c


  

Patients with typical symptoms of heartburn and regurgitation should be

treated empirically. Investigation is requires in patients with 

       

 
  and in patients with    despite empiric
therapy (PPI).

Please note: There is a certain degree of overlapping between the

investigations for etiology and causes and investigations for complications of
GERD.

m      

 

 m  !  ± gold standard for assessment of
the body of the esophagus. It is also mandatory before antireflux
operations.
i.m Assesment of the LES include:
1.m Resting pressure
2.m Relaxation
3.m Transient relaxation
4.m Quality of peristalsis

Thus, may be useful to diagnose motility disorders

presenting with atypical GERD-like symptoms eg
achalasia or diffuse esophageal spasm.

ii.m 24 hours esophageal monometry ± to identify esophageal

motility abnormalities as the cause of non-cardiac chest
pain
1.m Can be combined with 24 hours pH monitoring
2.m Evaluation of esophageal clearance function

i m     ± radionuclide measurement

(using a sensor similar to Geiger counter) of gastric emptying is
used selectively in patients who have postprandial abdominal
bloating or fullness that suggest delayed gastric emptying.

^m    
 

 m "  ± plays a limited role. In patients
with severe dysphagia, it is sometimes obtained prior to
endoscopy to identify a stricture, or the shape of a hiatal hernia


i m  ±
 To assess damage done,
^. To detect complications eg reflux esophagitis, esophageal
stricture, Barrett metaplasia, and esophageal adenocarcinoma,
and
#.To detect other gastroesophageal lesions/diseases (eg peptic
ulcer) that may mimic GERD. Indication for this procedure
includes:
i.m All patients prior to fundoplication surgery.
ii.m The ³alarm features´ mentioned
iii.m Elderly patient with GERD symptoms.
iv.m White males, 40 years or older, with chronic
heartburn (increased risk of Barrett¶s esophagus).
v.m Ongoing surveillance of patients with Barrett¶s esophagus.
vi.m Patients with extra-esophageal manifestations of GERD
(to possibly confirm the diagnosis).
vii.m Patients with severe heartburn, not responding to
appropriate therapy.

Grade 1 erosive esophagitis.

Grade 2 erosive esophagitis.

 Grade 3 erosive esophagitis.

Barrett metaplasia

 m i$c  %&   

i.m determines refluxate presence, distribution, clearance
time, liquid, gas or mixed.
ii.m Shows GER contents as acid, weak acid or non-acid and
determines bolus transfer of gas, liquid or solids.
iii.m done when there¶s lack of response to therapy (to
determine correlation between symptoms and acid and
non-acid reflux episodes) / Recurrence of symptoms after
discontinuation of acid-reducing medications
iv.m as a physiological assessment pre-fundoplication (to
confirm disease for which surgery is offered)
v.m can be catheter based or Bravo wireless capsule
vi.m Patients with endoscopically confirmed esophagitis do not
need pH monitoring to establish a diagnosis of
gastroesophageal reflux disease (GERD).
 a: Dual-channel proximal and distal esophageal pH monitoring is used to
monitor patients with reflux symptoms off therapy. b: Dual channel distal
esophageal and gastric pH monitoring is used to monitor patients with reflux
symptoms on acid suppressive therapy.

Bravo wireless capsule

 m "
i.m Useful for diagnosing cancers or causes of esophageal
inflammation other than acid reflux, particularly
infections.
ii.m Only means of diagnosing cellular changes of Barrett¶s
esophagus.
iii.m ½ay show widening of lining cells along esophagus which
indicate damage even though it may appear normal to the
eye.

 m  
 "    ± used to determine if chest
pain is caused by acid reflux. (rarely done)
 i.m A dilute, acid solution and a physiologic (normal) salt
solution are alternately poured (perfused) through the
catheter and into the esophagus.
ii.m The patient is unaware of which solution is being infused.
iii.m If the perfusion with acid provokes the patient's usual
pain and perfusion of the salt solution produces no pain,
it is likely that the patient's pain is caused by acid reflux.

Reference:

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