Gastroesophageal reflux disease (GERD): diagnosis

The main methods for diagnosing gastroesophageal reflux disease are X-ray examination of the esophagus, esophagoscopy, scintigraphy with radioactive technetium, manometric examination of the esophageal sphincters, daily monitoring of the intraepithelial pH. The prolonged intra-esophageal pH monitoring has a great value in atypical forms of gastroesophageal reflux disease (for verification of non-cardial pain behind the sternum, chronic cough and presumed pulmonary aspiration of gastric contents); with refractory treatment; when preparing a patient for an antireflux surgery.

Methods of diagnosis of gastroesophageal reflux disease

Methods of research	Features of the method
Daily monitoring of pH in the lower third of the esophagus.	Determines the number and duration of episodes of pH <4 and> 7 in the esophagus, their relationship to subjective symptoms, food intake, body position, smoking, medication intake. It allows individual selection of therapy and control of the effectiveness of the drugs.
X-ray examination of the esophagus.	Reveals a hernia of the esophageal aperture of the diaphragm, erosion, ulcers, stricture of the esophagus.
Endoscopic examination of the esophagus.	It reveals inflammatory changes in the esophagus, erosion, ulcers, esophageal stricture, Barrett's esophagus.
Scintigraphy of the esophagus with radioactive technetium (10 ml of egg white with Tc11, every 20 seconds the patient takes a pharynx, and for 4 minutes every second a picture is taken on the halochamber).	Allows assessing the esophageal clearance (isotope retention for more than 10 minutes indicates a delay in esophageal clearance).
Manometric examination of esophageal sphincters.	It allows to reveal the change in the tone of esophageal sphincters. DeMeester rate: Basal pressure NPS 14,3-34,5 mm Hg. Art. The total length of the NPS is at least 4 cm. The length of the abdominal part of the lower esophageal sphincter is at least 2 cm.

Additional methods are bilimetry and omeprazole test, Bernstein test, Stepenko test, standard acid reflux test, esophageal clearance study, methylene blue test, study of proteolytic intra-esophageal activity by VN method. Gorshkova, carrying out pulmonary functional tests after intra-esophageal perfusion of hydrochloric acid.

When carrying out an X-ray study to identify gastroesophageal reflux, the patient should drink a contrast suspension with barium sulfate, after evacuation from the esophagus to the stomach, the patient is examined in a horizontal position or in the Trendelenburg position. Use a number of additional methodical techniques that increase intra-abdominal pressure (Valsalva and Muller, Weinstein and others). In the presence of gastroesophageal reflux, barium again enters the esophagus. Often when fluoroscopy revealed signs of esophagitis: an expansion of the lumen of the esophagus, reconstruction of the relief of the mucosa of the esophagus, uneven outlines, weakening of peristalsis. Especially valuable is the x-ray method for revealing a hernia of the esophageal aperture of the diaphragm.

Diagnosis of hernia of the esophageal opening of the diaphragm includes direct and indirect signs. A direct indication is the definition of the hernial sac in the mediastinum, the main radiologic symptoms of which are: the accumulation of contrast material in the esophagus over the diaphragm with a horizontal barium level, the presence of a wide communication between the supra-diaphragm part of the esophagus and the stomach, the presence of characteristic folds of the gastric mucosa in the region of the esophageal-gastric transition, moving part or all of the anatomical cardia above the diaphragmatic orifice. Indirect signs include: the absence or decrease of the gas bubble in the stomach, its definition over the diaphragm, the smoothness of the angle of the Hyis, the vesicular arrangement of the folds of the gastric mucosa in the esophageal aperture of the diaphragm (3-4 folds), the elongation or shortening of the thoracic esophagus. In doubtful cases, it is advisable to apply pharmacoragentgenography - artificial hypotension with atropine, which makes it possible to detect even small HFO.

Additional diagnostic methods for gastroesophageal reflux disease

The presence of gastroesophageal refluxes can be determined by sounding using methylene blue. Through a thin gastric tube the patient is injected into the stomach with a dye (3 drops of a 2% solution of methylene blue in 300 ml of boiled water), then the probe is rinsed with saline, tightened slightly proximal to the cardia, and the contents of the esophagus are sucked. The sample is considered positive when the esophagus is colored blue.

For the detection of gastroesophageal refluxes, a standard acid reflux test is also applicable. The patient is injected with 300 ml of 0.1 M hydrochloric acid into the stomach and the pH is recorded using a pH probe located 5 cm above the lower esophageal sphincter, during maneuvers aimed at increasing intra-abdominal pressure: deep breathing, cough, Muller and Valsalva tests in four positions (lying on the back, right and left side, lying with 20 ° downward). The sample is positive if the decrease in the pH of the esophagus is recorded in at least three positions.

When conducting an acid perfusion test or a test of Bernstein and Baker, the patient is in a sitting position. The probe is inserted through the nose into the middle part of the esophagus (30 cm from the wings of the nose). At a rate of 100-200 drops per minute, 15 ml of 0.1 M hydrochloric acid are introduced. The test is considered positive when heartburn, chest pain and stifle after the introduction of saline. For reliability, repeat the test twice. The sensitivity and specificity of this test is about 80%.

More physiological is the Stepenko test, in which instead of hydrochloric acid, the patient is injected with his own gastric juice.

Laboratory research

Pathognomonic for GERD laboratory signs are not present.

Recommended laboratory tests: general blood test, blood group, Rh factor.

Instrumental research

Compulsory instrumental research

Single:

• esophagogastroduodenoscopy - allows to differentiate non-erosive reflux disease and reflux esophagitis, to detect the presence of complications;
• biopsy of the mucosa of the esophagus in the complicated course of GERD: ulcers, strictures, Barrett's esophagus;
• X-ray examination of the chest, esophagus and stomach.

Studies conducted in dynamics:

• esophagogastroduodenoscopy (with non-erosive reflux disease can be avoided);
• biopsy of the mucosa of the esophagus in the complicated course of GERD: ulcers, strictures, Barrett's esophagus;

Additional laboratory and instrumental methods of research

Single:

• 24-hour intraepithelial pH-metry: increase in the total reflux time (pH less than 4.0 more than 5% during the day) and the duration of the reflux episode (more than 5 minutes). The method allows to evaluate the pH in the esophagus and stomach, the effectiveness of drugs; the value of the method is especially high in the presence of extra-esophageal manifestations and the absence of the effect of therapy.
• Intra-esophagus manometry is performed to assess the functioning of the lower digestive sphincter (NPC), the motor function of the esophagus.
• Ultrasound examination of the abdominal cavity organs - with GERD unchanged, is performed to identify the concomitant pathology of the abdominal cavity organs.
• Electrocardiographic study, veloergometry - used for differential diagnosis with ischemic heart disease, with GERD do not show any changes.
• The test with the proton pump inhibitor is the relief of clinical symptoms (heartburn) against the background of taking proton pump inhibitors.

Differential diagnostics

In a typical clinical picture of the disease, a differential diagnosis usually presents no difficulties. In the presence of vnepishchevodnyh symptoms should be differentiated from IHD, bronchopulmonary pathology (bronchial asthma, etc.). For a differential diagnosis of gastroesophageal reflux disease with esophagitis of another etiology, a histological examination of the biopsy specimens is performed.

Indications for consultation of other specialists

The patient should be referred for advice to specialists with uncertainty of the diagnosis, the presence of atypical or non-esophageal symptoms or suspected complications (esophageal stricture, esophagus ulcer, bleeding, Barrett's esophagus). It may be necessary to consult a cardiologist (for example, if there are chest pains that do not stop on the background of taking proton pump inhibitors), a pulmonologist, an otorhinolaryngologist.

[1], [2], [3], [4]