COMMENTARY

Atypical Manifestations of Gastroesophageal Reflux Disease

Michael F. Vaezi, MD, PhD, MSEpi

Disclosures

October 27, 2005

In This Article

Diagnostic Tests

Commonly employed diagnostic tests for the detection of GERD include barium swallow, endoscopy, and 24-hour pH monitoring. However, based on a patient's history, empiric therapy is usually initiated without the need for any testing.[14] Testing is usually indicated in patients with persistent symptoms despite therapy, those with warning signs (ie, dysphagia, weight loss, bleeding), prior to fundoplication, or in those patients with long-standing GERD in order to rule out Barrett's esophagus.

Patients with atypical GERD symptoms usually have a low prevalence of endoscopic esophagitis. Most studies report only mild esophagitis in 10% to 30% of patients with atypical GERD.[2,4] This is in contrast to cases of typical GERD, in which esophagitis may be present in up to 50% of patients. Once considered to be the gold standard for detecting esophageal acid exposure, 24-hour pH monitoring suffers from poor sensitivity (70%-80%). The false-negative rate for this test (the patient has the disease by either prior pH monitoring or endoscopy) may range from 20% to 50%.[15] Therefore, a negative test may not exclude the diagnosis of GERD in patients with atypical complaints. More important, a positive test does not confirm that GERD is the etiology for the atypical symptoms; the cause-and-effect relationship is usually best established with sustained response to acid-suppressive therapy.[4,12] (However, one has to be mindful of placebo response when response to therapy is judged to be the gold standard.) Therefore, diagnostic tests for atypical GERD should usually be reserved for those patients who are unresponsive to therapy or have other indications for testing. It is now believed that in the majority of patients who continue to have symptoms despite aggressive acid suppression, GERD may not be the cause of their symptoms or laryngeal findings. The role of nonacid reflux continues to be questioned in this group of unresponsive patients. Impedance/pH monitoring allows for detection of acid as well as nonacid liquid or gas reflux events and may increase the sensitivity of GERD diagnosis in this group of patients. However, the overdiagnosis of GERD in many patients with atypical symptoms may be the most important limitation of any of the currently available diagnostic tests.

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