Abstract
The acid perfusion (Bernstein) test and esophageal pH monitoring are the two most popular tests for identifying esophageal acid sensitivity in difficult cases of reflux disease. Therefore, we prospectively compared these test results in 75 consecutive noncardiac chest pain patients who had both an acid perfusion test and chest pain during 24-hr pH testing. A positive acid perfusion test was defined by the replication of the patient's typical chest pain twice by the acid infusion. Esophageal pH testing identified abnormal amounts of acid reflux and correlated symptoms with acid reflux-the “symptom index.” Fifteen patients (20%) had a positive acid perfusion test while 45 patients (59%) had a positive symptom index (range 6–100%). Only 9/34 (26%) patients with abnormal reflux had a positive acid perfusion test. Although it had excellent specificity (83–94%), the acid perfusion test had poor sensitivity (32–46%) when compared to the symptom index regardless of the percent positive cutoff level. The best positive predictive value for the acid perfusion test was 87%, but this occurred when the test sensitivity was 32%. Modifying the end point of a positive acid perfusion test to include heartburn improves the sensitivity (52–67%) while markedly compromising specificity and positive predictive value. Thus, esophageal pH monitoring correlating symptoms with acid reflux is superior to the acid perfusion test for identifying an acid sensitive esophagus in patients with noncardiac chest pain.
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Proudfit WL, Shirley EK, Jones FM: Selective cine coronary arteriography: correlation with clinical findings in 1000 patients. Circulation 33:901–910, 1966
Dart AM, Alban Davies H, Dalal J, Ruttley M, Henderson AM: Angina and normal coronary arteriograms: A follow-up study. Eur Heart J 2:97–98, 1980
Richter JE, Bradley LA, Castell DO: Esophageal chest pain: current controversies in pathogenesis, diagnosis and therapy. Ann Intern Med 110:66–78, 1989
Janssens J, Vantrappen G, Ghillebert G: 24-hour recording of esophageal pressure and pH with non-cardiac chest pain. Gastroenterology 90:1978–1984, 1986
Peters L, Maas L, Petty D, Dalton C, Penner D, Wu W, Castell D, Richter JE: Spontaneous non-cardiac chest pain. Evaluation by 24-hour ambulatory esophageal motility and pH monitoring. Gastroenterology 94:878–886, 1988
Richter JE, Hewson EG, Sinclair JW, Dalton CB: 24-hour pH study: The most useful test in evaluating non-cardiac chest pain. Am J Gastroenterol 84:1151, 1989
Bernstein LM, Baker LA: A clinical test for esophagitis. Gastroenterology 34:760–781, 1958
Richter JE: Acid perfusion (Bernstein) test.In Gastroesophageal Reflux Disease. Pathogenesis, Diagnosis and Therapy. DO Castell, WC Wu, DJ Ott, (eds). Mt. Kisco, New York, Futura Publishing, 1985, pp 139–148
Behar J, Biancini P, Sheahan DG: Evaluation of esophageal tests in the diagnosis of reflux esophagitis. Gastroenterology 71:9–15, 1976
Richter JE, Castell DO: Gastroesophageal reflux. Pathogenesis, diagnosis and therapy. Ann Intern Med 97:93–103, 1982
Rosen SN, Pope CE II: Extended esophageal monitoring. An analysis of the literature and assessment of its role in the diagnosis and management of gastroesophageal reflux. J Clin Gastroenterol 11:260–270, 1989
Richter JE, Johns DN, Wu WC, Castell DO: Are esophageal motility abnormalities produced during the intraesophageal acid perfusion test? JAMA 253:1914–1917, 1985
Johnson LF, DeMeester TR: Twenty-four hour pH monitoring of the distal esophagus: A quantitative measure of gastroesophageal reflux. Am J Gastroenterol 62:325–332, 1974
Wiener GJ, Morgan TM, Copper JB, Wu WC, Castell DO, Sinclair JW, Richter JE: Ambulatory 24-hour esophageal pH monitoring. Reproducibility and variability of pH parameters. Dig Dis Sci 33:1127–1133, 1988
Wiener GJ, Richter JE, Copper JB, Wu WC, Castell DO: The symptom index: a clinically important parameter of ambulatory 24-hour esophageal pH monitoring. Am J Gastroenterol 83:358–361, 1988
De Caestecker JS, Pryde A, Heading RC: Comparison of intravenous edrophonium and oesophageal acid perfusion test during oesophageal manometry in patients with non-cardiac chest pain. Gut 29:1029–1034, 1988
Wranne B, Areskog M, Tribbling L: The acid perfusion test as differential diagnostic aid in patients with chest pain. Acta Med Scand 209(suppl):59–61, 1981
Areskog M: Angina-like chest pain. A study with special reference to oesophageal dysfunction and ischemic heart disease. Linkoping University medical dissertation No. 90. Sweden, 1980.
Katz PO, Dalton CB, Richter JE, Wu WC, Castell DO: Esophageal testing of patients with non-cardiac chest pain or dysphagia. Ann Intern Med 106:593–597, 1987
Soffer EE, Scalabrini P, Wingate DL: Spontaneous noncardiac chest pain: Value of ambulatory esophageal pH and motility monitoring. Dig Dis Sci 34:1651–1655, 1989
Hewson EG, Sinclair JW, Dalton CB, Wu WC, Castell DO, Richter JE: Acid perfusion test: Does it have a role in the assessment of non-cardiac chest pain? Gut 30:305–310, 1989
Murphy DW, Yuan Y, Castell DO: Does the intraesophageal pH probe accurately detect acid reflux? Simultaneous recording with two pH probes in humans. Dig Dis Sci 34:649–656, 1989
Johnsson F, Joelsson B: Reproducibility of ambulatory oesophageal pH monitoring. Gut 29:886–889, 1988
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Richter, J.E., Hewson, E.G., Sinclair, J.W. et al. Acid perfusion test and 24-hour esophageal pH monitoring with symptom index. Digest Dis Sci 36, 565–571 (1991). https://doi.org/10.1007/BF01297020
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DOI: https://doi.org/10.1007/BF01297020