Diagnosis of GERD in typical and atypical cases (Part 1)

This is an automatically translated article.

Posted by Master, Doctor Mai Vien Phuong - Department of Examination & Internal Medicine - Vinmec Central Park International General Hospital

The most common atypical presentation of GERD may include ear, nose, and throat (ENT) symptoms, pulmonary (chronic cough or asthma), or cardiac symptoms (noncardiac chest pain). Therefore, GERD should be strongly considered in the differential diagnosis of patients with atypical symptoms when alternative diagnoses have been ruled out by another specialist (ear, nose and throat surgeon, physician) Cardiologist, Respiratory Physician, Allergist).

1. Empiric therapy

In patients with a history suggestive of uncomplicated GERD presenting with typical symptoms of heartburn and/or regurgitation may be treated empiric. Typical symptoms in response to acid suppression provide further evidence for pathological esophageal acidosis and it is reasonable to assume the diagnosis of GERD in patients who respond to appropriate therapy. On the other hand, typical symptoms that do not improve require further testing to demonstrate the existence of GERD and evaluation for an alternative diagnosis. Similarly, patients with atypical presentation or noncardiac chest pain should be considered for esophageal function testing prior to empiric therapy.
However, this empiric test is contraindicated in patients with alarming symptoms such as dysphagia, weight loss, and bleeding according to the five recommendations of the Italian Association of Hospital Gastroenterologists (AIGO).

2. Upper gastrointestinal endoscopy

Upper gastrointestinal endoscopy allows evaluation of the esophageal mucosa in GERD patients and biopsy samples of associated lesions (eg, Barrett's metaplasia, esophageal stricture or tumor). There are limitations to the use of upper endoscopy in the diagnosis of GERD. Erosive reflux disease (ERD) occurs in a small number of patients with GERD (<30%), whereas the majority of them are included in the non-erosive reflux disease (NERD) phenotype, which is characterized Because of typical reflux symptoms, mainly heartburn, no esophageal mucosal lesions were visible on upper gastrointestinal endoscopy. Patients with atypical GERD symptoms often have a low incidence of endoscopic esophagitis. Therefore, upper gastrointestinal endoscopy is not diagnostic and is mainly performed to evaluate GERD-related complications and alternative diagnoses. Patients with alarming symptoms, such as anemia, weight loss and dysphagia, or a history of chronic GERD, and who are 50 years of age or older should have Barrett's esophagus endoscopically.

3. Contrast X-ray with Baryt Contrast

Baryt radiographs have historically been considered part of a potential diagnostic approach in patients with esophageal symptoms, including GERD. Although well-performed Baryt esophagography with dual contrast can detect signs of esophagitis, the overall sensitivity of this test is extremely low. The detection of reflux with Baryt contrast above the thoracic entry with or without provocative manipulations including water siphon testing increases the sensitivity of the Baryt contrast test; however, is not sufficient to be recommended as a diagnostic test without dysphagia.

4. Esophageal pressure measurement

Esophageal manometry is now considered the gold standard test for diagnosing esophageal dysfunction that can cause symptoms such as difficulty swallowing and chest pain. However, it has shown limited ability to diagnose GERD. With the advent of high-resolution manometers, it is now possible to more accurately assess esophageal motility. Furthermore, new measures have been developed to investigate the morphology and function of the gastroesophageal junction (EGJ). In particular, the antireflux barrier function of the gastroesophageal junction can now be assessed by evaluating the contractility integral of the junction. In addition, transient lower esophageal sphincter dilation can be more accurately identified with high-resolution manometry. Neither a decrease in lower esophageal sphincter pressure nor the presence of a motility abnormality are specific enough to diagnose GERD.

5. Measure Bilirubin concentration in 24 hours

Bilimeter allows spectral measurement of bilirubin levels in the esophagus due to gastroduodenal reflux (gastroduodenal reflux).
Although the role of bile in the pathogenesis of esophageal mucosal injury is unknown and there is a high prevalence of both acid and non-acid reflux, some authors recommend simultaneous monitoring of pH and measure billan.
The main indications for dual monitoring are patients with typical GERD symptoms who respond poorly to PPI therapy.
Bilitec 2000 is a new spectrophotometer system. Unfortunately, this technology is only a semi-quantitative measure for the detection of GERD. Validation studies show that this device underestimates bile reflux in acidic environments (pH <3.5). In solutions with pH <3.5, bilirubin undergoes monomer isomerization to dimer as reflected by a change in absorption wavelength from 435 nm to 400 nm. Since the Bilitec reading is based on absorption detection at 470 nm, this variation underestimates the extent of GERD. Therefore, Bilitec measurements of GERD should always be accompanied by simultaneous measurements of acid exposure by pH monitoring. Furthermore, many substances can cause false-positive results by Biltec, as it indiscriminately records any substances absorbed around 470 nm such as heme (i.e. during emesis), porphyrins, carotenoids , riboflavin and various foods such as tomatoes, bananas, carrots, beets, parmesan, cheeses, meat, tea and coffee. In addition, solid food can interfere with the transducer and reduce the accuracy of the records, for these reasons a standardized liquid diet is recommended to allow for registration. However, there was a limitation in the registration of gastroduodenal reflux patterns due to a different and lower calorie diet.
Although the measurement of bilirubin adds valuable information about the chemical nature of the flowing material, there are a number of limitations that do not allow for accurate and precise detection of the onset and frequency of flushes. gastroduodenal reverse.
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References
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