How to diagnose a patient with dull chest pain that worsens after spicy meals, emotional stress, and when lying flat, suggestive of gastroesophageal reflux disease (GERD)?

Diagnostic Approach to Suspected GERD with Typical Symptoms

For this patient presenting with dull chest pain worsening after spicy meals, emotional stress, and when lying flat—classic features of GERD—the answer is D. pH monitoring, but only after initial management steps have been completed. However, the most appropriate initial diagnostic approach depends on whether typical GERD symptoms are present and the response to empiric therapy.

Initial Diagnostic Strategy

Begin with a 4-8 week trial of single-dose PPI therapy without diagnostic testing, as typical esophageal symptoms (heartburn, regurgitation, chest pain) are approximately 70% sensitive and specific for objective GERD. 1 This patient's symptom pattern—pain after meals, worsening when supine, and triggered by spicy foods—represents typical GERD presentation that warrants empiric treatment before invasive testing. 1

• Cardiac evaluation must be completed first before attributing chest pain to GERD, as ischemic heart disease carries substantially greater morbidity and mortality. 1
• Once cardiac etiology is excluded, twice-daily PPI therapy for 4 weeks is strongly recommended as an empirical trial for suspected reflux chest pain syndrome. 1

When to Pursue Objective Testing

If symptoms persist after 8-12 weeks of optimized PPI therapy (twice daily dosing), proceed directly to objective testing rather than continuing empiric treatment. 1

Endoscopy (Option B) - First-Line Objective Test

Upper endoscopy should be performed first in PPI non-responders to evaluate for:

• Erosive esophagitis (Los Angeles classification) 1
• Barrett's esophagus (Prague classification with biopsy) 1
• Hiatal hernia and Hill grade of flap valve 1
• Alternative diagnoses (stricture, malignancy, eosinophilic esophagitis) 1

Endoscopy has limited diagnostic value for extraesophageal GERD manifestations but is essential to rule out structural abnormalities and complications. 1

pH Monitoring (Option D) - Definitive Diagnostic Test

If endoscopy shows no erosive disease (Los Angeles B or greater) or long-segment Barrett's esophagus (≥3cm), perform prolonged wireless pH monitoring off PPI therapy (96-hour preferred) to confirm or rule out GERD. 1

• Ambulatory pH monitoring is the gold standard for diagnosing non-erosive reflux disease (NERD), which accounts for approximately 60% of GERD patients. 1, 2
• Testing should be performed off acid suppressive therapy to accurately assess esophageal acid exposure, unless previous objective evidence of GERD already exists. 1
• pH monitoring objectively quantifies reflux burden and can demonstrate pathologic acid exposure with symptom-reflux association. 1

Why Not Barium Swallow (Option A)?

Barium swallow is not recommended in the diagnostic algorithm for GERD as it does not appear in current AGA guidelines for reflux evaluation. 1 It may identify structural abnormalities like strictures or hiatal hernias but does not confirm pathologic reflux.

Why Not Esophageal Manometry (Option C)?

Esophageal manometry is indicated to rule out major motility disorders (achalasia, distal esophageal spasm) and assess peristaltic function before anti-reflux surgery, not as a primary diagnostic test for GERD. 1 It should be performed after normal endoscopy in patients with persistent dysphagia or when considering surgical intervention. 1

Clinical Algorithm Summary

1. Exclude cardiac etiology in all chest pain patients 1
2. Trial of twice-daily PPI for 4-8 weeks for typical symptoms 1
3. If adequate response: Taper to lowest effective dose 1
4. If inadequate response:
   • Perform upper endoscopy first 1
   • If erosive disease/Barrett's found: Confirmed GERD, optimize therapy 1
   • If endoscopy normal: Perform 96-hour wireless pH monitoring off PPI 1
   • If pH monitoring shows pathologic acid exposure: Confirmed GERD 1
   • If pH monitoring normal: Consider functional esophageal disorder, neuromodulation 1

Critical Pitfalls to Avoid

• Do not continue empiric PPI therapy beyond 12 months without objective confirmation of GERD, as 50-60% of patients with suspected GERD symptoms will not have pathologic reflux. 1
• Do not perform pH monitoring while on PPI therapy for initial diagnosis, as normative data interpretation is unclear and may miss acid reflux. 1
• Do not skip endoscopy in favor of pH monitoring when alarm symptoms exist (dysphagia, weight loss, bleeding) or in patients meeting Barrett's screening criteria. 1