Diagnostic Value of Potent Acid Inhibition in Gastro-Oesophageal Reflux Disease

Abstract

Gastro-oesophageal reflux disease (GORD) is defined as 'Chronic symptoms or mucosal damage produced by abnormal reflux of gastric contents into the esophagus'. The Genval Workshop Report defines that GORD exists when the frequency of heartburn is equal to or greater than 2 days/week and that it is one of the most common gastrointestinal conditions in the general population. Endoscopy is the most recommendable exploratory procedure in a patient with symptoms of GORD, fundamentally heartburn and regurgitation. However, 50-75% of the patients with symptoms compatible with GORD have normal endoscopy. Thus, endoscopy does not appear to be indispensable in a large group of patients with GORD. Endoscopy is therefore the gold standard for the diagnosis of reflux oesophagitis (histopathological changes in the oesophageal mucosa), but there is no gold standard for the diagnosis of non-erosive GORD. Twenty-four-hour pH monitoring has come to be considered the most sensitive and specific test in the diagnosis of GORD, but a significant proportion of patients (about 25%) have symptoms compatible with GORD and have 24-h pH monitoring results that can be considered normal. Besides, demonstrating the presence of acid reflux alone does not prove that it is the cause of suspected GORD-related signs or symptoms. Therefore, despite 'positive' pH studies, there is a significant number of patients failing to respond to therapy, mainly ear, nose and throat complaints, supposed as manifestations of gastro-oesophageal reflux disease. Despite 24-h oesophageal pH testing being an excellent diagnostic tool, it has no utility in routine clinical settings and hence its availability should be limited to tertiary care settings. With the demonstration that antisecretory treatment with high doses of proton pump inhibitors (PPIs) for 1 week or 2 weeks achieves significant improvement or even remission of the symptoms of GORD, it not surprising that it has been proposed as a diagnostic test for the disease. For patients with symptoms compatible with GORD without alarm symptoms or other suspected complications of GORD, a short course of empiric PPI therapy gives valuable information about the presence of GORD. The PPI test is a simple, sensitive and cost-effective tool, but it has insufficient specificity for use as an objective criterion alone. The use of PPIs both as a diagnostic test (1-2 weeks) and as a diagnostic-therapeutic test (1-4 months) has a moderate usefulness and may be used especially in those environments in which there are difficulties in performing the objective test.