The diagnosis of gastroesophageal reflux disease (GERD) serves the following purposes:
- Visualization of any mucosal damage (up to Barret’s esophagus).
- Determination of the extent of reflux (reflux).
- Clarification of the respective etiology (cause).
Notice:
- Medical device diagnosis is required only in the presence of alarm symptoms, risk factors, atypical symptoms, or failure of 4 weeks of proton pump inhibitor (PPI; acid blocker) therapy. See also under “Symptoms – complaints / warning signs (red flags) and risk factors“.
- If reflux disease is not confirmed, it is recommended that medical device diagnostics be performed without a proton pump inhibitor (“off” PPI; without an acid blocker).
Optional medical device diagnostics – depending on the results of the history, physical examination, laboratory diagnostics and obligatory medical device diagnostics – for differential diagnostic clarification.
- Esophago-gastro-duodenoscopy (EGD; endoscopy of esophagus, stomach, and duodenum)* – for suspected Barrett’s esophagus as chromoendoscopy by applying acetic acid or methylene blue to the mucosa to detect dysplastic areas; targeted biopsy from all suspicious lesions (in case of Barrett’s esophagus additionally 4-quadrant biopsies); furthermore, complications such as peptic stenosis are searched for; an inconspicuous macroscopic finding does not exclude GERD! Furthermore, OED is indicated (indicated) in:
- Dysphagia (difficulty swallowing), odynophagia (pain on swallowing), recurrent (“recurring”) vomiting, (involuntary) weight loss, anemia (anemia), evidence of gastrointestinal blood loss (gastrointestinal bleeding) or a mass
Note: An unremarkable endoscopy (mirror examination) does not exclude reflux disease, rather in such cases the performance of reflux monitoring (pH-metry or multichannel intraluminal impedance pH-metry) is required.
- Esophageal pre-swallow (administration of a water-soluble contrast agent to assess esophageal passage into the stomach and gastric emptying) – in cases of suspected passenger disorders due to stenosis (narrowing) or stricture (high-grade constriction); indication: patients with recurrent vomiting and dysphagia (difficulty swallowing).
- Abdominal ultrasonography (ultrasound of abdominal organs) – to visualize the gastroesophageal junction; to exclude the differential diagnosis of pyloric stenosis (in infants).
- With the help of the so-called amber test, endoscopically invisible inflammation of the esophageal mucosa can be detected. It is for this purpose diluted hydrochloric acid and physiological saline solution dribbled onto the esophagus. In patients with reflux esophagitis, dilute hydrochloric acid triggers heartburn, but physiological saline does not. In healthy people, on the other hand, neither hydrochloric acid nor saline solution cause discomfort.
- Esophageal manometry (recording of muscular pressure (muscle tone) using a thin probe) – To determine if there is reduced pressure in the lower esophageal sphincter (UES). Esophageal peristalsis is also measured.Indications (areas of application):
- Dysphagia dysphagia) in the case of suspected primary motility disorder of the esophagus (movement disorder of the esophagus) and in the case of inconspicuous endoscopy including biopsies (mirror examination including tissue samples).
- Identification of differential diagnoses in patients who do not respond adequately to PPI therapy.
- Prior to antireflux surgery (required!).
Note: Esophageal manometry is not a method to diagnose reflux disease.
- 24-h pH-metry* * (acid measurement) – measures pH fluctuations in the esophagus. Advantageous here is the longer measurement duration (“more physiological conditions”). The reflux index RI (% of time pH < 4) is assessed. If necessary, perform a 24-hour pH-metry-Mll (multicanal intraluminal impedance measurement). This also allows the recording of a slightly acidic or non-acidic reflux and additionally records the rising height of the reflux episodes. Indication (field of application):
- Reflux symptoms (eg.B. Heartburn) that do not respond to empirical PPI therapy (therapy with proton pump inhibitors; proton pump inhibitors), i.e. clarification of whether the treatment failure is due to the persistence of acid reflux (pH-metry, if necessary bipolar) or pathological non-acid reflux (impedance pH-metry; see above).
[“true NERD” (non-erosive reflux disease, NERD; Non erosive reflux disease) is present when a pathological (pathological) acid exposure (AET) can be detected in endoscopically (by mirroring) inconspicuous gastroesophageal transition (esophagus-stomach): Acid exposure of > 6% “acid exposure time”(AET)/24 h in pH-metry or > 80 reflux episodes/24 h]
- Electrocardiogram (ECG; recording of the electrical activity of the heart muscle) – to exclude cardiac causes.
* Based on the extent of lesions detected, Savary and Miller distinguish four stages of disease (see below Gastroesophageal Refux Disease/Classification). * * To confirm the diagnosis of reflux disease, at least 5 days of PPI abstinence (“off PPI”); if persistent symptoms are present despite PPI therapy, then examination under therapy (“on PPI”) is reasonable.
