What is a BRAVO pH study?

A gastroscopy (also called endoscopy) is a test to examine the inner lining of the oesophagus (gullet), stomach and upper small bowel (duodenum). The BRAVO pH study is an extra test that can be performed during the gastroscopy to evaluate for gastroesophageal reflux disease (GORD).

The doctor may spray the back of your throat with a local anaesthetic and/or give you a sedative injection to make you sleepy and relaxed.

The doctor will gently insert a flexible tube with a camera on the end (called a gastroscope or endoscope) through your mouth into your stomach and small bowel. The stomach will be gently inflated by passing air through it to give a clearer view of the bowel lining and the doctor will check whether any disease is present. The doctor will then attach a wireless transmitter to the lining of the oesophagus.

When the test is finished, the gastroscope is removed quickly and easily. The test takes approximately 15 minutes.

Will the test be done on or off my usual acid suppression medicines?

Most people will be asked to STOP their usual acid suppression medicines 7 days before the test. See the section ‘BRAVO Test Done off PPI Therapy’ below. Please check with us if you are unsure about what you should be doing. 

Please click on the relevant section headings to find out what you need to know. 

Many people who have the BRAVO pH study are already taking acid suppression treatment, usually in the form of a proton pump inhibitor (PPI). If we ask you to stop these before the test, you must stop the following drugs 7 days before the test: 

Losec: Omeprazole
Zoton: Lansoprazole
Nexium: Esomeprazole
Motilium: Domperidone
Protium: Pantoprazole
Pariet: Rabeprazole
Tagamet: Cimetidine
Zantac: Ranitidine
Famotidine

You may continue to take antacids eg Gaviscon, Rennies, Maalox and Settlers until 24 hours before the test. All other medications for other conditions should continue as normal unless stated below.

Blood Thinning Medicines

If you are taking clopidogrel (Plavix) for a coronary artery stent, you must only stop this after discussion with the doctor. Other patients taking clopidogrel should usually stop this 7 days before the procedure. If you are unsure whether you should stop this you must ask us.

We usually ask patients to stop taking warfarin for 7 days before the procedure also. If you have had a heart valve replacement, you must not stop your warfarin but you must let us know. You may require a special drug regime before the test.

If you are taking one of the new blood thinning agents such as apixaban, rivaroxaban, dagibatran etc, you will usually need to stop these 2 days before the procedure. Please check with us.

Other Regular Medicines 

You should continue to take your other medicines normally but follow any specific advice you have been given with regard to your regular medications. We may ask you to stop taking diuretics and non – steroidal anti – inflamatory drugs and sometimes we may ask you to stop taking acid suppression medicines such as omeprazole and other PPI drugs.

Morning procedure:

Blood pressure medicines should be taken no later than 2 hours before the test is due with a small amount of water.

For all medicines you have not stopped, except for blood pressure medicines, please take these only AFTER the test.

Afternoon / evening procedure:

For medicines you have not stopped, please take the morning dose normally. Please take lunchtime or evening doses only AFTER the test.

If you have any questions, please ask us. 

Please follow the correct section below.

For patients taking insulin:

 For a procedure taking place in the morning:

 On the evening before, take your normal insulin dose.

On the morning of the procedure, take your normal dose after the procedure is finished.

For a procedure taking place in the afternoon or evening:

 On the morning before the procedure, take half the normal dose of insulin.

Take your normal dose of insulin when you eat after the procedure is finished.

For patients taking tablets:

 For a procedure taking place in the morning:

 On the evening before, take your normal tablets.

On the morning of the procedure, take your normal tablets after the procedure is finished.

For a procedure taking place in the afternoon or evening:

 On the morning before the procedure, take half the normal dose of tablets.

Take your normal dose of tablets when you eat after the procedure is finished

You are not allowed to eat for 6 hours before the gastroscopy. You can drink fluids until 4 hours before your procedure. Please continue to take all medication as normal including the day of the procedures unless you have been advised otherwise.

Please go to the endoscopy unit. You will be shown to your cubicle where you will meet the nurse who will look after you during your stay. She will also verify your personal details and preferred method of payment.

The nurse will then prepare you for your procedures. If you have any worries or questions at this stage don’t be afraid to ask. The staff will want you to be as relaxed and informed as possible for the test and will be happy to answer your queries.

The procedure will happen about 45 minutes after you arrive.

 Your doctor will explain the test to you and will ask you to sign a consent form. This is to signify that you understand the test  and its implications. Please tell the consultant or nurse if you have had any allergies or bad reactions to drugs or other tests.

When you go into the endoscopy room you will be asked to remove any false teeth and lie on your left side on a trolley. You will have some equipment attached to you so we can monitor you blood pressure and your oxygen levels.  You will also have a small amount of oxygen during the procedure.  A plastic mouthpiece will be placed between your teeth to help keep your mouth slightly open. 

Most people prefer to be sedated (sleepy) for the tests. The doctor will administer the medication (painkillers and sedation) via a small plastic tube placed in the back of your hand or arm.  The medication may take a few minutes to work. The medication makes you relaxed and drowsy; it is not a general anaesthetic. The doctor will then start the gastroscopy by gently passing the gastroscope through your mouth into your stomach. The gastroscopy  and BRAVO transmitter placement usually takes around 10 minutes unless treatment is being performed. If you get a lot of saliva in your mouth, the nurse will suck this out with a sucker.

Sometimes the doctor takes a biopsy (a sample of the bowel lining). A small piece of tissue is removed painlessly through the scope, using tiny forceps. This is then sent to the laboratory for further tests. He will then carefully attach the BRAVO transmitter to the lining of the oesophagus. This is simple to do and painless.

The test should not be painful but it may feel uncomfortable in the throat. You may develop a sore throat for 2 – 3 days after the procedure.

Immediately After The Test

After the test, you will return to your cubicle. You will stay there for approximately one hour so the effects of the sedation can wear off. Your blood pressure and oxygen levels will be monitored during this time. You will also be offered a drink and some biscuits. You may bring your own food if you prefer. If you do not have sedation you will not need to stay in recovery for as long.

One of the doctors or nurses will come to explain the results of your procedure. You should expect to stay in the hospital for a total of 2-3 hours.

Going Home

If you have had sedation, do not use public transport, particularly if you will need to stand on the train or bus.

DO NOT drive yourself. Please have someone to take you home in a car or taxi.

DO NOT drink alcohol, drive a car or operate heavy machinery for 24 hours after sedation is given.

When You Get Home

Once you get home you may eat and drink as normal. You may find that you have a sore throat. You may also feel a bit full up or bloated. This is because of the air in your bowel. This feeling usually only lasts for a few hours but may last for a few days in some people. Peppermint or chamomile tea helps release the trapped wind and buscopan or mebeverine tablets can reduce any cramps you feel. These tablets can be bought at any chemist.

The BRAVO Recording

You will take the BRAVO recorder home with you. It will record how much acid reflux you have for between 48 and 96 hours. You will need to wear it on your belt or to put in your pocket or handbag. At night, place it next to your bed and when you are in the bathroom, keep it well away from the bath or shower. It can detect signals to a distance of 2 metres. There is a blue light that flashes intermittently on the unit for up to 96 hours. It stops flashing at the end of the test. 

If the receiver goes out of range, it beeps for 2 minutes and the LCD display will continue to flash after this. If this happens, just put the receiver on your chest and it will stop flashing and/or beeping. Please keep a diary of when you lie down and get up and of when you start and finish your meals. Please press the grey button on the top of the box when you get what you think is a characteristic symptom of possible reflux. 

Returning the BRAVO recorder for analysis

At the end of 48 or 96 hours, the recorder box will turn off automatically You will be given an envelope and an appointment to return the recorder to the hospital. Please also return the diary sheet. Alternatively, you may arrange with the nurses to return it by post.

What are the Risks?

Procedure Risks

Gastroscopy is a common test with very few side effects or complications. However you should be aware of the following potential complications: 
For the BRAVO test, most people are not even aware that the transmitter capsule is inside.
About one in three people are aware of it and notice chest discomfort, particularly on swallowing. If this happens to you, don’t worry. Just chew your food well and, if necessary, take paracetamol.
The transmitter capsule will detach and disappear into your stools, never to be seen again, after 2-14 days. Once this happens, any discomfort in your chest will quickly settle down. It is possible to remove the transmitter capsule at endoscopy, but this is rarely needed.
Please note that the BRAVO transmitter is an electronic device. As with all electronics, there is a very small chance that it will not work properly. The risk is around 1 in 100.
For gastroscopy itself, overall, the risks of haemorrhage (bleeding) or perforation (a hole in the lining of the bowel) are very low at about 1 in 15,000 (British Society of Gastroenterology). The risk of bleeding with the BRAVO transmitter are probably slightly higher at around 1 in 1,000.
Sedation causes breathing problems in about 1 in 200 cases although these are usually mild (British Society of Gastroenterology). You will be monitored through out the procedure and the sedation can be reversed if necessary. Other rare problems include aspiration pneumonia and a slight risk to teeth or dental bridgework.
Sometimes the doctor is unable to complete the entire test. It is possible to miss abnormalities during the test.

What are the Alternatives?

Barium Swallow: This is an X-ray test. It can be used to examine swallowing problems, but it is a poor test for assessing acid reflux.

Manometry and pH study: Both these tests involve placing a small tube through the nose into the oesophagus. Manometry measures oesophageal motility and is often needed for patients who are considering fundoplication surgery to treat their acid reflux. This test takes a few minutes to do.A pH study measures acid reflux over a 24 hour period. It is considered less good than the BRAVO because it only measures reflux for one day rather than two. In addition, because the tube comes out of the nose, people find the test bothersome and they tend not to do the things they usually do. This can reduce the acid reflux and the results are therefore less accurate.

24 hour pH & impedance study: This test is similar to the standard 24 hour pH study but the tube has an extra capability to measure non- acid reflux as well. This may be preferable, particularly for people who have recurrent symptoms after previous surgery or complex symptoms which may or may not be due to acid reflux.

Sometimes due to emergencies and other unforeseen circumstances your appointment may be delayed. We try our best to see everyone on time but please understand that delays can occur and we ask for your patience in these circumstances.

Given that delays can occur, it would be a good idea if you bring a book with you to read while you are waiting or bring some relaxing music to listen to. Reading a good novel will get you into a calm state of mind as will the right music. Both will help make the procedure more pleasant for you. 

The hospital aims to ensure that your procedure is as safe as possible. Staff are swabbed regularly. Patients with Covid-19 are treated in separate areas to those who do not have the disease. If you have Covid-19 you must cancel your procedure and have it done after you have recovered. 

To ensure safety for all patients and staff, we follow these rules:

If you are double vaccinated you will need to do a lateral flow test the day before the procedure. You should upload the result to the NHS app and bring a copy of the certificate to the hospital showing that you are Covid negative.

If you are not at least double vaccinated, please follow strict self-isolation for a minimum of 3 days prior to your procedure. Please also follow increased vigilance – social distancing, washing hands regularly, wearing a face covering in public places, limiting contact with other people, 7 days prior to your procedure. You will need to have a negative PCR swab performed within 3 days of the procedure. We can arrange this for you. 

Getting to and from the hospital

To minimise the risk of catching Covid-19, particularly when case numbers are high, please avoid public transport. If someone is bringing you to the hospital, they will usually need to stay away from the hospital itself. They should collect you at the entrance when you are ready to leave.