ASGE Esophagology: Tailoring Management from Testing to Treatment (Live and Virtual)

Schnoll - GERD Diagnostic
Pdf Summary
GERD diagnosis is complex and requires careful evaluation. There is no one-size-fits-all approach, as symptom generation varies from case to case. Personalized approaches are ideal, although they may not be backed by the highest quality graded evidence. The use of symptom questionnaires and expert history by gastroenterologists have limitations in accurately diagnosing GERD.<br /><br />Some common diagnostic tools include the PPI test, EGD, reflux monitoring, esophagram, biopsy, HRM, Mucosal Integrity, and MNBI. Diagnostic PPI trials are recommended for patients with typical symptoms and no alarm features. EGD should be performed in cases with alarm symptoms, inadequate response to PPI, symptom recurrence after discontinuation of PPI, chest pain without heartburn, and patients at risk for Barrett's esophagus.<br /><br />A complete endoscopic evaluation for GERD involves grading erosive esophagitis, inspecting the diaphragmatic hiatus, measuring axial hiatus hernia length, assessing for Barrett's esophagus, and excluding other diseases such as EOE, achalasia, and cancer. Grade C or D erosive esophagitis, long segment Barrett's esophagus, and peptic strictures are confirmatory evidence of GERD on EGD.<br /><br />Routine histopathology is not sensitive or specific for diagnosing GERD. Esophagrams are helpful for assessing luminal diameter, evaluating for hiatal hernia, and eliminating achalasia. Reflux monitoring measures acid exposure time, number of reflux events, reflux symptom correlation, and other metrics. Acid exposure time greater than 6% is considered abnormal.<br /><br />Reflux-symptom correlation has limited value as a standalone test but is useful when combined with other diagnostic measures. pH-impedance monitoring is recommended for refractory symptoms, suspicion of rumination, belching, and respiratory symptoms. Wireless pH monitoring is preferred for infrequent symptoms, intolerance to catheters, and high clinical suspicion.<br /><br />High-resolution manometry is used to diagnose major motor disorders and assess peristaltic performance before antireflux surgery. Nocturnal baseline impedance (MNBI) can help determine pathologic reflux when other metrics are inconclusive. Mucosal integrity testing is evolving and has a potential role in GERD diagnosis. For patients with isolated extraesophageal symptoms, further evaluation and testing may be needed.<br /><br />Overall, GERD diagnosis requires a comprehensive evaluation using multiple diagnostic tools and personalized approaches based on individual patient characteristics and symptoms.
Keywords
GERD diagnosis
evaluation
personalized approaches
diagnostic tools
PPI test
EGD
reflux monitoring
esophagram
biopsy
HRM