and Diagnostic Evaluation of GERD

Gastroesophageal reflux disease symptoms

Esophageal

Heartburn

Regurgitation

Dysphagia

Gastric

Bloating

Early satiety

Belching

Nausea

Pulmonary

Aspiration

Dyspnea

Wheezing

Cough

Asthma

Ears-nose-throat

Globus

Hoarseness

Cardiac

Chest pain

The clinical evaluation should also investigate the effect of antireflux medications on symptoms relief. In fact, a good response to therapy with proton-pump inhibitors (PPI) is a good predictor of both the presence of abnormal reflux and success after antireflux surgery [6–8].

A diagnosis of GERD based only on symptoms is wrong in many patients because clinical findings are neither sensitive nor specific, and there is considerable overlap with other gastrointestinal disorders [9]. For instance, Patti and colleagues [10] showed that after performing pH monitoring in 822 patients referred for antireflux surgery with the diagnosis of GERD based on symptom evaluation, 247 (30%) had a normal reflux score. Thus, objective esophageal testing is mandatory to document the presence of GERD, particularly when surgical treatment is considered.

Diagnostic Evaluation

Patients with suspected GERD should be evaluated with upper endoscopy, barium swallow, esophageal manometry, and ambulatory pH monitoring. A gastric emptying study and combined multichannel impedance pH may be needed in selected cases.

Upper Endoscopy

An upper endoscopy is often the first test performed in patients with suspected GERD. However, around 50–60% of patients with abnormal reflux evidenced by pH monitoring do not have any evidence of mucosal damage [11, 12]. A diagnosis of erosive reflux esophagitis is established when there are patchy, striated, or circular and confluent epithelial defects (erosions) in the mucosa in the distal esophagus.

The Los Angeles (LA) classification is the most validated classification system for esophagitis (Table 13.2). LA grade A refers to one or more mucosal breaks no longer than 5 mm, not bridging the tops of mucosal folds (Fig. 13.1). LA grade B refers to one or more mucosal breaks more than 5 mm long that does not extend between the tops of two mucosal folds (Fig. 13.2). LA grade C is defined by one or more mucosal breaks bridging the tops of mucosal folds involving <75% of the circumference (Fig. 13.3). LA grade D is defined by one or more mucosal breaks bridging the tops of mucosal folds involving >75% of the circumference (Fig. 13.4). Unfortunately, particularly for low-grade esophagitis, a high interobserver variability has been shown for the determination of the LA grade [13].

Table 13.2

Los Angeles classification system for esophagitis

Los Angeles classification
Grade A	Mucosal breaks ≤5 mm long, none of which extends between the tops of the mucosal folds
Grade B	Mucosal breaks >5 mm long, none of which extends between the tops of two mucosal folds
Grade C	Mucosal breaks that extend between the tops of ≥2 mucosal folds, but which involve <75% of the esophageal circumference
Grade D	Mucosal breaks which involve ≥75% of the esophageal circumference

../images/473262_1_En_13_Chapter/473262_1_En_13_Fig1_HTML.png — Fig. 13.1

LA grade A : one or more mucosal breaks no longer than 5 mm, not bridging the tops of mucosal folds

../images/473262_1_En_13_Chapter/473262_1_En_13_Fig2_HTML.png — Fig. 13.2

LA grade B : one or more mucosal breaks more than 5 mm long that does not extend between the tops of two mucosal folds

../images/473262_1_En_13_Chapter/473262_1_En_13_Fig3_HTML.jpg — Fig. 13.3

LA grade C : one or more mucosal breaks bridging the tops of mucosal folds involving <75% of the circumference

../images/473262_1_En_13_Chapter/473262_1_En_13_Fig4_HTML.jpg — Fig. 13.4

LA grade D : one or more mucosal breaks bridging the tops of mucosal folds involving >75% of the circumference

The endoscopy is also useful for diagnosing complications of GERD such as Barrett’s esophagus and/or strictures. In addition, this study is valuable for excluding other pathologies such as eosinophilic esophagitis, gastritis, peptic ulcer , and cancer.

Barium Swallow

The barium swallow test has no diagnostic role per se because the presence of gastroesophageal reflux during the test does not correlate with the pH monitoring data. For instance, a previous study demonstrated the absence of any radiological sign of reflux in 53% of patients with GERD confirmed by ambulatory 24-hour pH monitoring [14].

Although this test does not provide objective evidence of GERD, it has a great value in preoperative planning because it gives information about different anatomic variables (i.e., presence and degree of esophageal shortening, diverticulum, stricture, or hiatal hernia). In particular, the ability to distinguish between a type I sliding hiatal hernia and a type III paraesophageal hernia has implications for the complexity of the operation.

Esophageal Manometry

The esophageal manometry has limited valued for the diagnosis of GERD. However, it plays an important role during the evaluation of a patient with suspected GERD. First, the manometry is necessary for the correct placement of the pH monitoring probe (5 cm above the upper border of the lower esophageal sphincter). Second, it can rule out primary esophageal motility disorders (mainly achalasia) that present with similar symptoms to those with GERD. Finally, most surgeons will tailor the degree of fundoplication (total vs. partial) based on the peristaltic coordination and contractile force of the esophageal body (Fig.13.5).