Expert consensus document: Advances in the physiological assessment and diagnosis of GERD

Oesophageal symptoms can be associated with conditions such as eosinophilic oesophagitis, lichen planus and infectious oesophagitis (oesophageal candidiasis, herpes simplex oesophagitis, cytomegalovirus oesophagitis). Finally, functional disease can give rise to any oesophageal symptom, including symptoms similar to GERD [38]. Ambulatory reflux monitoring demonstrates physiological reflux parameters, but minor motor disorders and contraction-wave abnormalities on HRM are compatible with functional oesophageal disorders [38].



Conclusions

Combining existing data on reflux testing with expert consensus opinion, this Consensus Statement describes the modern evaluation of GERD, especially when oesophageal symptoms persist despite empiric antisecretory therapy and when EGD does not identify an alternate mechanism for symptoms. In this setting, HRM identifies motor pathophysiology conducive to gastro-esophageal reflux and ambulatory reflux monitoring describes pathological oesophageal reflux burden and symptom-reflux association. Other novel parameters on pH testing or pH-impedance testing, including MNBI and the PSPW index, might complement conventional reflux parameters in improving confidence for a reflux diagnosis. In the future, understanding GERD pathophysiology in more detail, particularly the inter-relationship between GERD and oesophageal motor dysfunction, and evaluating oesophageal reflux burden with novel metrics could help identify GERD phenotypes better and improve management outcomes (Box 3). A need now exists for prospective and collaborative outcome studies to determine the clinical value of oesophageal function testing in predicting symptomatic outcome.

Box 3: Open research questions

· Understanding mechanisms of pathological acid reflux in terms of abnormalities of oesophageal and oesophagogastric junction structure and function, including the acid pocket

· Clarification as to whether pathological acid reflux is the cause of abnormal oesophageal motor function, or if reflux is the consequence of abnormal motor function in GERD

· Exploration of the clinical utility of existing and novel oesophageal physiological metrics from high-resolution manometry and ambulatory reflux monitoring in identifying GERD phenotypes that predict GERD management outcome

Elucidation of the importance of oesophageal sensitivity as a mechanism for GERD symptom reporting and a potential target for treatment

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Acknowledgements

The International Working Group for Disorders of Gastrointestinal Motility and Function initiated the consensus meetings and provided material support for the consensus process. Five separate groups reviewed the current state-of-the-art in clinical measurement of gastrointestinal motility and function: oropharynx, esophagus, reflux disease, stomach / intestine and anorectum. This process was endorsed by the European Society of Neurogastroenterology and Motility (ESNM) and the European Society of Colo-Proctology (ESCP) with representation and support from the American Neurogastroenterology and Motility Society (ANMS), South and Latin American Neurogastroenterology and Motility Society (SLNG), Asian Neurogastroenterology and Motility Association (ANMA) and members of the Australasian Neurogastroenterology and Motility Association (ANGMA). Financial support was provided by the United European Gastroenterology (UEG) Education Committee, registration fees for meetings and sponsorship from all major manufacturers of physiological measurement equipment.

Contributions

C.P.G., E.S. and S.R. wrote the manuscript. All authors contributed equally to researching data, discussing content as well as reviewing and editing the manuscript before submission.

Competing interests statement

E.S. has served as consultant for Medtronic and Sandhill Scientific. A.B. received research funding from Endostim, as well as speaker and consulting fees from Medical Measurement Systems. M.F. received research funding from AstraZeneca, Medtronic and Reckitt Benckiser, and educational grants or speaker fees from Medical Measurement Systems, Medtronic, Mui Scientific, Reckitt Bencki and Sandhillser. J.E.P. has served as a consultant and speaker for Medtronic and Sandhill Scientific, a speaker for Astra Zeneca and Takeda, and a consultant for Ironwood. He also has stock options from Trimedyne Inc. S.R. has served as consultant for Medtronic and Sandhill Scientific and received research grant from Crospon. C.P.G. has served as a consultant for Ironwood, Medtronic and Torax, he is a speaker for Allergan and Medtronic, and has received research funding from Medtronic.

Citation

Savarino E, Bredenoord AJ, Fox M, Pandolfino JE, Roman S, Prakash Gyawali C. Expert consensus document: Advances in the physiological assessment and diagnosis of GERD. Nature Reviews Gastroenterology and Hepatology. 2017 Nov 1;14(11):665-676.

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