Optimizing ambulatory reflux monitoring: current findings and future directions

ABSTRACT

Introduction

Gastroesophageal reflux disease (GERD) is the most common diagnosis seen in outpatient gastroenterology clinics. The diagnosis is made by a variable combination of symptoms, response to acid suppressive therapy, endoscopic evaluation, and pH testing. In this review, we evaluate how to utilize various reflux testing in clinical practice based on current evidence.

Areas covered

Ambulatory reflux monitoring is a recognized diagnostic tool for clinical decision making in patients with/without established GERD, persistent reflux symptoms, and lack of response to proton pump inhibitor (PPI) therapy. Standard evaluation approaches include 24-hour pH or impedance monitoring via transnasal catheter, prolonged (48 to 96 hour) wireless pH monitoring, and the recently developed mucosal integrity testing. Testing using one of these methods allows for measurement of acid exposure, frequency of reflux, and to phenotype patients to personalize treatment recommendations.

Expert opinion

The primary goal of future studies should be to simplify ambulatory reflux monitoring, reduce diagnostic latency, improve patient tolerance, and to obtain clinical outcomes-based studies. The current paradigm of reflux testing is vastly complex with multiple modalities and shifting cutoffs of pH abnormality that lead to high economic burden on the society.

KEYWORDS:

• Gastroesophageal reflux disease
• endoscopy
• ambulatory ph testing
• wireless ph testing
• mucosal integrity testing

Article highlights

• Understanding both functional and GERD phenotypes is crucial in personalizing treatment options in patients who present with heartburn and/or regurgitation.

• pH testing OFF therapy should be performed in patients with low likelihood of reflux and impedance-pH testing ON therapy should be performed in patients who have definitive evidence of reflux (prior abnormal pH testing, LA grade B/C/D esophagitis, or long segment Barrett’s esophagus) and are still symptomatic despite treatment.

• The current paradigm of reflux testing is vastly complex with multiple modalities and shifting cutoffs of pH abnormality that lead to high economic burden on the society.

• Novel testing that measures changes in esophageal mucosal integrity might reduce diagnostic latency and expedite treatment, but clinical outcome studies are needed.

Declaration of interests

M Vaezi has had advisory roles for Ironwood, Phathom, Isothrive, Sanofi, Bethanamist, Ellodi, Cinclus; M Vaezi has worked on patents for Mucosal integrity testing and Vanderbilt co-owns the patent on MI technology. M Vaezi has consulted in litigation relating to acid suppressive therapy. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

D Dasarathy drafted the manuscript), M Vaezi critically revised the manuscript), and D Patel drafted the manuscript and critically revised manuscript).

Additional information

Funding

This paper was not funded.