Gastroesophageal reflux disease: how to diagnose it?

Excessive exposure of the esophagus to an acidic environment can cause symptoms and structural damage to the esophageal viscera itself. To prevent this from happening, the body has several protective mechanisms, such as the lower esophageal sphincter (intrinsic sphincter) and the diaphragm muscle (extrinsic sphincter). Defect in one or both sphincters, the presence of hiatal hernia, and several other factors can lead to excessive reflux, such as - if chronic - gastroesophageal reflux disease (GERD) can occur, preventing a good quality of life.

Over time, the wall of the esophagus may also become damaged and suffer erosions (esophagitis) or a transformation of the epithelium (Barrett's esophagus). The main symptoms are: 

• esophageal (retrosternal heartburn and acid regurgitation);
• extra-oesophageal (such as pharyngitis, hoarseness, cough): the latter poorly controlled by medical therapy. 

A complete and correct diagnostic course involves, first of all, the completion of some screening questionnaires, upon receipt of which the patient is referred to an initial specialist gastroenterological or general surgical examination. During the examination, the specialist considers whether to prescribe diagnostic investigations. The following are the main procedures:

• esophagogastroduodenoscopy (EGDS): commonly referred to as gastroscopy, is aimed at examining the wall of the esophagus, stomach and duodenum to diagnose any gastrointestinal diseases. It also allows samples to be taken using a biopsy forceps, following which histological analysis can be performed;
• X-ray of the digestive tract with contrast medium: allows for assessment of the anatomy of the early digestive tract and the transit of contrast medium through the organs examined;
• esophageal manometry: allows for assessment of esophageal motility and esophageal sphincter function by measuring pressures in the esophagus;
• esophageal pH-impedancometry: allows for assessment of the presence of acid and nonacid gastroesophageal reflux over 24 hours; it also allows us to ascertain whether there is a correlation between the patient's symptoms and any reflux.

We elaborate, below, on each examination with experts from Policlinico San Donato.

Esophagogastroduodenoscopy (EGDS)

EGDS is aimed at a wide range of patients: first and foremost, those who have symptoms such as difficulty swallowing (dysphagia), retrosternal burning or pain, acid regurgitation, or other symptoms potentially attributable to conditions such as gastroesophageal reflux, gastritis, tumors, or other esophago-gastric diseases. Then, to patients with anemia, suspected high gastrointestinal bleeding or suspected celiac disease. Finally, it is used as a diagnostic investigation prior to any surgery on the esophago-gastric junction and follow-up in patients with certain diseases such as hiatal hernia and Barrett's esophagus. 

In order to make the examination more tolerable, the patient is given local anesthesia spray and, if desired, intravenous sedation. The patient remains, however, conscious throughout the examination. At this point, the examiner introduces the gastroscope and visualizes the surface of all organs involved in the examination. The duration of the examination is about 5 minutes. 

The patient is required to fast 6 hours before the examination and to come to the hospital accompanied. After intravenous sedation, in fact, the patient cannot drive any vehicle for the next 24 hours.

X-ray of the digestive tract with contrast medium

Radiography of the digestive tract is particularly aimed at patients with dysphagia (difficulty swallowing), esophageal diverticula, tumors, voluminous hiatal hernias, or used as a preoperative examination for antireflux surgery. 

The examination consists of taking serial X-rays while the patient is asked to drink contrast medium. The patient is then placed supine and prone to increase the diagnostic power of the method. The patient is required to fast 6 hours before the examination.

Esophageal manometry and esophageal pH-impedancometry

Manometry is performed on patients with: 

• dysphagia (difficulty in transit of food) as a second-level examination after EGDS or contrast-enhanced radiography;
• non-cardiac chest pain. 

It also helps to identify the cause of possible gastroesophageal reflux, the diagnosis of which is ensured by pH-impedancemetry. 

Esophageal manometry and pH-impedancemetry are examinations performed on an outpatient basis. Sedation is not given as active cooperation of the patient is required. The manometric tube is introduced nasally, after local anesthesia with lidocaine, in a semisitting position. The patient is asked to take a few swallows with a small amount of water administered by the operator. At the end of the examination, some provocative tests are performed.

The manometric tube is then removed and a smaller tube is inserted. The tube remains in place for 24 hours, during which the patient is asked to live a life as superimposed as possible as the one he/she lives every day. After 24 hours, the patient returns to the outpatient clinic, where the tube is removed.

At the end of the diagnostic examinations, an overall evaluation is issued, in addition to the reports of the individual examinations, with which the patient returns to the specialist, either in person or by teleconsultation, for the therapeutic decision. 

"At Policlinico San Donato, we guarantee a follow-up program to monitor over time the symptoms and any mucosal damage that emerged when the instrumental examinations were performed. Our experts also perform intensive scientific research focused, precisely, on the study of GERD and hiatal hernia, adhering to national and international studies, with about 100 scientific publications in international journals," explains Prof. Emanuele Asti.

A comprehensive diagnostic pathway is in place at Policlinico San Donato: experts ensure that patients can have all 4 diagnostic procedures performed within just 48 hours.