Acid and Nonacid Reflux Monitoring

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Key points

  • •

    Esophageal reflux monitoring, although helpful in the diagnostic assessment of gastroesophageal reflux disease, has its limitations and should be used as a supporting component in the diagnosis.

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    Not all reflux events cause symptoms, and not all symptoms are caused by reflux.

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    Acid reflux is uncommon while on proton pump inhibitor (PPI) therapy; thus, pH monitoring without impedance may have limited usefulness if performed on patients on PPIs.

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    Detection of nonacid reflux may be helpful

Indications for esophageal reflux monitoring

Esophageal reflux monitoring can be used to support a diagnosis of GERD, such as before antireflux procedures, or when the diagnosis of GERD may be in question, such as when there is a lack of response to effective therapy. After an empirical trial of acid suppression therapy, generally with proton pump inhibitors (PPIs), upper endoscopy is the initial diagnostic test performed, because it can assess for complications (especially if patients show alarm symptoms, eg, dysphagia) and also confirm

Performance of esophageal reflux monitoring

Once the decision to pursue reflux monitoring has been made, the next step is to choose which type of device to use (Fig. 1): pH monitoring, either catheter-based (conventional) or wireless (Bravo pH monitoring system, Given Imaging, Yoqneam, Israel), or impedance pH. The basic equipment needed to perform any type of reflux monitoring includes a portable data logger, the sensor (pH or impedance pH), a computer, and analysis software.

There are also tests available to measure gastroduodenal or

Test interpretation

pH measurements from the distal esophagus are reported in terms of the percent time at abnormal pH (pH <4) and the number of reflux events (Fig. 3). In addition to detecting retrograde liquid reflux events, impedance studies also qualify reflux events in terms of pH: acid (pH <4) or nonacid (pH ≥4) (Fig. 4). Patient-provided data entered into the data logger can be used for symptom-reflux association analysis. Data can also be incorporated into a composite score (the Demeester score), which

Summary

When applied and interpreted appropriately, esophageal reflux monitoring is an important component in the armamentarium for the diagnosis of GERD. In the absence of specific endoscopic findings, a confident diagnosis of GERD based on the detection of reflux of gastric contents that causes troublesome symptoms can be challenging. Reflux monitoring can detect refluxed contents, both acid and nonacid (if impedance is incorporated), and causality of troublesome symptoms can be inferred from the

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    Disclosures: Given Imaging (speaker, consultant), Astra Zeneca (speaker) (J.E. Pandolfino); none (D.A. Carlson).

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