Is a patient with a positive distal esophagus acid DeMeester score but no symptoms or pathological reflux a candidate for Endoscopic Gastric Fundoplication?

Endoscopic Gastric Fundoplication is Not Indicated for Patients with Positive DeMeester Score but No Symptoms or Pathological Reflux

Endoscopic gastric fundoplication is not indicated for a patient with a positive distal esophagus acid DeMeester score of 26 but no symptoms and no pathological reflux. This patient lacks the necessary criteria for anti-reflux interventions according to current guidelines.

Patient Selection Criteria for Anti-Reflux Procedures

The American Gastroenterological Association (AGA) provides clear guidance on appropriate candidates for anti-reflux procedures:

Required Criteria for Intervention:

• Objective evidence of pathological GERD
• Presence of symptoms related to reflux
• Confirmatory testing showing correlation between symptoms and reflux events

Assessment of Current Patient:

• Positive DeMeester score (26) but explicitly noted to have "no pathological reflux"
• No symptoms related to reflux (explicitly stated)
• No symptom-reflux correlation (cannot exist without symptoms)

Evidence-Based Decision Making

The 2022 AGA Clinical Practice Update on GERD management clearly states that "candidacy for invasive anti-reflux procedures includes confirmatory evidence of pathologic GERD" 1. This patient has contradictory findings - a positive DeMeester score but "no pathological reflux" - which requires careful interpretation.

The guidelines further specify that anti-reflux procedures should only be considered in "highly selected patients" with:

1. Concomitant heartburn/regurgitation (absent in this patient)
2. Prior response to PPI therapy (not applicable without symptoms)
3. High burden of acid reflux demonstrated by pH monitoring 1

Interpretation of Conflicting Test Results

When pH study results and clinical presentation conflict, the 2022 AGA guidelines recommend prioritizing the clinical picture. A positive DeMeester score alone is insufficient to warrant intervention when:

• The patient explicitly has "no pathological reflux" per clinical assessment
• The patient has no symptoms related to reflux

Management Algorithm for This Patient

1. Do not proceed with endoscopic gastric fundoplication
2. Consider re-evaluation of the pH study results, as there appears to be a discrepancy between the DeMeester score and the clinical assessment of "no pathological reflux"
3. Monitor for development of symptoms over time
4. If symptoms develop in the future, reassess using comprehensive testing including:
   • Endoscopy to evaluate for esophagitis
   • Repeat pH monitoring
   • Assessment of symptom correlation with reflux events

Common Pitfalls to Avoid

• Treating the number, not the patient: Research shows that symptomatic response to treatment is a poor indicator of actual acid exposure 2. The reverse is also true - abnormal acid exposure without symptoms may not require intervention.
• Overreliance on a single test parameter: The DeMeester score should be interpreted in context with other clinical findings.
• Performing unnecessary procedures: Endoscopic fundoplication carries risks including bleeding, perforation, and mediastinal abscess 3, 4.

Endoscopic fundoplication is best suited for patients with small hiatal hernias, mild-to-moderate typical symptoms, and documented pathological reflux 3, none of which are present in this case.