Diagnosis of gastroesophageal reflux: an update on current and emerging modalities

Gastroesophageal reflux disease (GERD) is a common condition characterized by troublesome symptoms or esophageal mucosal lesions attributed to excessive esophageal acid exposure. Various pathophysiological mechanisms account for GERD, including impaired esophageal peristalsis and anatomical or physiological defects at the esophagogastric junction (EGJ). Endoscopy identifies GERD complications and detects potential alternative diagnoses. However, if symptoms persist despite proton pump inhibitor therapy, functional esophageal tests are useful to characterize reflux burden and define the symptom association profile. Ambulatory pH or pH‐impedance monitoring measures the 24‐h acid exposure time, which remains the most reproducible reflux metric and predicts response to antireflux therapy. Apart from identifying peristaltic dysfunction, esophageal high‐resolution manometry defines the morphology and contractile vigor (EGJ‐CI) of the EGJ. Novel metrics obtained from pH‐impedance monitoring include the postreflux swallow–induced peristaltic wave index and mean nocturnal baseline impedance, which augment the diagnostic value of pH‐impedance testing. Mucosal impedance can also be recorded using a probe inserted through a gastroscope, or a novel balloon catheter with arrays of impedance electrodes inserted following sedated endoscopy. The latest developments in functional esophageal tests define the GERD phenotype based on pathogenesis, reflux exposure, structural or motility disorders, and symptom burden, facilitating appropriate treatment. In this review, we provide an updated summary of the modern approach to gastroesophageal reflux disease (GERD) evaluation. Novel diagnostic metrics recently described include mucosal impedance and the postreflux swallow–induced peristaltic wave index, which enhance the diagnostic yield of pH‐impedance monitoring. A comprehensive evaluation of the anatomy, motor function, reflux burden, and symptom profile defines the individual patient phenotype and allows the clinician to direct appropriate treatment.