The Role of Esophageal pH Testing For Evaluating Gastroesophageal Reflux Disease
Do I have Reflux? This is the question we need to ask when acid reducing symptoms fail to resolve our symptoms of Gastroesophageal Reflux Disease (GERD) or Laryngopharyngeal Reflux (LPR or Silent Reflux). We also need to ask if it is truly Reflux when symptoms are not typical such as the patient with Non-Cardiac Chest Pain or Cough without Heartburn.
How do we answer the question “Do I have Reflux?” Measuring acid going up into the esophagus can define the severity of reflux in objective fashion. Measuring the flow of fluid up into the esophagus and larynx (voice box) with impedance testing not only helps evaluate acid reflux, but also the flow of stomach juices that beyond just acid. Pharyngeal pH testing evaluates the extent of acid flow into the airway above the esophagus contributing to Silent Reflux.
ProHEALTH Care Associates now offers three ways to evaluate Gastroesophageal Reflux Disease with pH testing. They each have a unique role that can enhance your care and obtain the best diagnosis.
Pharyngeal pH testing is optimal for patients who have laryngopharyngeal symptoms of unclear significance or who have not responded to a course of PPI therapy. Many patients come in with symptoms of cough, throat clearing, throat burn, hoarseness, swallowing discomfort or a feeling of a lump in the throat. Examination of the throat with a laryngoscope may show some swelling, redness, or other damage including vocal cord polyps and granuloma. These may suggest Silent Reflux but are not specific enough to make the diagnosis. Symptoms overlap post viral vagal neuropathy or neurogenic cough, allergic rhinitis, asthma, and functional vocal fold disorders. Pharyngeal pH testing (Restech) can be diagnostic in these patients.
48-hour wireless esophageal pH testing (BRAVO) is optimal for understanding the cause of Non-Cardiac Chest Pain. It can also evaluate reflux symptoms that have not responded appropriately to proton pump inhibitor therapy. 48-hour testing has been proven to be more sensitive than 24-hour testing because of day-to-day variability in Gastroesophageal Reflux.
Impedance pH testing is optimal for the patient on treatment in order to understand whether acid suppression is inadequate or nonacid reflux is persisting despite therapy. Proton Pump Inhibitors frequently convert acid reflux into non-acid reflux. The most specific symptom that indicates non-acid reflux is volume regurgitation without burning.
Patients are often switched from one Proton Pump Inhibitor to another or the dose is changed on an trial and error basis. If one agent does not work at usual doses, it is critical to understand why the treatment has failed. These lateral changes from one acid blocker to another fail to educate us about the process. Perhaps the lack of response suggests a need for a different treatment. Other times it is a sign that the diagnosis needs to be challenged. The failure of therapy after eight weeks should lead to questions about either the diagnosis or treatment. Many patients can out eat their proton pump inhibition.
Some patients will require surgical intervention. Esophageal Manometry and one of these forms of Esophageal Acid testing is required for all patients who are considered for surgical intervention of Gastroesophageal Reflux Disease or Laryngopharyngeal Reflux. This is necessary to get the surgical results we need and to minimize the risk of complications. The greatest complications occur in patients who did not need the surgery in the first place. Excellent patient selection leads to excellent surgical results in eliminating acid reflux and its complications.
Esophageal Acid pH testing is necessary in patients whose symptoms are not responsive to medication after eight weeks, as well as those who have symptoms that are not definitively due to reflux. Patients who may need to have surgical therapy for their reflux and do not have definitive erosions or Barrett’s esophagus need to have Esophageal Acid pH testing.