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Gastroesophageal Reflux Disease: Diagnosis and Investigations


Gastroesophageal Reflux Disease: Diagnosis and Investigations Dr. Abdulmalik Altaf References Richter, Joel E. Diagnostic tests for gastroesophageal reflux disease. – PowerPoint PPT presentation

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Title: Gastroesophageal Reflux Disease: Diagnosis and Investigations

Gastroesophageal Reflux Disease Diagnosis and
  • Dr. Abdulmalik Altaf

  • Western populations
  • GERD is a very common condition
  • One third of population experience symptoms of
    GERD at least once a month,
  • Four to 7 experience symptoms daily
  • The prevalence and severity of GERD reflux are
    likely increasing
  • The diagnosis of a columnar cell-lined esophagus
    is also increasing at a rapid rate

Symptoms of GERD
  • Three categories of symptoms
  • Typical symptoms
  • Regurgitation and Heartburn
  • Worse in a recumbent position or when bending
  • Frequent in tense and overweight pts
  • Age of onset and duration possible markers of
    increased risks for Barrett's esophagus
  • These two symptoms were the only valid ones that
    indicate a difference between patients who have
    normal and pathologic pH-metry when heartburn is
  • Specificity is considered adequate, but
    sensitivity is low

Symptoms of GERD
  • Symptoms related to complications of GERD
  • Dysphagia and odynophagia
  • Associated with mechanical or functional
    obstructions that may cause reflux damage
  • Hematemesis and melena
  • Rarer complications
  • Related to bleeding esophagitis,
  • Indicate extensive mucosal damage and suggest the
    possibility of columnar-lined mucosa

Symptoms of GERD
  • Atypical reflux symptoms
  • Oropharyngeal dysphagia and aspiration
  • Episodes of asthma
  • Noncardiac chest pain
  • Hoarseness and pharyngitis
  • Stress, psychologic traits, and chronic anxiety
    may have an effect on reflux symptoms

Symptoms of GERD
  • Usually, regurgitation and heartburn seen in
    uncomplicated GERD
  • In 22 of patients, typical heartburn result from
    stomach or duodenal abnormalities
  • Even in cases in which the esophagus is the
    source of symptoms, they are not necessarily
    caused by reflux
  • Heartburn may be absent in severe reflux

Symptoms of GERD
  • 25 of patients with columnar-lined esophagus
    have no symptoms that suggest reflux
  • Overall, symptoms are not good predictors of the
    presence and severity of esophagitis and its
  • Because of this unspecificity and poor
    sensitivity, symptoms must not be used as a guide
    to therapy but rather to investigate and document
    the condition

Diagnostic Tests
  • Empiric Trial of Acid Suppression
  • Endoscopy
  • Esophageal Biopsy
  • Esophageal pH Monitoring
  • Barium Esophagram
  • Esophageal Manometry

Empiric Trial of Acid Suppression
  • The simplest and most definitive method for
    diagnosing GERD and assessing its relationship to
  • Assures a cause-and-effect relationship between
    GERD and symptoms
  • Became the first test used in patients with
    classic or atypical reflux symptoms without alarm
  • Approach was aided by the introduction PPIs
  • Symptoms usually respond to a PPI trial in 7 to
    14 days

Empiric Trial of Acid Suppression
  • GERD may be assumed if symptoms disappear with
    therapy and then return when the medication is
  • Reported empiric trials with heartburn
  • The initial dose of PPI was high (eg, 4080
    mg/day omeprazole) and given for not less than 14
  • A positive response was defined as at least 50
    improvement in heartburn
  • Sensitivity of 68 to 83

Empiric Trial of Acid Suppression
  • Fass et al,1998
  • In noncardiac chest pain, a 7-day trial of 40 mg
    of omeprazole in the morning and 20 mg in the
  • Sensitivity of 78 and specificity of 86 for
    predicting GERD, compared with traditional tests
  • Ours et al, 1999
  • 40 mg omeprazole twice daily for 2 weeks a very
    reliable method for identifying acid-related
  • Patients with suspected asthma and ENT symptoms
  • Two to 4-month regimen of twice-daily PPIs

Empiric Trial of Acid Suppression
  • Advantages
  • Office-based, easily performed, relatively
    inexpensive, available to all physicians, and
    avoids many needless procedures
  • Disadvantages
  • Placebo response and uncertain symptomatic
    endpoint if symptoms do not totally resolve with
    extended treatment

Upper GI Endoscopy
  • The standard for documenting the type and extent
    of mucosal injury to the esophagus
  • Identifies the presence of esophagitis
  • Excludes other causes of the patients complaints
  • Only 40 to 60 of patients with abnormal
    esophageal reflux by pH testing have endoscopic
    evidence of esophagitis
  • Sensitivity is 60 at best
  • Specificity 90 to 95

Upper GI Endoscopy
  • Endoscopic signs of acid reflux
  • Edema and erythema
  • Earliest signs but neither is specific for GERD
  • Very dependent upon the quality of endoscopic
    visual images
  • Friability, granularity, and red streaks
  • More reliable
  • Erosions
  • Develop with progressive acid injury
  • May also be caused by NSAIDs use, heavy smoking,
    and infectious esophagitis

Upper GI Endoscopy
  • Ulcers
  • Reflect more severe esophageal damage
  • They have depth into the mucosa, tend to have
    either a white or yellow discolored base
  • May be seen either isolated along a fold or
    surrounding the EG junction
  • Other signs
  • Schatzki ring
  • A thin, pearly white tissue structure located at
    the squamocolumnar junction
  • Recent debate suggests that it is a complication
    of GERD

Upper GI Endoscopy
  • Peptic strictures
  • Narrowing of the distal esophagus because of
    long-term chronic acid-induced inflammation
  • Shortened, thick, noncompliant region of scarring
  • Like rings, peptic strictures tend to occur
    distally at the EG junction
  • Typically short and less than 1 cm in length
  • If they are longer, other causes, should be
  • Further evidence of esophagitis is often seen
    proximal to the stricture

Upper GI Endoscopy
  • Barrett esophagus
  • Appears as a salmon- or pink-colored mucosa in
    the tubular esophagus
  • Mucosal biopsies are always necessary to confirm
    the presence of specialized intestinal metaplasia

Upper GI Endoscopy
  • Endoscopic grading of GERD
  • Depends upon the endoscopists interpretation of
    visual images
  • There is no standard classification scheme for
    endoscopic findings
  • Several grading systems are available, but none
    is completely satisfactory
  • Savary-Miller classification
  • Most popular scheme in Europe
  • Based on degree of mucosal erosions
  • Hetzel and Los Angeles systems
  • Most popular in the United States
  • Hetzel the area of mucosal injury
  • Los Angeles system the number, length, and
    location of mucosal breaks

Upper GI Endoscopy
Upper GI Endoscopy
  • What is the role of endoscopy?
  • Initially, endoscopy was used to characterize
    patients into mild erosive and severe erosive
    disease and to better direct their management.
  • Because PPIs treat both groups equally well,
    early endoscopy has less impact on the choice of

Upper GI Endoscopy
  • When to do endoscopy?
  • Patients experiencing alarm symptoms
    dysphagia, odynophagia, weight loss, and GI
  • To rule out other entities such as infections,
    ulcers, cancer, or varices
  • Currently, the most important reason for
    performing endoscopy in GERD patients is to
    identify reflux complications
  • Using this rationale, most patients with chronic
    GERD need only one endoscopy while on therapy

Esophageal Biopsy
  • Microscopic changes may occur even when the
    mucosa appears normal endoscopically
  • Biopsy helps to..
  • identify reflux injury
  • exclude other esophageal diseases
  • confirm complications, especially Barrett
  • In classic esophagitis, biopsies are not taken
    unless needed to exclude other diagnoses
  • When Barrett esophagus is suspected
  • biopsies are mandatory
  • best done when esophagitis is healed

Esophageal Biopsy
  • Where to biopsy?
  • If lesions are present
  • from the base of the lesion to demonstrate the
    depth of injury as well as reparative process
  • If no lesions are noted
  • at least 3 cm above the EG junction (Z-line) to
    look for reactive changes caused by reflux
  • Multiple biopsies are gathered because of the
    sporadic nature of the histological changes
  • Tissue closer to the Z-line is not sampled
    because of the decreased specificity for
    diagnosing GERD
  • Diagnostic yield
  • Depends on the sample size, biopsy location,
    tissue orientation, and the expertise of the

Esophageal Biopsy
  • Histopathology
  • The most sensitive markers are reactive
    epithelial changes
  • An increase in the basal cell layer greater than
    15 of the epithelium thickness or papillae
    elongation into the upper third of the epithelium
  • Papillae height increases because of loss of
    surface cells from acid injury
  • Basal cell hyperplasia is indicative of mucosal
  • These changes are also noted in up to 50 of
    healthy persons
  • Sensitive markers for GERD but have poor
  • Short-term inflammation characterized by the
    presence of neutrophils and eosinophils

Esophageal pH Monitoring
  • Ambulatory intraesophageal pH monitoring is now
    the standard for establishing pathologic reflux
  • Technique
  • The test is performed with a pH probe passed
    nasally and positioned 5 cm above the
    manometrically determined lower esophageal
    sphincter (LES)
  • The probe is connected to a battery-powered data
    logger capable of collecting pH values every 4 to
    6 seconds
  • An event marker is activated by the subject in
    response to symptoms, meals, and body position
  • Patients are encouraged to eat normally and have
    regular daily activities
  • Monitoring is carried out usually for 18 to 24
  • Reflux episodes are detected by a drop in pH to
    below 4

Esophageal pH Monitoring
  • Commonly measured parameters
  • percentage of total time at pH lt 4
  • percentage of time upright and supine at pH lt 4
  • total number of reflux episodes
  • duration of longest reflux episode
  • number of episodes greater than 5 minutes
  • Total percentage of time at pH lt 4
  • The most reproducible measurement for GERD
  • Reported upper limits of normal values ranging
    from 4 to 5.5

Esophageal pH Monitoring
  • Problems with esophageal pH monitoring
  • No absolute threshold value that reliably
    identifies pathologic GER
  • Validation studies comparing the presence of
    esophagitis with abnormal pH tests
  • Sensitivities ranging from 77 to 100
  • Specificities from 85 to 100.
  • False-negative studies caused by dietary or
    activity limitations from poor tolerability of
    the nasal probe

Esophageal pH Monitoring
  • Advantages of ambulatory esophageal pH monitoring
  • Ability to record and correlate symptoms with
    reflux episodes over extended periods
  • Replaced the shorter acid perfusion (Bernstein)
    test, the standard acid reflux (Tuttle) test and
    radionuclide scintigraphy

Esophageal pH Monitoring
  • Clinical applications for ambulatory pH
  • Patients with a normal endoscopy and suspected
    reflux symptoms
  • Before fundoplication, pH testing should be
    performed in patients with normal endoscopy to
    identify the presence of pathological reflux
  • Persistent or recurrent symptoms after antireflux
  • Evaluation of patients with reflux symptoms
    resistant to treatment with normal or equivocal
    endoscopic findings
  • pH testing may help in defining patients with
    extraesophageal manifestations of GERD

Barium Esophagram
  • Most useful in demonstrating structural narrowing
    of the esophagus
  • Consuming a 13-mm radiopaque pill along with the
    barium liquid is the most sensitive test
  • Sensitivity 95-100
  • Shows subtle findings usually missed by endoscopy
  • Schatzki rings, webs, or minimally narrowed
    peptic strictures
  • Allows good assessment of peristalsis
  • By giving the patient swallows of barium in the
    prone oblique position
  • Helpful preoperatively in identifying a weak
    esophageal pump

Barium Esophagram
  • Identifies GER when contrast moves in a
    retrograde fashion from the stomach into the
  • Only has a sensitivity of about 40 for defining
  • Provocative maneuvers can be used to elicit
    stress reflux but might also decrease its
  • Primarily used in evaluating the GERD patient
    with new-onset dysphagia because it can define
    subtle strictures and rings as well as assess
  • The ability to detect esophagitis varies
  • Also falls short when addressing the presence of
    a Barrett esophagus

Esophageal Manometry
  • Provides information on the functional ability of
    the esophageal muscles
  • Quantifies the contractile activities of the
    esophageal sphincters and body during swallowing
  • Records
  • Resting pressures of the lower and upper
    esophageal sphincters
  • The timing and completeness of the relaxation
  • In the esophageal body, peristalsis is evaluated
  • The presence, propagation, velocity, amplitude,
    and duration of contraction waves in response to
    wet swallows
  • Measurement of LES pressures logically should be
    associated with the severity of GERD because of
    its importance as a major barrier to reflux

Esophageal Manometry
  • Generally not indicated in the evaluation of the
    uncomplicated GERD patient
  • The vast majority of have a normal resting LES
    pressure, and transient LES relaxation is the
    primary mechanism by which their reflux occurs
  • Esophageal manometry is an essential test in the
    preoperative evaluation of patients before
    antireflux surgery
  • A normal LES pressure does not preclude surgery
  • Occasionally. an alternative diagnosis is made,
    which may change the clinical approach
  • Most importantly, the presence of ineffective
    peristalsis suggests a weak esophageal pump. A
    loose 360 fundoplication or an incomplete
    fundoplication will minimize the risk of
    postoperative dysphagia.

  • Richter, Joel E. Diagnostic tests for
    gastroesophageal reflux disease. Am J Med Sci.
    2003 Nov326(5)300-8.
  • Greenfield, LA et al. Surgery scientific
    principles and practice, 3rd ed. Lippincott
    Williams Wilkins, Philadelphia, 2001.
  • Duranceau A, Ferraro P, Jamieson GG.
    Evidence-based investigation for reflux disease.
    Chest Surg Clin N Am. 2001 Aug11(3)495-506, vi.