patientswith heartburn and negative endoscopy by means of MII-pH. Methods: A group (33) ofendoscopy negative patients with heartburn underwent MII-pH and were classified accord-ingly: 18 with non-erosive reflux disease (NERD) (i.e., pathological acid exposure time,AET); 15 with functional heartburn (FH) (i.e., normal AET and reflux number, negativesymptom association). MII-pH tracings were reviewed manually using a 5-min window.During recumbent time, we identified sleep disruptions when at least 2 swallows wereobserved in a 5-min window. This data was evaluated in each group. We also calculatedthe overnight swallowing breaking sleep (OSBS) index (i.e., number of windows withswallows/total number of 5-min windows during the sleep period). All patients performeda validated questionnaire to assess the quality of sleep. Results: Male/female ratio was 7/11in NERD and 3/12 in FH patients. Mean age was 51.3±12.4 in NERD and 49.3±9.7 in FH.The quality of a restful sleep was 64.3±8.3% in NERD and 67.3±7.8% in FH (p=0.299).Mean AET was higher in NERD (5.4±0.4) than in FH (0.4±0.4) (p<0.05). NERD grouprecorded higher total reflux number and acid reflux number (p<0.05). The total recumbenttime was 541.4±64.7 min in NERD and 547.3±59.3 min in FH (p=0.39). During the sleepperiod, NERD patients recorded higher reflux number (9.8±8.7) than FH patients (0.6±0.9)(p<0.05). Moreover, the total number of 5-min windows presenting at least 2 swallows washigher in NERD patients (49.7 ±6.4) compared to those with FH (27 ±5.3; p<0.01). TheOSBS index was 46.2±4.0 in NERD and 25.3±5.5 in FH (p=0.023). Conclusions: The manualanalysis of the MII-pH tracings during the recumbent period might be useful to estimatesleep disruptions in patients with NERD, thus helping to identify those patients in whomGERD is perceived more severe and quality of life is much more impaired.

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Pregnancies With In Vitro Fertilization Techniques Predispose toGastroesophageal Reflux DiseaseIlker Turan, Gul Kitapcioglu, Ege Tavmergen Goker, Gulnaz Sahin, Serhat Bor

INTRODUCTION: It has been shown that the risk of gastroesophageal reflux disease (GERD)in years following pregnancy was 6.4% for pregnancies without heartburn and 36.1% forpregnancies with heartburn (1). Women who were conceived with in vitro fertilization (IVF)treatment are likely to have a variety of risk factors which can predispose to GERD such asmultiple medications (aspirin, progesterone, calcium etc), stress, and immobilization. AIMS &METHODS: We aimed to evaluate whether conceiving through IVF and multiple births

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might be associated with a higher risk of developing GERD in the future compared to thepregnancies without IVF. We also evaluated whether there is a difference between singleand multiple births, possible predisposing effects of the weight gain during pregnancy, thetype of the delivery, and weight of the newborn. Since we have shown in the previous studythat number of pregnancies was accompanied with the increasing risk of having GERD,only women with one completed pregnancy were recruited. A validated reflux questionnaire(92 questions in total) was applied to 111 women having a single naturally conceived birth,102 with a single birth with IVF and 54 with multiple (twin or triplet) birth with IVF whohad undergone labor more than 1 year ago. Frequent symptoms (GERD) were defined asa major symptom (heartburn and/or regurgitation) occurring at least once a week or more.RESULTS: The prevalence of current GERD was 4.5% in singleton natural birth group,12.7% in singleton IVF birth group, and 14.8% in multiple IVF birth group (p=0.048). Thesingleton and multiple IVF birth groups did not differ significantly in this respect. Theprevelance of GERD was 6.3% in women who had cesarean delivery, 5% in women whohad delivered vaginally (p=0.8). The mean weight of the newborn was 3198 g ± 481 inwomen who had GERD symptoms, 3071 ± 591 in women without GERD (p=0.3). Themean weight gain (kg) was 11.5 ± 8.4 in women with GERD (n=26), 15.1 ± 6.3 withoutGERD (n=205) (p=0.009). CONCLUSION: The risk of developing GERD at least one yearafter delivery was increased by conceiving through IVF treatment. No difference has beenshown between singleton and multiple birth groups. The type of the delivery and the weightof the newborn were not found as a risk factor, however lower weight gain during pregnancywas related with higher chance for having GERD. IVF treatment might be a predisposingfactor for gastroesophageal reflux disease. Whether GERD therapy in pregnancy decreasesthis risk needs further prospective studies. REFERENCE(S): 1. Bor et al. Clin GastroenterolHepatol. 2007; 5: 1035

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Appropriateness of Upper Endoscopy Referrals in Patients With GERD bySpecialtyFasika Aberra, Fehmi Ates, Zhuoyan Li, James C. Slaughter, Tina Higginbotham, MichaelF. Vaezi

BACKGROUND AND AIMS: Gastroesophageal reflux disease (GERD) is the most commonoutpatient gastrointestinal complaint in primary care practice. Esophagogastroduodenoscopy(EGD) is commonly used in the diagnosis & management of GERD. However, evidencedemonstrates that it is indicated only in certain situations, and inappropriate use can poten-tially generate unnecessary costs & expose patients to harm without improving outcomes.Aims of this study were to assess: 1) overall rate of appropriate EGD referrals made forGERD, 2) appropriate rate according to specialty of referring physician, 3) relevance offindings according to appropriateness of indication. METHODS: Retrospective chart reviewof patients who underwent EGD for GERD from January 2008 to May 2013 was completedlooking at patients' clinic notes to assess specific indications for EGD referral & specialtyof referring physician (primary care physician (PCP) vs. specialist). EGD reports & biopsyresults were reviewed to assess findings. Indications were classified as appropriate or inappro-priate based on criteria from best practice advice by the American College of Physicians(Ann Intern Med. 2012 Dec; 157(11): 808-16). Findings were classified as relevant orirrelevant based on their correlation to reflux symptoms or diagnosis of GERD. Relevantfindings were esophagitis, esophageal ring/stricture, Barrett's esophagus (BE), achalasia,esophageal cancer, hiatal hernia & peptic ulcer in the setting of anemia or GI bleed. Irrelevantfindings were normal EGD, gastritis, gastric polyps & duodentitis. RESULTS: Total of 405patients who had EGD for GERD indications were included. Overall rate of referrals forappropriate vs. inappropriate indications were 68 % & 32% respectively (Table 1). Rate ofinappropriate referrals was 43% for PCPs & 30% for specialists (P < 0.05). The most frequentinappropriate indications among PCPs were inadequate trial of PPI (27%) & serial EGD forGERD or BE without dysplasia (7%) & among specialists were "other" (10%) which mainlyconsisted of extraesophageal symptoms. Overall rates of relevant & irrelevant endoscopicfindings were 57% & 42% respectively. Odds of an appropriate referral in relevant findingswere 1.72 times larger than odds when findings were irrelevant (95% CI: 1.12 to 2.64).CONCLUSIONS: In patients with GERD referred for EGD;1) inappropriate referrals aremore common among PCPs compared to specialists; 2) probability of endoscopic detectionof clinically relevant finding was higher in procedures performed for appropriate indications.Hence, use of endoscopic evaluation for appropriate indications is crucial to cost-effectivepractice. Improvement of appropriate referrals may be achieved by implementing educationalprograms for PCPs or developing a reminder system in the medical chart to assess forappropriateness of indications prior to EGD referral.Table 1. Appropriateness of indications according to specialty of referring physician

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