What is the appropriate workup for a patient with suspected gastro‑oesophageal reflux disease?

Workup for Suspected Gastroesophageal Reflux Disease

Begin with an empirical trial of proton pump inhibitor (PPI) therapy as the initial diagnostic approach for patients with typical reflux symptoms (heartburn, regurgitation) who lack alarm features. 1

Initial Clinical Assessment

When to Start with Empirical PPI Therapy (No Testing Required)

• Typical GERD symptoms (heartburn, regurgitation) without alarm features warrant a 4-8 week trial of once-daily PPI therapy without initial testing 1
• If symptoms persist on once-daily PPI, escalate to twice-daily PPI before pursuing diagnostic testing 1
• Extraesophageal symptoms (cough, laryngitis, asthma) accompanied by typical GERD symptoms can receive empirical PPI therapy 1, 2

When Endoscopy is Required First

Perform upper endoscopy before empirical therapy in these scenarios:

• Alarm symptoms present: dysphagia, odynophagia, weight loss, gastrointestinal bleeding, anemia, or epigastric mass 1
• Barrett's esophagus screening criteria met: chronic GERD symptoms (>5 years) in men over 50 with additional risk factors 1, 2
• Isolated extraesophageal symptoms (cough, laryngitis, chest pain) without typical reflux symptoms 1, 2
• Older patients with atypical presentations or underlying comorbidities (scleroderma, large hiatal hernia suspected) 2
• Dysphagia of any kind - obtain at least 5 esophageal biopsies to evaluate for eosinophilic esophagitis 1

Workup for PPI Non-Responders

After Failed Twice-Daily PPI Trial

The diagnostic sequence is critical and should follow this order:

1. Upper endoscopy first - identifies Barrett's metaplasia, stricture, esophagitis, eosinophilic esophagitis, or alternative diagnoses 1

2. Esophageal manometry second - rules out achalasia, diffuse esophageal spasm, and other major motility disorders that masquerade as GERD 1

3. pH/impedance monitoring third - determines if excessive acid exposure exists and whether symptoms correlate with reflux events 1

Reflux Monitoring Specifics

For patients with heartburn/regurgitation refractory to twice-daily PPI:

• Use pH/impedance monitoring rather than pH monitoring alone 1
• Perform off PPI if no previous pathological findings documented 1
• Perform on PPI if previous erosive disease or pathological pH monitoring already confirmed 1

For chest pain, throat, or respiratory symptoms refractory to twice-daily PPI:

• Use pH/impedance monitoring to detect both acid and non-acid reflux 1
• This enables diagnosis of pathological reflux and symptom-reflux association 1

Special Scenarios

Chest Pain Evaluation

Cardiac causes must be excluded first - the morbidity and mortality of ischemic heart disease substantially exceeds GERD 1, 3, 4

After cardiac workup is complete:

• Trial twice-daily PPI for 4 weeks (Grade A recommendation) 1
• If chest pain persists, proceed to esophageal manometry and pH/impedance monitoring 1

Pre-Surgical Evaluation

All patients being considered for antireflux surgery require:

1. Esophageal manometry - mandatory to rule out achalasia and major motor disorders (diffuse esophageal spasm) 1
2. Reflux monitoring off PPI - confirms excessive acid exposure and/or symptom-reflux association 1
   • Use pH monitoring alone if symptoms are PPI-responsive 1
   • Use pH/impedance monitoring if symptoms are PPI-refractory 1

Extraesophageal Symptoms

• Do NOT use empirical PPI for isolated laryngitis or asthma without concomitant esophageal symptoms (Grade D - recommend against) 1
• Dual probe monitoring offers no advantage over single distal esophageal probe 1

Common Pitfalls

• Avoid reflux monitoring in PPI-responsive patients unless antireflux surgery is planned - it does not increase diagnostic yield 1
• Never perform pH monitoring alone in PPI non-responders - pH/impedance is superior for detecting non-acid reflux and reducing false negatives 1
• Do not skip manometry before antireflux surgery - missing achalasia leads to surgical failure and worsened dysphagia 1
• Symptom indices (SAP, SI) are only valid for heartburn, regurgitation, and chest pain - not for throat or respiratory symptoms 1