Diagnosis:

A person with chronic heartburn is also likely to have GERD. (Occasional heartburn does not necessarily indicate the presence of GERD.) The following is the general way to diagnose GERD:

• A physician can usually diagnose GERD if the patient finds relief from persistent heartburn and acid regurgitation after taking antacids for short periods of time.
• If the diagnosis is uncertain but the physician still suspects GERD, a drug trial using a proton pump inhibitor (PPI) medication, such as omeprazole (Prilosec) identifies 80% - 90% of people with the condition. This class of medication blocks stomach acid secretion.

Laboratory or more invasive tests, including endoscopy, may be required if:

• The diagnosis is still uncertain
• Symptoms are not typical
• Barrett's esophagus is suspected
• Complications, such as signs of bleeding or difficulty swallowing, are present

Some of these tests are described below.

Barium Swallow Radiograph

A barium swallow radiograph (x-ray) is useful for identifying structural abnormalities and erosive esophagitis. For this test, the patient drinks a solution containing barium, and then x-rays of the digestive tract are taken. This test can show stricture, active ulcer craters, hiatal hernia, erosion, or other abnormalities. However, it cannot reveal mild irritation.

Upper Endoscopy

Upper endoscopy, also called esophagogastroduodenoscopy or panendoscopy, is more accurate than a barium swallow radiograph. It is also more invasive and expensive. It is widely used in GERD for identifying and grading severe esophagitis, monitoring patients with Barrett's esophagus, or when other complications of GERD are suspected. Upper endoscopy is also used as part of various surgical techniques.

Until recently, experts recommended screening with endoscopy for Barrett's esophaguus and esophageal cancer at least once in a lifetime for patients with chronic GERD. However, new guidelines from the American Gastroenterological Association do not recommend endoscopy screening because there is no evidence that it can improve survival.

Endoscopy to Diagnose GERD. Endoscopy may be performed either in a hospital or doctor's office:

• The patient should eat nothing for at least 6 hours before the procedure.
• The doctor administers a local anesthetic using an oral spray and an intravenous sedative to suppress the gag reflex and relax the patient.
• Next, the physician places an endoscope (a thin, flexible plastic tube containing a tiny camera) into the patient's mouth and down the esophagus. The procedure does not interfere with breathing. It may be slightly uncomfortable for some patients; others are able to sleep through it.
• Once the endoscope is in place, the camera allows the physician to see the surface of the esophagus and look for abnormalities, including hiatal hernia and damage to the mucus lining.
• The physician performs a biopsy (the removal and microscopic examination of small tissue sections). The biopsy may detect tissue injury from GERD. It may also be used to detect cancer or other conditions, such as yeast (Candida albicans) or viral infections (such as herpes simplex and cytomegalovirus). Such infections are more likely to occur in people with impaired immune systems.

Complications from the procedure are uncommon. If they occur, complications are almost always mild and typically include minor bleeding from the biopsy site or irritation where medications were injected.

If a patient has moderate-to-severe GERD symptoms and the procedure reveals injury in the esophagus, usually no further tests are needed to confirm a diagnosis. The test is not foolproof, however. A visual view misses about half of all esophageal abnormalities.

Capsule Endoscopy. In this test, the patient swallows a small capsule containing a tiny camera. Then, a series of color pictures are transmitted to a recording device where they can be downloaded and interpreted by a doctor. The entire procedure takes 20 minutes. The capsule is naturally passed through the digestive system within 24 hours. A newer technique has a string attached to the capsule for retrieval. Capsule endoscopy may provide a more attractive and less invasive alternative to traditional endoscopy. However, while capsule endoscopy is useful as a screening device for diagnosing esophageal conditions such as GERD and Barrett's esophagus, traditional endoscopy is still required for gathering tissue samples or removing polyps.

Monitoring for Barrett's Esophagus and Cancer

Barrett's esophagus is diagnosed using endoscopy.

Monitoring High-Risk GERD Patients. Some experts recommend a one-time screening test for BE using endoscopy in high-risk patients (such as Caucasian overweight men) with chronic GERD.

Monitoring Patients with Barrett's Esophagus for Cancer. Periodic endoscopy is recommended for detecting early cancer in patients who have been diagnosed with Barrett's esophagus. When Barrett's esophagus is diagnosed, multiple biopsies are generally taken. The biopsy results will determine the frequency of future monitoring. Unfortunately, monitoring patients with Barrett's esophagus has not been proven to change mortality from esophageal cancer.

pH Monitor Examination

The (ambulatory) pH monitor examination may be used to determine acid backup. It is useful when endoscopy has not detected damage to the mucus lining in the esophagus, but GERD symptoms are present. pH monitoring may be used when patients have not found relief from medicine or surgery. Traditional trans-nasal catheter diagnostic procedures involved inserting a tube through the nose and down to the esophagus. The tube was left in place for 24 hours. This test was irritating to the throat, and uncomfortable and awkward for most patients.

A new method known as the Bravo pH test uses a small capsule-sized data transmitter that is temporarily attached to the wall of the esophagus during endoscopy. The capsule records pH levels and transmits these data to a pager-sized receiver the patient wears. Patients can maintain their usual diet and activity schedule during the 24 - 48-hour monitoring period. After a few days, the capsule detaches from the esophagus, passes through the digestive tract, and is eliminated through a bowel movement.

Manometry

Manometry is a technique that measures muscular pressure. It uses a tube containing various openings, which is placed through the esophagus. As the muscular action of the esophagus puts pressure on the tube in various locations, a computer connected to the tube measures this pressure. Manometry is useful for the following situations:

• To determine whether a GERD patient would benefit from surgery, by measuring pressure exerted by the lower esophageal sphincter muscles.
• To detect impaired stomach motility (an inability of the muscles to contract normally) that cannot be surgically corrected with standard procedures.
• To determine whether impaired peristalsis or other motor abnormalities are causing chest pain in people with GERD.

Other Tests

Blood and Stool Tests. Stool tests may show traces of blood that are not visible without a microscope. Blood tests for anemia should be performed if bleeding is suspected.

Bernstein Test. For patients with chest pain in which the diagnosis is uncertain, a procedure called the Bernstein test may be helpful, although it is rarely used. A tube is inserted through the patient's nasal passage. Solutions of hydrochloric acid and saline (salt water) are administered separately into the esophagus. A diagnosis of GERD is established if the acid infusion causes symptoms and the saline solution does not.

Ruling out Other Disorders

Because many illnesses share similar symptoms, a careful diagnosis and consideration of the patient's history is key to an accurate diagnosis. The following are only a few of the conditions that could accompany or resemble GERD:

Dyspepsia. The most common disorder confused with GERD is dyspepsia, which is pain or discomfort in the upper abdomen without heartburn. Specific symptoms may include a feeling of fullness (particularly early in the meal), bloating, and nausea. Dyspepsia can be a symptom of GERD, but it does not always occur with GERD. Treatment with both antacids and proton pump inhibitors can have benefits. The drug metoclopramide (Reglan) helps stomach emptying and may be useful for this condition.

Angina and Chest Pain. About 600,000 people come to emergency rooms each year with chest pain. More than 100,000 of these people are believed to actually have GERD. Chest pain from both GERD and severe angina can occur after a heavy meal. In general, a heart problem is probably not responsible for the pain if it is worse at night and does not occur after exercise. It should be noted that the two conditions often coexist. In fact, there is a theory that in patients with coronary artery disease, acid reflux may actually trigger angina. In such cases, experts believe that acid in the esophagus may activate nerves that temporarily impair blood flow to the heart.

Other Diseases. Many gastrointestinal diseases (such as inflammatory bowel disease, ulcers, and intestinal cancers) can cause GERD, but they are often easily identified, because they have other symptoms and affect different areas of the intestinal tract.