What is the next step in workup for a patient with persistent acid reflux in an outpatient Gastrointestinal (GI) setting when Esophagogastroduodenoscopy (EGD) does not show a hiatal hernia?

Next Step Workup for Persistent Acid Reflux with Normal EGD

For patients with persistent acid reflux symptoms despite a normal EGD (no hiatal hernia), the next step in outpatient GI workup should be prolonged wireless pH monitoring off PPI therapy to confirm and phenotype GERD or rule it out. 1

Diagnostic Algorithm for Persistent Reflux Symptoms

1. Confirm Absence of Erosive Disease

• EGD has already been performed and showed no hiatal hernia
• Ensure complete endoscopic evaluation was done, including:
  • Assessment for erosive esophagitis (LA classification)
  • Evaluation of diaphragmatic hiatus (Hill grade of flap valve)
  • Inspection for Barrett's esophagus 1

2. Objective Reflux Testing

• Prolonged wireless pH monitoring (96-hour preferred if available) 1, 2
  • Must be performed off PPI medication (discontinue PPI 7-14 days prior)
  • Provides definitive diagnosis of pathologic GERD
  • Helps categorize patients into:
    • No GERD: AET <4.0% on all days
    • Borderline GERD: AET ≥4.0% but not meeting criteria for conclusive GERD
    • Conclusive GERD: AET ≥6.0% on 2 or more days 1

3. Additional Testing Based on Clinical Suspicion

• High-resolution manometry if:
  • Rumination or esophageal motility disorder is suspected
  • Dysphagia is present
  • Considering anti-reflux procedures 1, 2
• Consider barium esophagram if:
  • Small hiatal hernia might have been missed on EGD
  • Functional assessment is needed 2

Management Based on pH Testing Results

If pH Testing Confirms GERD

• Optimize PPI therapy (appropriate timing, dosing)
• Consider twice-daily dosing for severe symptoms 1, 3
• Add adjunctive therapies based on symptom pattern:
  • Alginate antacids for breakthrough symptoms
  • H2-receptor antagonists for nighttime symptoms
  • Baclofen for regurgitation-predominant symptoms
  • Prokinetics if concurrent gastroparesis 1

If pH Testing Shows No GERD

• Discontinue PPI therapy
• Consider functional esophageal disorder diagnosis
• Implement:
  • Cognitive behavioral therapy
  • Gut-directed hypnotherapy
  • Neuromodulators as indicated 1

If pH Testing Shows Borderline GERD

• Optimize PPI to lowest effective dose
• Aggressive lifestyle modifications and weight management
• Consider on-demand therapy with H2 blockers/antacids 1

Persistent Symptoms After Optimization

If symptoms persist despite appropriate therapy based on pH testing:

• Consider pH-impedance monitoring ON PPI therapy to determine mechanism of persisting symptoms 1
• Evaluate for non-GERD causes of symptoms (functional heartburn, esophageal hypersensitivity)

Important Caveats

1. Small hiatal hernias can be missed on EGD, with sensitivity varying by hernia size 4
2. The absence of hiatal hernia doesn't rule out GERD, as reflux can occur through other mechanisms 5, 6
3. Motility disorders of the tubular esophagus can contribute to reflux symptoms even without hiatal hernia 7
4. Endoscopic anti-reflux procedures may be considered for patients with proven GERD without hiatal hernia 8

Remember that objective testing is crucial in this scenario, as empiric PPI therapy without diagnostic confirmation can lead to inappropriate long-term medication use in patients who don't actually have GERD.