Gastroesophageal Reflux Disease Workup

  • Author: Marco G Patti, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Mar 26, 2012
 

Approach Considerations

Mandatory studies include upper GI endoscopy and manometry. Endoscopy can help confirm the diagnosis of reflux by demonstrating complications of reflux (esophagitis, strictures, Barrett esophagus) and can help in evaluating the anatomy (eg, hiatal hernia, masses, strictures). Manometry helps surgical planning by determining the lower esophageal sphincter (LES) pressure and identifying any esophageal motility disorders. Esophageal amplitudes and propagation of esophageal swallows are also evaluated.

Optional studies include 24-hour pH probe test and upper GI series. Use of 24-hour pH testing helps confirm the diagnosis in patients in whom the history is not clear, atypical symptoms dominate the clinical picture, or endoscopy shows no complications of reflux disease. Upper GI series can be ordered to further delineate the anatomy. Hiatal hernias can be evaluated (size) and reflux can be demonstrated. In addition, gastric emptying can be evaluated to a limited. If a question exists regarding inadequate gastric emptying or if the patient has a history of nausea and vomiting, a nuclear medicine gastric emptying study can be obtained.

At the authors' institution, endoscopy, manometry, and 24-hour pH studies are obtained routinely. Upper GI series and nuclear medicine gastric emptying studies are ordered only if clinically indicated. Currently, no role exists for CT, MRI, or ultrasonography in the routine evaluation of patients with reflux disease.

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Upper Gastrointestinal Endoscopy

Esophagogastroduodenoscopy (EGD) demonstrates anatomy and identifies the possible presence and severity of complications of reflux disease (esophagitis, Barrett esophagus, strictures) (see the image below). Using the patient's history and pathologic analysis of biopsy specimens obtained during endoscopy, the diagnosis of GERD can be made. EGD also excludes the presence of other diseases (eg, peptic ulcer) that can present similarly to GERD.

Esophagogastroduodenoscopy indicating Barrett esopEsophagogastroduodenoscopy indicating Barrett esophagus.

Although EGD is frequently performed to help diagnose GERD, it is not the most cost-effective diagnostic study, because esophagitis is present in only 50% of patients with GERD.

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Esophageal Manometry

Esophageal manometry defines the function of the LES and the esophageal body (peristalsis). Esophageal manometry is essential for correctly positioning the probe for the 24-hour pH monitoring.

Indications for esophageal manometry and prolonged pH monitoring include the following:

  • Persistence of symptoms while taking adequate antisecretory therapy, such as PPI therapy
  • Recurrence of symptoms after discontinuation of acid-reducing medications
  • Investigation of atypical symptoms, such as chest pain or asthma, in patients without esophagitis
  • Confirmation of the diagnosis in preparation for antireflux surgery
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Ambulatory 24-Hour pH Monitoring

Ambulatory 24-hour pH monitoring is the criterion standard in establishing a diagnosis of GERD, with a sensitivity of 96% and a specificity of 95%. It quantifies the gastroesophageal reflux and allows a correlation between the symptoms of reflux and the episodes of reflux.

Patients with endoscopically confirmed esophagitis do not need pH monitoring to establish a diagnosis of GERD.

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Imaging in Gastroesophageal Reflux Disease

Plain radiographic findings are not useful in evaluating patients for GERD, but they are helpful in evaluating pulmonary status and basic anatomy. Chest images may demonstrate a large hiatal hernia, but small hernias can be easily missed. Upper GI contrast-enhanced studies are the initial radiologic procedure of choice in the workup of the patient in whom GERD is suggested. Esophageal inflammatory and neoplastic diseases are better detected with double-contrast techniques. Conversely, single-contrast techniques are more sensitive for structural defects such as hiatal hernias and strictures or esophageal rings.[26]

Although delayed gastric emptying is present in as many as 60% of patients with GERD, this emptying is usually a minor factor in the pathogenesis of the disease in most patients (except in patients with advanced diabetes mellitus or connective tissue disorders). Patients with delayed gastric emptying typically experience postprandial bloating and fullness in addition to other symptoms. Gastric-emptying studies may be worthwhile in the evaluation of patients in whom delayed gastric emptying is believed to contribute to the manifestation of GERD symptoms.

Please go to the main article on Imaging in Gastroesophageal Reflux Disease for more information.

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Nuclear Medicine Gastric Emptying Study

Gastroesophageal reflux scintigraphy can be performed with acidified orange juice labeled with technetium-99m sulfur colloid. Compared with fluoroscopy, this allows for a longer time of evaluation, a decreased radiation dose, and the ability to semiquantitate the amount of reflux. However, gastroesophageal reflux scintigraphy has little role in the adult patient due to limited sensitivity and the availability of other methods of evaluation.

Gastroesophageal reflux scintigraphy is much more commonly used in infants and children due to the noninvasive nature of the study and relatively low radiation dose. In infants and children the study is often performed with labeled milk. In addition to evaluating the degree of reflux, pulmonary aspiration can be detected by imaging over the lungs.

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Intraluminal Esophageal Electrical Impedance

Intraluminal esophageal electrical impedance (EEI), a newer test, is useful for detecting both acid reflux and nonacid reflux by measuring retrograde flow in the esophagus. Gastroesophageal reflux episodes as brief as 15 seconds may be measured (see the image below).

The image is a representation of concomitant intraThe image is a representation of concomitant intraesophageal pH and esophageal electrical impedance measurements. The vertical solid arrow indicates commencement of a nonacid gastroesophageal reflux (GER) episode (diagonal arrow). The vertical dashed arrow indicates the onset of a normal swallow.

In adult studies, impedance measurements have been used in conjunction with 24-hour intraesophageal pH monitoring in order to provide a more complete picture of bolus movement in the esophagus. EEI has not been thoroughly validated, and normal values have not been determined in the pediatric age group.

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Contributor Information and Disclosures
Author

Marco G Patti, MD  Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine

Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Surgical Association, Association for Academic Surgery, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, and Western Surgical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Showkat Bashir, MD  Assistant Professor, Department of Medicine, Division of Gastroenterology, George Washington University, Washington, DC

Showkat Bashir, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Medical Association

Disclosure: Nothing to disclose.

Jack Bragg, DO  Associate Professor, Department of Clinical Medicine, University of Missouri School of Medicine

Jack Bragg, DO is a member of the following medical societies: American College of Osteopathic Internists and American Osteopathic Association

Disclosure: Nothing to disclose.

Abhishek Choudhary, MD  Resident Physician, Department of Internal Medicine, University Hospital of Missouri-Columbia

Abhishek Choudhary, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Abraham H Dachman, MD, FACR  Professor, Department of Radiology, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine; Director of CT, Department of Radiology, The University of Chicago Hospitals

Abraham H Dachman, MD, FACR is a member of the following medical societies: Radiological Society of North America

Disclosure: iCAD, Inc. Consulting fee Consulting; GE Healtcare, Inc. Honoraria Speaking and teaching

Gautam Dehadrai, MD  Department Chair, Section Chief, Department of Interventional Radiology, Norman Regional Hospital

Gautam Dehadrai, MD is a member of the following medical societies: American College of Radiology, Medical Council of India, and Radiological Society of North America

Disclosure: Nothing to disclose.

Fernando AM Herbella, MD, PhD, TCBC  Affiliate Professor, Attending Surgeon in Gastrointestinal Surgery, Esophagus and Stomach Division, Department of Surgery, Federal University of Sao Paulo, Brazil; Private Practice; Medical Examiner, Sao Paulo's Medical Examiner's Office Headquarters, Brazil

Fernando AM Herbella, MD, PhD, TCBC is a member of the following medical societies: Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Eugene C Lin, MD  Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine

Disclosure: Nothing to disclose.

Mohamed Othman, MD  Resident Physician, Department of Internal Medicine, University of New Mexico School of Medicine

Disclosure: Nothing to disclose.

Praveen K Roy, MD, AGAF  Gastroenterologist, Ochsner Clinic Foundation; Adjunct Associate Research Scientist, Lovelace Respiratory Research Institute; Editor-in-Chief, The Internet Journal of Gasteroenterology; Editorial Board, Signal Transduction Insights; Editorial Board, The Internet Journal of Epidemiology; Editorial Board, Gastrointestinal Endoscopy Review Letter

Praveen K Roy, MD, AGAF is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Michael AJ Sawyer, MD  Consulting Staff, Department of Surgery, Southwestern Medical Center; Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Inc

Michael AJ Sawyer, MD is a member of the following medical societies: American College of Surgeons, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Homayoun Shojamanesh, MD  Former Fellow, Digestive Diseases Branch, National Institutes of Health

Homayoun Shojamanesh, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Manish K Varma, MD  Chief of Interventional Radiology, Department of Radiology, Tripler Army Medical Center

Manish K Varma, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America

Disclosure: Nothing to disclose.

Specialty Editor Board

John Gunn Lee, MD  Director of Pancreaticobiliary Service, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, University of California at Irvine School of Medicine

John Gunn Lee, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Noel Williams, MD  Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

David Chelmow, MD  Leo J Dunn Distinguished Professor and Chair, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, American Society for Colposcopy and Cervical Pathology, Association of Professors of Gynecology and Obstetrics, Council of University Chairs of Obstetrics and Gynecology, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Piero Marco Fisichella, MD and Thomas F Murphy, MD, to the development and writing of the source articles.

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Relationship of the phrenoesophageal ligament to the diaphragm and esophagus.
Arterial blood supply and lymphatic drainage of the esophagus.
Barium swallow indicating hiatal hernia.
Ambulatory pH monitoring indicating episodes of reflux correlating with the heartburn experienced by the patient.
Peptic esophagitis. A rapid urease test (RUT) is performed on the esophageal biopsy sample. The result is positive for esophagitis.
Reflux esophagitis is demonstrated on barium esophagram.
Esophagogastroduodenoscopy indicating Barrett esophagus.
Gastroesophageal reflux disease (GERD)/Barrett esophagus/adenocarcinoma sequence.
Endoscopy demonstrating intraluminal esophageal cancer.
The image is a representation of concomitant intraesophageal pH and esophageal electrical impedance measurements. The vertical solid arrow indicates commencement of a nonacid gastroesophageal reflux (GER) episode (diagonal arrow). The vertical dashed arrow indicates the onset of a normal swallow.
Nissen fundoplication.
Laparoscopic Nissen fundoplication.
Hiatal hernia.
 
 
 
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