Diagnostics

There is no gold standard test for the diagnosis of GERD. The diagnosis is based on clinical presentation, endoscopic evaluation, reflux assessment, and therapeutic response

• All patients

  • Perform a clinical evaluation, focusing on red flags in GERD and evaluating dyspepsia if present

  • Rule out life-threatening differential diagnoses of GERD and chest pain (e.g., acute coronary syndrome)

• Typical symptoms without red flags in GERD: Initiate treatment for GERD; start an empiric once-daily PPI trial.

  • If there is relief after 8 weeks of PPI: GERD is likely; PPI can be discontinued.

  • If symptoms persist on PPI or recur after discontinuing PPI: Refer to gastroenterology for EGD.

• Red flags in GERD: Refer to gastroenterology for EGD before initiating treatment.

• Extraesophageal symptoms: Rule out other diagnoses prior to initiating treatment for GERD.

• Refractory symptoms: Optimize PPI therapy.

  • If symptoms are relieved: Continue PPI.

  • If symptoms persist: Refer to gastroenterology.

• Red flags in GERD

• Risk factors for Barrett esophagus

• No symptomatic improvement after PPI trial

• Red flags of dyspepsia

• (typically in the lowest third of the esophagus)

  • Erythema, edema, friability

  • Erosions, mucosal breaks, ulcerations

  • Peptic strictures and rings

  • Salmon pink mucosa (suggestive of Barrett esophagus)

  • Proximal migration of the gastroesophageal junction (Z line), e.g., in Barrett esophagus or hiatal hernia

> 50% of patients with GERD present with nonerosive reflux and normal endoscopic findings.

Despite the limited value of esophageal biopsies in diagnosing GERD, they are necessary for establishing a diagnosis of eosinophilic esophagitis.

Esophageal pH monitoring can be used to objectively identify abnormal reflux of gastric content into the esophagus; however, it is not a routine diagnostic test.

• Indications

  • Refractory GERD symptoms despite PPI therapy

  • Confirmation of suspected NERD

• Procedure

  • Measurement of esophageal pH over 24–48 hours using a telemetry capsule or a transnasal catheter

  • Documentation of relevant events by the patient

• Supportive finding: Drops in esophageal pH to 4 or less that correlate with symptoms of acid reflux and precipitating activities.

Not routinely indicated, as they play a limited role in the diagnosis of GERD; useful if endoscopy is inconclusive.

• Esophageal barium swallow

  • Consider if the main symptom is dysphagia or if there is suspicion of structural abnormalities (e.g., esophageal rings or webs) or motility disorders (e.g., achalasia, distal esophageal spasm)

• Esophageal manometry: Consider if achalasia or esophageal hypermotility disorders are suspected.