How to Diagnose Acid Reflux – Step by Step Guide

How to diagnose acid reflux (GERD) disease. Check out our step by step guide to understand more about it.


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)

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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).

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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 testIndicationHighest Level of EvidenceRecommendation
PPIs TrailClassic symptoms, no warning signs.Meta-analysisA negative trial does not rule out
Barium SwallowNot for GERD diagnosis. Use for evaluation of dysphagiaCase controlDo not use unless evaluating for complication (stricture, ring).
EndoscopyAlarm symptoms, screening of high-risk patients, chest pain.Randomized Controlled TrialConsider early for the elderly, those at risk for Barrett’s, noncardiac chest pain, and patients unresponsive to PPI.
Oesophagal biopsyExclude non GERD causes for symptomsCase control.Not indicated for the diagnosis of GERD.
Oesophageal manometryPreoperative evaluation for surgery.ObservationalNot recommended for GERD diagnosis. Rule out achalasia/ scleroderma-like oesophagus preop
Ambulatory reflux monitoringPreoperatively for non-erosive disease. refractory GERD symptoms, GERD diagnosis in question.ObservationalCorrelate symptoms with reflux, and document abnormal acid exposure or reflux frequency.
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GERD, gastroesophageal reflux disease; PPI, proton pump inhibitor.

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