Investigations
1st investigations to order
Investigations to consider
oesophagogastroduodenoscopy (OGD)
Test
Indicated for alarm symptoms or symptoms suggesting complicated disease (atypical, persistent, or relapsing symptoms).[1][5][37][38][Figure caption and citation for the preceding image starts]: Moderate to severe oesophagitis with multiple linear, clean-based oesophageal ulcersFrom the collection of Dr Douglas G. Adler; used with permission [Citation ends].
Consider evaluation for non-gastrointestinal causes before endoscopy in patients with isolated extra-oesophageal features (e.g., laryngitis, globus, tooth enamel erosion, halitosis).[6]
PPIs should be stopped 2-4 weeks before the procedure.[1]
Normal mucosa is the most common finding in patients with typical GORD symptoms.[1] Routine biopsies are not recommended if there are no clinical and/or endoscopic features suggestive of eosinophilic oesophagitis or Barrett's oesophagus.[38][46] Biopsies should be performed if endoscopy is performed for refractory GORD, even if the mucosa appears normal.[1]
Evidence is conflicting as to whether the frequency and severity of symptoms can predict Barrett's oesophagus, severity of oesophagitis, or other complications. Healing of higher grades of erosive oesophagitis may be associated with the finding of Barrett's oesophagus. Thus, if endoscopy is performed because of concern for Barrett's oesophagus (e.g., long-standing symptoms), it may be best to carry out the procedure after an 8-week course of proton-pump inhibitor treatment.[38]
Result
normal or may show oesophagitis (erosion, ulcerations, strictures) or Barrett's oesophagus
ambulatory pH monitoring
Test
Ambulatory pH monitoring can demonstrate abnormal exposure to oesophageal acid in the absence of oesophagitis.[47]
There are two types of pH monitoring: naso-oesophageal catheter and wireless radiotelemetry capsule monitoring. Wireless radiotelemetry allows monitoring for 48 hours without a naso-oesophageal catheter, which results in less discomfort and fewer interruptions of daily activities.
Either ambulatory pH or impedance-pH is recommended to evaluate patients with a suspected oesophageal GORD syndrome who have not responded to an empirical trial of PPI therapy, have normal findings on endoscopy, and have no major motor abnormality on manometry.[1][3]
Controversy exists whether to perform pH monitoring while on or off PPI therapy. AGA guidance recommends ambulatory pH or impedance-pH monitoring while off PPI therapy for 7 days.[3][37] The Lyon Consensus recommends pH testing off PPI therapy for patients with no (or low-grade) oesophagitis at endoscopy and no prior positive pH testings.[48]
To measure non-acid reflux, ACG guidelines recommend impedance-pH monitoring while on PPI therapy.[1]
Result
pH <4 more than 4% of the time is abnormal
oesophageal manometry
Test
Manometry evaluates oesophageal contractions and lower oesophageal sphincter function. It may detect subtle presentations of oesophageal motility disorders such as achalasia or diffuse oesophageal spasm.
According to the American Gastroenterological Association guidelines , motility abnormalities associated with GORD can be detected using high-resolution oesophageal manometry; however, manometry should not be used as the sole diagnostic test.[1]
UK guidelines recommend that manometry is performed prior to anti-reflux surgery.[49]
The American College of Gastroenterology advises that manometry is performed before anti-reflux surgery, in patients unresponsive to PPIs in whom impedance-pH monitoring has not determined an aetiology, and in patients with non-cardiac chest pain, especially those who have not responded to a trial of PPIs.[1]
Result
may suggest achalasia, oesophageal spasm, or other motor disorders
combined impedance-pH testing
Test
Oesophageal impedance testing detects antegrade and retrograde bolus transit of liquid and gas. Impedance monitoring cannot detect the acid content or volume of the intraluminal contents. Therefore, a pH probe is usually incorporated into the assembly.
Combined impedance-pH monitoring can thus detect acid as well as non-acid reflux, to assess correlation with symptoms.[3][50]
Either ambulatory pH or impedance-pH is recommended to evaluate patients with a suspected oesophageal GORD syndrome who have not responded to an empirical trial of PPI therapy, have normal findings on endoscopy, and have no major motor abnormality on manometry.[1][3]
Controversy exists whether to perform pH monitoring while on or off PPI therapy. AGA guidance recommends ambulatory pH or impedance-pH monitoring while off PPI therapy for 7 days.[3][37]
To measure non-acid reflux, ACG guidelines recommend impedance-pH monitoring while on PPI therapy.[1]
Outcome studies evaluating usefulness are needed for impedance-pH testing in investigation of refractory reflux symptoms.[51][52]
For patients who have heartburn or regurgitation that has not responded to twice-daily PPIs, UK guidelines recommend combined pH-impedance testing while off acid suppression therapy.[49]
Result
may detect acid or non-acid reflux events
barium swallow
Test
A barium swallow may be useful in patients with dysphagia for whom endoscopy is contraindicated or unavailable.[42][43]
Barium imaging should not be used solely as a diagnostic test for GORD.[1] The presence of reflux on a barium oesophagram has poor sensitivity and specificity for GORD, compared with pH testing.[1]
Result
may exclude other causes of dysphagia
oesophageal capsule endoscopy
Test
Involves swallowing a capsule endoscope to visualise the oesophagus. Capsule endoscopy does not require sedation.
A less-invasive alternative to upper endoscopy, and a potential screening and diagnostic tool to evaluate oesophageal pathology. Studies have shown only moderate sensitivity and specificity for diagnosis of oesophageal disorders, and it has a limited role and acceptance in screening for mucosal disease (erosive oesophagitis and Barrett's oesophagus).[39][40][41]
Capsule endoscopy is done for patient convenience in select circumstances. It is contraindicated in the presence of suspected (e.g., presence of dysphagia) or known stricture or adhesions.
Result
may show oesophagitis or Barrett's oesophagus
Emerging tests
endoluminal functional lumen imaging probe
Test
FDA approved catheter-based assessment that simultaneously measures the cross-sectional area, distensibility, and intraluminal pressure of the oesophagus. Performed during upper endoscopy.
Due to limited evidence, the endoluminal functional lumen imaging probe is not currently recommended in routine GORD management.[53]
Result
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