Ambulatory reflux monitoring in GERD--which test should be performed and should therapy be stopped?

Abstract

Diagnosing gastroesophageal reflux disease (GERD) often entails using a combination of patient symptoms, response to proton pump inhibitors (PPI), upper endoscopy, and ambulatory reflux testing. Each of these has limitations of which the clinician must be aware when managing patients with reflux symptoms. Ambulatory reflux monitoring, in particular, can potentially document the true presence of pathologic GERD. Consequently, reflux testing is often necessary in our evaluation of patients with reflux symptoms, and can be useful in distinguishing etiologies driving a lack of response to PPI therapy. Reflux testing results can be also used to guide appropriate PPI prescribing and clinical decision making for appropriate or unnecessary therapy. This review focuses on the limitations of our current diagnostic paradigm and highlights how reflux testing can be helpful in the diagnosis and management of patients with poor response to PPI therapy.

Figure 1

Figure 1a: Diagnostic approach for patients presenting with reflux symptoms (modified from Kahrilas and Smout² ) ¹ EOE=eosinophilic esophagitis; ² EGJOO=esophagogastric junction outflow obstruction; ³ DES=diffuse esophageal spasm Figure 1b: Empiric proton pump inhibitor therapy for patients with reflux symptoms (modified from Tytgat et al.) Figure 1c: Ambulatory reflux monitoring algorithm for PPI non-responders (modified from Richter et al.)

Figure 1

Figure 1a: Diagnostic approach for patients presenting with reflux symptoms (modified from Kahrilas and Smout² ) ¹ EOE=eosinophilic esophagitis; ² EGJOO=esophagogastric junction outflow obstruction; ³ DES=diffuse esophageal spasm Figure 1b: Empiric proton pump inhibitor therapy for patients with reflux symptoms (modified from Tytgat et al.) Figure 1c: Ambulatory reflux monitoring algorithm for PPI non-responders (modified from Richter et al.)

Figure 1

Figure 1a: Diagnostic approach for patients presenting with reflux symptoms (modified from Kahrilas and Smout² ) ¹ EOE=eosinophilic esophagitis; ² EGJOO=esophagogastric junction outflow obstruction; ³ DES=diffuse esophageal spasm Figure 1b: Empiric proton pump inhibitor therapy for patients with reflux symptoms (modified from Tytgat et al.) Figure 1c: Ambulatory reflux monitoring algorithm for PPI non-responders (modified from Richter et al.)