What's confirmatory evidence of pathologic GERD (Gastroesophageal Reflux Disease)?

Confirmatory Evidence of Pathologic GERD

The definitive confirmatory evidence of pathologic gastroesophageal reflux disease (GERD) includes endoscopic findings of erosive esophagitis (Los Angeles grade B or higher), abnormal acid exposure time on pH monitoring, or the presence of Barrett's esophagus. 1

Diagnostic Testing for Confirming Pathologic GERD

Endoscopic Evaluation

• Complete endoscopic evaluation should document the presence or absence of erosive esophagitis (graded according to the Los Angeles classification), diaphragmatic hiatus assessment (Hill grade of flap valve), axial hiatal hernia length, and inspection for Barrett's esophagus 1
• Erosive esophagitis of Los Angeles Grade B or higher constitutes conclusive GERD evidence 1
• The presence of Barrett's esophagus (which should be graded according to the Prague classification and biopsied) confirms pathologic GERD 1

Ambulatory Reflux Monitoring

• Prolonged ambulatory reflux monitoring off PPI therapy is the gold standard for confirming GERD in patients without higher grades of reflux esophagitis 1
• Acid exposure time (AET) ≥6.0% on 2 or more days constitutes conclusive GERD evidence 1
• Absence of pathologic acid exposure on ambulatory reflux monitoring (AET <4.0% on all days) with a normal endoscopy rules out GERD 1
• For patients with isolated extra-esophageal symptoms, upfront objective reflux testing off medication (rather than an empiric PPI trial) should be performed 1

Borderline GERD Findings

• Patients with LA grade A esophagitis, and/or AET ≥4.0% but not meeting criteria for conclusive GERD are considered to have borderline GERD 1
• In symptomatic patients with proven GERD, ambulatory 24-hour pH-impedance monitoring on PPI can determine the mechanism of persisting esophageal symptoms despite therapy 2

Importance of Confirmatory Testing Before Interventions

• Candidacy for invasive anti-reflux procedures specifically requires confirmatory evidence of pathologic GERD, exclusion of achalasia, and assessment of esophageal peristaltic function 1, 3
• The presence of Los Angeles C or D esophagitis, bipositional reflux, extreme levels of acid exposure (AET > 12.0% or DeMeester Score ≥ 50), and/or large hiatal hernia may indicate a more severe phenotype of GERD 1
• For patients requiring long-term PPI therapy, objective reflux testing should be offered to establish a definitive diagnosis of GERD 1

Clinical Approach to GERD Diagnosis

• For patients with typical reflux symptoms without alarm symptoms, a trial of single-dose PPI therapy for 4-8 weeks is appropriate, but this is not confirmatory evidence 1
• In patients with PPI non-response, presence of alarm signs/symptoms, isolated extra-esophageal symptoms, or in patients who meet criteria for Barrett's esophagus screening, objective testing with upper GI endoscopy is warranted 1
• In the absence of confirmed erosive disease or Barrett's esophagus on endoscopy, prolonged wireless pH monitoring off PPI therapy should be utilized to assess esophageal acid exposure 1

Pitfalls in GERD Diagnosis

• Up to 50% of patients with suspected GERD symptoms do not derive adequate relief with empirical PPI therapy, often because they don't actually have pathologic GERD 1
• Relying solely on symptom response to PPI therapy is insufficient for confirming pathologic GERD, particularly before considering invasive interventions 1, 4
• Patients without erosive disease on endoscopy and with physiologic acid exposure often have a functional esophageal disorder rather than true GERD 1
• Previous endoscopic anti-reflux devices have been withdrawn from the market due to safety concerns or lack of efficacy, highlighting the importance of proper patient selection based on confirmatory testing 4