What is the purpose and procedure of the BRAVO (Bravo Acid Reflux Test) test for patients with suspected Gastroesophageal Reflux Disease (GERD)?

BRAVO Test for GERD Diagnosis

The BRAVO pH monitoring system is the preferred ambulatory reflux monitoring method for objectively assessing GERD in symptomatic patients, as it provides prolonged wireless pH monitoring for up to 96 hours to account for day-to-day variability in acid exposure. 1

Purpose of BRAVO Test

The BRAVO test serves several critical purposes in GERD diagnosis:

• Quantifies esophageal acid exposure to facilitate objective GERD diagnosis, particularly in non-erosive reflux disease 1
• Assesses the relationship between patient-reported symptoms and acid reflux episodes 1
• Confirms excess esophageal acid exposure before antireflux surgery 1
• Evaluates patients with persistent symptoms despite PPI therapy 1
• Determines appropriateness of long-term PPI therapy in patients with unproven GERD 1
• Helps diagnose extraesophageal manifestations of GERD when other tests are inconclusive 1

Procedure of BRAVO Test

The BRAVO pH monitoring procedure involves several key steps:

1. Placement: The pH capsule is introduced via a trans-oral catheter during sedated esophagogastroduodenoscopy (EGD) 1
2. Attachment: The capsule adheres to the distal esophagus (6 cm proximal to the endoscopically identified squamocolumnar junction) using a vacuum suction mechanism 1
3. Monitoring Period: The capsule measures acid exposure for up to 96 hours (based on recorder battery life), though 48 hours is the minimum recommended duration 1
4. Data Collection: The patient carries a small external receiver that records pH data transmitted from the capsule 2
5. Symptom Recording: Patients record symptoms using a diary or button on the recorder to establish temporal relationships with reflux events 1
6. Capsule Detachment: The capsule naturally detaches and passes through the digestive system within 7-10 days 3, 2

Clinical Indications

BRAVO pH monitoring is indicated in the following scenarios:

• Patients with heartburn or regurgitation not responding to twice-daily PPIs 1
• Before antireflux surgery to confirm excess esophageal acid exposure 1
• Patients with persistent symptoms following antireflux surgery 1
• Patients with isolated extraesophageal symptoms suspected to be due to GERD 1
• Establishing appropriateness of long-term PPI therapy in patients with unproven GERD 1
• Patients with idiopathic pulmonary fibrosis or other pulmonary disorders that might require lung transplantation 1

Advantages Over Traditional pH Monitoring

The BRAVO system offers several advantages over catheter-based systems:

• Improved patient comfort and tolerance 2, 4
• Less interference with normal daily activities, eating, and sleeping 4
• Extended monitoring period (up to 96 hours vs. 24 hours) increasing diagnostic yield 1, 4
• Ability to detect day-to-day variability in acid exposure 1
• Higher completion rates and patient satisfaction 5, 2
• Increased diagnostic yield (10% of patients diagnosed with GERD using day 2 data after normal day 1) 4

Interpretation and Clinical Significance

The test provides several key measurements:

• Total acid exposure time (abnormal if >4.0% of total time pH <4) 1
• Upright and supine acid exposure times 4
• Symptom association with reflux episodes (using symptom association probability and symptom index) 1
• Johnson-DeMeester score (composite score of reflux parameters) 4

Safety and Tolerability

The BRAVO system is generally well-tolerated:

• Most common side effects include mild foreign body sensation (especially while eating) and mild chest pain 3, 2
• Symptoms are typically mild and self-limiting 2
• Premature detachment or technical failures occur in a small percentage of cases 5
• No significant complications requiring capsule removal have been reported in studies 5, 2

Cost-Effectiveness

Early use of BRAVO testing can be cost-effective:

• Can identify patients unnecessarily taking double-dose PPIs 6
• Break-even analysis showed that BRAVO testing with EGD paid for itself in 33 months for patients on long-term, high-dose PPI therapy 6
• May help diagnose other clinically important conditions more readily 6

Common Pitfalls to Avoid

• Testing should be performed off PPI therapy (after withholding for 2-4 weeks) unless previous objective evidence for GERD exists 1
• Los Angeles A esophagitis alone is not considered evidence of erosive reflux disease 1
• Assuming all extraesophageal symptoms are due to GERD without appropriate evaluation 7
• Using a single day of monitoring when 48-96 hours provides more reliable results 1, 4

The BRAVO test represents an important advance in GERD diagnosis, providing extended, patient-friendly monitoring that improves diagnostic accuracy and helps guide appropriate treatment decisions.