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Diagnosis of Gastro-Esophageal Reflux Disease (GERD)

By Dr Ananya Mandal, MD

Gastro-Esophageal Reflux Disease (GERD) is most commonly diagnosed based on the symptoms. Typical symptoms include heart burn, acid regurgitation and difficulty in swallowing.

Diagnosis of GERD entails taking a medical history, a physical examination and so forth. 1-5

Medical history

This includes a history of a similar condition in the family and other relevant points like intake of certain drugs like pain relievers (Ibuprofen), calcium channel blockers (for high blood pressure), antidepressants, corticosteroids, bisphosphonates (for osteoporosis) etc.

Physical examination

Physical examination is usually performed to look for features like anemia, weight loss and malnutrition due to difficulty in swallowing.

Acid seepage into the airways may lead to worsening of asthma and other respiratory conditions like lung abscess, pneumonia and interstitial pulmonary fibrosis. These may be noted on examination.

Further tests

Further tests are advised if the patient has severe difficulty swallowing or if they show no improvement on taking medication

Alternative diagnosis

Other possible causes that may lead to similar symptoms include:

  • irritable bowel syndrome

  • esophagitis due to swallowed corrosives or drugs like NSAIDS

  • infections in HIV positive

  • other immune-suppressed patients due to herpes, candida, cytomegalovirus etc.

Other causes of similar symptoms are gastric or esophageal cancers, peptic ulcer, esophageal spasm etc.

Endoscopy

Endoscopy is a procedure where an instrument called an endoscope examines the insides of the esophagus.

This is a long thin flexible tube with a camera on its tip. The camera sends images of the examined area to the external monitor. The endoscope is inserted into the mouth and passed into the esophagus.

The patient is usually awake but sedated during the procedure. The endoscope checks the insides of the esophagus for possible irritation and inflammation caused by the regurgitating acid. It can also rule out more serious conditions that can also cause heartburn, such as stomach or esophagus cancer.

After endoscopy the lesions are graded for severity using the Savary Miller grading system;

  1. Grade 1: single or multiple erosions on a single fold.

  2. Grade 2: multiple erosions affecting multiple folds. Erosions may be confluent.

  3. Grade 3: multiple circumferential or rounded erosions.

  4. Grade 4: ulcer, stenosis or esophageal shortening.

  5. Grade 5: Barrett's epithelium. Columnar metaplasia (cellular changes on the miscroscopic level) in the form of circular or non-circular (islands or tongues) extensions.

Manometry

Manometry is suggested if endoscopy does not find any evidence of damage to the esophagus. This assesses the strength of the lower esophageal sphincter (LES). It measures the pressure levels inside the sphincter muscle.

During the procedure one of the nostrils will be numbed using a topical anaesthetic. A small tube will then be passed down it into the esophagus up to the LES.

The tube contains a number of pressure sensors that are connected to an external computer. The patient is then given some food and drink to swallow and the pressure at the LES is recorded.

A manometry test takes around 20 to 30 minutes and is usually not painful. It may leave a slight nosebleed or a sore throat but these usually resolve without treatment.

Manometry can be useful for confirming a diagnosis of GERD and also helps to detect other conditions like muscle spasms or achalasia cardia (a defect of the esophageal muscles).

24 hour pH monitoring

If manometry is unable to detect GERD a 24 hour pH monitoring is recommended. pH is a unit of measurement used in chemistry, and describes how acidic a solution is. The lower the pH level, the more acidic the solution.

This test looks at the pH levels around the esophagus. Before the test the patient is advised to stop all GERD medications for at least 7 days.

During the test, a small tube containing a probe will be passed through the nostril into the esophagus. This is usually done after applying a local anesthetic within the nose. The probe is connected to a portable recording device that is worn around the wrist.

Throughout the 24-hour test period the patient presses a button when he or she is aware of symptoms. A normal diet ensures a regular recording. If test results indicate a sudden rise in the pH levels after meals, GERD can be diagnosed.

A wireless pH monitoring capsule may also be sued for the same purpose. There is no gold standard for diagnosing GERD however 24-hour pH monitoring is the accepted standard for establishing or excluding its presence.

Oesophageal impedance and pH via nasal catheter is used to check for actual reflux and changes in the pH.

Barium swallow test

This assesses the ability to swallow and also finds the site of the problem. The test can often identify blockages or problems with the muscles used during swallowing.

Patient is given a barium solution to drink. Barium is a non-toxic chemical. Then a series of X rays of the chest is taken to see how the Barium moves down the esophagus into the stomach. The test helps in detection of hiatus hernia as well.

A Barium swallow test involves fasting for at least 6 hours before the test. A barium swallow usually takes about 15 minutes to perform. There may be a mild nausea or constipation after the test. These usually resolve without therapy.

Stools may be white for a few days afterwards as the barium passes through the system. Barium radiology is seldom useful for diagnosing GERD.

Blood tests

Routine blood tests are performed to rule out anemia.

Reviewed by , BA Hons (Cantab)

Further Reading

Last Updated: Aug 12, 2012

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