How to diagnose acid reflux (GERD) disease. Check out our step by step guide to understand more about it.
Recommendations
1. A presumptive diagnosis of GERD can be established in the setting of typical symptoms of heartburn and regurgitation. Empiric medical therapy with a PPI is recommended in this setting. (Strong recommendation, moderate level of evidence).
2. Patients with non-cardiac chest pain suspected due to GERD should have a diagnostic evaluation before the institution of therapy. (Conditional recommendation, moderate level of evidence) A cardiac cause should be excluded in patients with chest pain before the commencement of a gastrointestinal evaluation (Strong recommendation, low level of evidence)
3. Barium radiographs should not be performed to diagnose GERD (Strong recommendation, high level of evidence)
4. Upper endoscopy is not required in the presence of typical GERD symptoms. Endoscopy is recommended in the presence of alarm symptoms and for screening of patients at high risk for complications. Repeat endoscopy is not indicated in patients without Barrett’s oesophagus in the absence of new symptoms. (Strong recommendation, moderate level of evidence)
5. Routine biopsies from the distal oesophagus are not recommended specifically to diagnose GERD. (Strong recommendation, moderate level of evidence)
6. Esophageal manometry is recommended for preoperative evaluation but has no role in the diagnosis of GERD. (Strong recommendation, low level of evidence)
7. Ambulatory oesophagal reflux monitoring is indicated before consideration of endoscopic or surgical therapy in patients with NERD, as part of the evaluation of patients’ refractory to PPI therapy, and in situations when the diagnosis of GERD is in question. (Strong recommendation, low level evidence). Ambulatory reflux monitoring is the only test that can assess reflux symptom association (Strong recommendation, low level of evidence).
8. Ambulatory reflux monitoring is not required in the presence of short or long-segment Barrett’s oesophagus to establish a diagnosis of GERD. (Strong recommendation, moderate level of evidence). Screening for Helicobacter pylori infection is not recommended in GERD. Eradication of H. pylori infection is not routinely required as part of antireflux therapy (Strong recommendation, low level of evidence).
| Diagnostic test | Indication | Highest Level of Evidence | Recommendation |
|---|---|---|---|
| PPIs Trail | Classic symptoms, no warning signs. | Meta-analysis | A negative trial does not rule out |
| Barium Swallow | Not for GERD diagnosis. Use for evaluation of dysphagia | Case control | Do not use unless evaluating for complication (stricture, ring). |
| Endoscopy | Alarm symptoms, screening of high-risk patients, chest pain. | Randomized Controlled Trial | Consider early for the elderly, those at risk for Barrett’s, noncardiac chest pain, and patients unresponsive to PPI. |
| Oesophagal biopsy | Exclude non GERD causes for symptoms | Case control. | Not indicated for the diagnosis of GERD. |
| Oesophageal manometry | Preoperative evaluation for surgery. | Observational | Not recommended for GERD diagnosis. Rule out achalasia/ scleroderma-like oesophagus preop |
| Ambulatory reflux monitoring | Preoperatively for non-erosive disease. refractory GERD symptoms, GERD diagnosis in question. | Observational | Correlate symptoms with reflux, and document abnormal acid exposure or reflux frequency. |
GERD, gastroesophageal reflux disease; PPI, proton pump inhibitor.
