Investigations in Heartburn, continued particularly in patients complaining of dysphagia. In patients with classic erosive reflux esophagitis, biopsies are rarely taken, except to exclude neoplasm and infection. In summary, the current primary indication for esophageal biopsy is to define Barrett`s epithelium and to exclude eosinophilic esophagitis. pH monitoring Ambulatory intra-esophageal pH monitoring is still the gold standard for establishing pathologic acid reflux; clinical indications for this test are now well-established. Before fundoplication, pH testing should be performed in patients with a normal endoscopy to confirm pathologic acid reflux and establish a firm diagnosis of GERD. After anti-reflux surgery, persistent or recurrent symptoms warrant repeat esophageal pH testing. Esophageal reflux testing is particularly helpful in evaluating patients with a normal endoscopy. However, here there is controversy whether this should be done on or off PPI therapy to define two populations: those with and those without continued abnormal acid or non-acid exposure times Finally, ambulatory esophageal pH testing may help to identify patients who have extra-esophageal manifestations of GERD. In this situation, pH testing is often done with additional pH probes in the proximal esophagus or pharynx. In addition to various types of catheter-based pH monitoring systems, there are: (1) a catheter-free system using a wireless pH capsule that is affixed to the esophageal mucosa with a delivery system that drives a small needle into the epithelium and transmits pH data to a portable receiver using radiofrequency signals, and (2) a catheter-based system which combines impedance monitoring with pH testing, allowing the measurement of acid and non-acid reflux. A critical limitation of esophageal pH monitoring is that there are no absolute threshold values that can identify GERD patients, reliably. Under these circumstances, statistical evaluation of esophageal pH recordings using, for example, the symptom association probability (SAP) or symptom index (SI), can define an association between symptom complaints and GER; however, only a treatment trial can address the critical clinical issue of causality. Manometry The advent of multichannel, high-resolution manometry (HRM) has revolutionized esophageal motility testing. With 32 to 36 pressure transducers spanning the entire esophagus, HRM can now accurately assess LES pressure and relaxation, as well as peristaltic activity, including contraction amplitude, duration, and velocity. However, esophageal manometry is generally not indicated in the evaluation of the uncomplicated GERD, because most GERD patients have a normal resting LES pressure and it is difficult to evaluate transient lower esophageal sphincter relaxations (TLESRs) in short-term HRM studies. Having said this, esophageal manometry is, traditionally, recommended to document adequate esophageal peristalsis and exclude variants of achalasia and scleroderma before anti-reflux surgery. Radiology The barium esophagogram is an inexpensive, readily available and non-invasive esophageal test. It is most useful in demonstrating anatomic narrowing of the esophagus and assessing the presence and reducibility of a hiatal hernia. Schatzki’s rings, webs or minimally narrowed peptic strictures may only be seen with an esophagogram, being missed by endoscopy, which may not adequately distend the esophagus. Giving a 13-mm radiopaque pill or marshmallow along with the barium liquid can help to identify these subtle narrowing’s. The spontaneous reflux of barium into the proximal esophagus is very specific for reflux, but is not sensitive and it does not, necessarily, indicate that the patient’s symptoms are caused by GER. Provocative manoeuvres (e.g. leg lifting, coughing, Valsalva manoeuvre or water siphon) can elicit stress reflux and improve the sensitivity of barium esophagogram, but some argue that these manoeuvres also decrease its specificity. In general, barium contrast studies are not used to make a diagnosis of GERD but rather to identify structural lesions that may be associated with alarm features. Conclusion National guidelines recommend that GERD can be diagnosed, clinically, without the need for formal investigations. Structured questionnaires are cumbersome to use in clinical practice and add little to the accuracy of clinical diagnosis. Diagnostically, upper endoscopy is indicated primarily for patients who have alarm features or who have not responded to a 4-8 week course of twice-daily PPI therapy; esophageal biopsies are not needed to make a diagnosis of GERD but are appropriate if there is a suspicion of eosinophilic esophagitis or Barrett’s esophagus. Esophageal pH monitoring, with or without luminal impedance monitoring may be helpful before anti-reflux surgery or for patients with persistent symptoms despite therapy, as may esophageal manometry, especially if there is a suspicion of an underlying motility disorder. Upper GI contrast radiology has a limited role for the diagnosis of GERD and is useful, primarily, if there is a strong suspicion of an underlying structural lesion. References 1. Richter JE, Friendenberg FK. “Gastroesophageal Reflux Disease.” in Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 10th Edition. Eds: Feldman M, Friedman LS, Brandt LJ. Elsevier 2015. pp 733-754. 2. Jonasson C, Moum B, Bang C, Andersen KR, Hatlebakk JG. Randomised clinical trial: a comparison between a GerdQbased algorithm and an endoscopy-based approach for the diagnosis and initial treatment of GERD. Aliment Pharmacol Ther 2012;35:1290-1300. World Digestive Health Day WDHD May 29, 2015 WGO HANDBOOK HEARTBURN: A GLOBAL PERSPECTIVE 7
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