New Ambulatory Impedance-pH Score Can Detect Rumination in Refractory GERD

Gastroesophageal reflux disease (GERD), caused when the lower esophageal sphincter (LES) does not close properly, and stomach contents leak back (reflux) into the esophagus. When refluxed stomach acid touches the lining of the esophagus, it causes a burning sensation (heartburn). GERD may lead to histopathological changes in the esophagus.
Findings reveal new MII-pH-based score can effectively detect postprandial rumination in refractory GERD with persistent regurgitation with high sensitivity and specificity.

A new, simple multichannel intraluminal impedance-pH (MII-pH) score can diagnose rumination in refractory gastroesophageal reflux disease (GERD) with high sensitivity and specificity, according to study results published in The American Journal of Gastroenterology.

Up to 20% of patients with refractory GERD may have postprandial rumination, but the clinical distinction between rumination and persistent frequent postprandial regurgitation can be difficult. Researchers wanted to distinguish rumination from persistent postprandial regurgitation in patients with refractory GERD undergoing ambulatory MII-pH monitoring.

Related Articles

The study composed of 2 parts. For part 1, researchers characterized postprandial and 24-hour MII-pH patterns in patients (n=28) clinically diagnosed with rumination syndrome. Both of these patterns were then compared with those of healthy controls (n=27) and patients (n=30) with typical GERD symptoms including nonerosive reflux disease (n=10), hyperactive esophagus (n=10), and functional heartburn (n=10).

For part 2, researchers used receiver operating characteristic curves to choose the best MII-pH parameters from part 1 to create a new MII-pH rumination score, and then used this score to analyze MII-pH patterns from another set of patients (n=26) with refractory GERD despite double-dose proton pump inhibitor therapy.

Results revealed that patients with rumination were younger (P =.01) compared with GERD controls, yet older when compared with healthy controls (P =.002). Patients were more often women and had a significantly higher number of upright reflux episodes (REs) with high proximal extent. Patients with rumination also had a higher number of postprandial retrograde flow episodes with a distinct pH profile over time, and were more likely than patients with GERD to mark symptoms earlier. 

Researchers determined that the best postprandial MII-pH parameters to distinguish rumination from persistent regurgitation in GERD are the number of nonacid REs per hour and Symptom Index (SI). The rumination score (0-2) used the postprandial number of nonacid REs per hour (cutoff value 3/hr, 1 point) and postprandial SI (cutoff value 60%, 1 point). This new MII-pH-based score can diagnose rumination in refractory GERD with a sensitivity of 91.7% and specificity of 78.6%.

This study had several limitations. First, ambulatory studies can provide observations after multiple meals, but do not provide as much information about the mechanism of reflux as postprandial high-resolution manometry. Second, the number of patients with rumination was limited and only included adults, most of which were women (n=25). Third, researchers mainly targeted patients with persistent postprandial regurgitation, and not a mix of patients with typical and atypical symptoms of GERD. Fourth, researchers do not have evaluation outcomes of rumination treatment in patients who were diagnosed using the new MII-pH score.

According to the study researchers, an MII-pH score using simple parameters (the number of postprandial nonacid REs per hour and SI) can effectively detect postprandial rumination in refractory GERD with persistent regurgitation with high sensitivity and specificity.

Disclosure: Several authors declared associations with the pharmaceutical industry. Please see original reference for a full list of authors’ disclosures.


Nakagawa K, Sawada A, Hoshikawa Y, et al. Persistent postprandial regurgitation vs rumination in patients with refractory gastroesophageal reflux disease symptoms: identification of a distinct rumination pattern using ambulatory impedance-pH monitoring [published online June 26, 2019]. Am J Gastroenterol. doi: 10.14309/ajg.0000000000000295