Are findings of reflux esophagitis, Los Angeles (LA) classification, a 3 cm hiatus hernia, and bile reflux gastritis indicative of the need for pH monitoring using a wireless capsule?

From the Guidelines

pH monitoring with a wireless capsule is indicated in this case. The findings of reflux esophagitis LA grade A, 3 cm hiatus hernia, and bile reflux gastritis suggest gastroesophageal reflux disease (GERD), but pH monitoring would provide objective confirmation of abnormal acid exposure. This is particularly useful if symptoms persist despite appropriate therapy with proton pump inhibitors (PPIs) such as omeprazole 20-40 mg daily or esomeprazole 20-40 mg daily, as recommended by the AGA clinical practice update on the personalized approach to the evaluation and management of GERD: expert review 1.

Key Points to Consider

• The wireless capsule method is preferred over traditional catheter-based monitoring as it's better tolerated, allows for longer recording periods (48-96 hours versus 24 hours), and permits normal daily activities, as noted in the British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring 1.
• The procedure involves endoscopically attaching a small capsule to the esophageal mucosa that transmits pH data to an external receiver, providing an objective measurement of esophageal acid exposure to determine if symptoms correlate with reflux events and guide appropriate management.
• According to the AGA clinical practice update, patients with esophageal symptoms with unproven GERD and incomplete response to PPI trial for 4-8 weeks should undergo EGD off PPI for 2-7 days concurrent with prolonged wireless pH monitoring off PPI, especially if there is no erosive disease or Los Angeles A esophagitis on endoscopy 1.
• 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, as suggested in the AGA clinical practice update 1.
• A personalized approach to diagnosis and GERD based on findings on endoscopy and prolonged ambulatory wireless pH monitoring is recommended, with consideration of discontinuing PPIs in patients with no GERD, titrating PPIs to the lowest dose or frequency that controls symptoms in patients with borderline GERD, and using adjunctive approaches such as lifestyle and behavior modification 1.

Management Considerations

• The management of GERD should be guided by the severity of symptoms, the presence of erosive esophagitis, and the response to initial therapy, with consideration of surgical options like fundoplication if medical management fails, as recommended by the AGA clinical practice update 1.
• The use of wireless pH monitoring can help identify patients with abnormal acid exposure and guide management decisions, including the optimization of PPI therapy, the use of adjunctive therapies, and the consideration of surgical options, as noted in the British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring 1.

From the Research

Indications for PH Monitoring Wireless Capsule

The findings of Reflux oesophagitis LA, a Hiatus hernia 3 cm, and Bile reflux gastritis may indicate the need for PH monitoring using a wireless capsule. The following points summarize the relevance of these findings:

• Reflux oesophagitis and Hiatus hernia are associated with gastroesophageal reflux disease (GERD) 2, 3, 4, 5
• Hiatus hernia can contribute to the development of GERD, Barrett's esophagus, and esophageal adenocarcinoma 5
• Bile reflux gastritis can be a symptom of GERD and may require monitoring to assess the severity of reflux 4, 5
• The size of the Hiatus hernia (3 cm) may be relevant in determining the need for PH monitoring, as larger hernias may be associated with more severe reflux 2, 5

Diagnostic Criteria for Gastro-esophageal Reflux

The diagnostic criteria for gastro-esophageal reflux following sleeve gastrectomy or in patients with non-erosive reflux disease (NERD) may be relevant in this case. The following points summarize the diagnostic criteria:

• Reflux score and supine acid exposure are discriminant factors for symptomatic reflux 6
• A reflux score of 11.5 or more or supine acid exposure of 2.65% or more may be considered diagnostic in defining symptomatic reflux 6
• Hiatus hernia, less non-acid reflux, and lower post-reflux swallow-induced peristaltic wave index (PSPWI) are associated with lower mean nocturnal baseline impedance (MNBI) in the distal esophagus 5

Relevance of Findings to PH Monitoring

The findings of Reflux oesophagitis LA, a Hiatus hernia 3 cm, and Bile reflux gastritis may indicate the need for PH monitoring using a wireless capsule to assess the severity of reflux and to guide treatment. The following points summarize the relevance of these findings:

• PH monitoring can help assess the severity of reflux and guide treatment 2, 4, 6, 5
• The size of the Hiatus hernia and the presence of bile reflux gastritis may be relevant in determining the need for PH monitoring 2, 4, 5
• The diagnostic criteria for gastro-esophageal reflux may be relevant in this case, and PH monitoring can help assess the severity of reflux and guide treatment 6