Diagnosis

Methods

Several methods exist that help in the differential diagnosis of upper GI disorders and to evaluate severity of disease.
All the techniques listed can be used in the diagnosis of GORD.

1. Clinical signs and symptoms
2. pH measurement
3. Endoscopy
4. Laparoscopy
5. Gamma-scintigraphy
6. Barium meal
7. Combined multi channel Intraluminal Impedance (m11)

1. Clinical signs and symptoms

Diagnosis of upper GI disorders, including GORD, based on the presence of clinical signs and symptoms, such as heartburn and epigastric pain, is a reliable but qualitative method of diagnosis.

The symptoms profile can, however, be virtually indistinguishable in patients both with and without oesophagitis, and there is no way of determining the presence or severity of any oesophagitis or other complications. In patients where treatment of oesophageal lesions is an aim of therapy, other techniques are required.

In addition, in a significant proportion of patients with more severe oesophageal disease, in particular Barrett’s oesophagus, pathology may be associated with decreased incidence of symptoms such as heartburn.[Spechler, 1989]

Perceived location of discomfort

In order to describe the location of signs and symptoms of GI disease more accurately, the abdomen is divided into nine regions by four imaginary lines (Figure 1).

The upper horizontal line joins the lowest part of the ribs on each side, and the lower horizontal line joins the highest point of the hip bones (the iliac crests). The two vertical lines pass through the nipples.

1. Right hypochondriac
2. Right lumbar
3. Right iliac
4. Epigastric
5. Umbilical
6. Hypogastric
7. Left hypochondriac
8. Left lumbar
9. Left iliac

The abdominal regions are useful in describing the location of pain, swellings and discomfort in the abdomen, and precise knowledge of location can aid in the diagnosis of GI disease. For example, the pain of reflux oesophagitis (heartburn) is normally felt in the epigastric region of the abdomen, behind the breastbone (retrosternal). A pain beginning in the hypogastric region and gradually moving to the right iliac region might indicate developing appendicitis. People suffering from indigestion, however, tend to report a wider range of areas of perceived discomfort, which are usually below the epigastric region.

2. pH measurement

Twenty-four hour continuous ambulatory pH monitoring is useful in assessing the frequency and severity of reflux episodes, and is currently the diagnostic ‘gold standard’ for GORD. pH probes are passed nasogastrically (through the nostrils) and positioned in the oesophagus. Hence, pH changes can be continuously monitored. This method was developed in the 1970s, with advances in technology making ambulatory pH monitoring possible by 1982.

pH monitoring is indicated when symptoms are typical, there is no oesophagitis present, when previous treatments have failed, and in preparation for anti-reflux surgery.

From the data collected, the time the oesophageal mucosa is exposed to gastric juice can be quantified, the ability of the oesophagus to clear refluxed acid can be measured and the reflux episodes can be correlated with symptoms.

However, many reflux episodes are 'silent'. Typical traces from a normal subject and a patient with chronic reflux are shown in Figure 2.

3. Endoscopy

Endoscopy is most useful when damage to the oesophageal mucosa needs to be assessed or any oesophagitis present graded. To assess the oesophageal mucosa, an endoscope (Figure 3) is passed into the oesophagus.

The findings of endoscopy can determine the extent of disease and, thus, the appropriate treatment to be initiated (Figure 4). Endoscopy can also be utilised to take biopsies for further evaluation.

Endoscopic oesophageal damage is graded on a scale of 0–4 with increasing severity of damage (Savary-Miller classification of oesophagitis).

• Grade 0 is given to normal oesophagus with no macroscopic damage
• Grade 1 describes an oesophagus with a few areas of erythema, mucosal friability and contact bleeding. These are minor changes regarded as normal by some gastroenterologists
• Grade 2 oesophagitis has small superficial linear erosions. These tend to lie on the crests or tops of the mucosal folds and may have some surface exudate
• Grade 3 describes the condition when these erosions coalesce and join around the circumference of the oesophagus. A cobblestone appearance is created by islands of oedematous tissue between the erosions
• Grade 4 is characterised by extensive mucosal damage with deep ulcers. Strictures may develop, and where this happens there may be less damage above the stricture because the stricture forms a barrier to stomach acids

Rationalising the use of endoscopy

Endoscopy is usually indicated in older patients (>55 years of age [NICE guidelines]) with a brief history of symptoms, in patients with associated weight loss, in patients experiencing bleeding or difficulties in swallowing, and in those unresponsive to H2-receptor antagonists (H2-RAs).

• Review medications for possible causes of dyspepsia (for example, calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and non-steroidal antiinflammatory drugs [NSAIDs]). In patients requiring referral, suspend NSAID use. with a breath test or a stool antigen test.
• Urgent specialist referral for endoscopic investigation* is indicated for patients of any age with dyspepsia when presenting with any of the following: chronic gastrointestinal bleeding, progressive unintentional weight loss, progressive difficulty swallowing, persistent vomiting, iron deficiency anaemia, epigastric mass or suspicious barium meal.
• Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs, is not necessary. However, in patients aged 55 years and older with unexplained** and persistent** recentonset dyspepsia alone, an urgent referral for endoscopy should be made.

Treatment before endoscopy

Treatment with antisecretory drugs may mask significant diagnoses at endoscopy; therefore, it is recommended stopping such treatments at least 4 weeks before endoscopy.

Patients with dyspepsia in whom endoscopy is inappropriate

• Patients known to have a duodenal ulcer who have responded symptomatically to treatment
• Patients <55 years with uncomplicated dyspepsia
• Patients who have recently undergone a satisfactory endoscopy for the same symptoms

4. Laparoscopy

Laparoscopy is a minimally invasive surgical technique that uses a small video camera and a few customized instruments to perform surgery with minimal tissue injury. The procedure allows visual examination of abdominal and pelvic organs using a fibre-optic instrument called a laparoscope. A small incision is made close to the patient’s navel and carbon dioxide gas is used to inflate the abdomen. The laparoscope is then passed through the incision in the wall of the abdomen.

Laparoscopy can be used as both an investigative procedure/diagnostic aid, and to carry out surgical techniques, such as laparoscopic fundoplication, an operation where the upper part of the stomach is wrapped around the lower part of the oesophagus to reconstruct the LOS and prevent reflux.

This method reduces the recovery time due to its minimal tissue damage, permitting the patient to return to normal activity in a shorter period of time.

5. Gamma-scintigraphy

Gamma-scintigraphy uses radiography to quantitatively detect reflux of the stomach contents into the oesophagus and evaluates gastric mixing and emptying.

The patient or volunteer takes a meal that is radiolabelled with a radio isotope, technetium, which appears in blue when viewed through a gamma detection camera. The gamma camera is situated outside the body and can detect the meal inside the body from the radio emissions of the technetium mixed with the food (Figure 5).

In comparison to previously available diagnostic techniques, gamma-scintigraphy is a far more sensitive procedure and can detect gastro-oesophageal reflux accurately, rapidly and non-invasively, and an example of a reflux episode is shown in Figure 6.
In addition, measurements are quantitative, and the effects of different therapeutic strategies can be easily and accurately monitored.

6. Barium meal

Reflux can be assessed by monitoring the movement of barium after a barium meal. The degree of reflux is determined radiographically by noting whether the flow of barium extends into the lower, middle or upper oesophagus. In approximately 50% of symptomatic patients, however, reflux of barium is not observed. Consequently barium meals are more useful for evaluating motor function, and diagnosing hiatus hernia and oesophageal complications such as stricture and ulceration.

7. Combined multi channel Intraluminal Impedance (m11)

m11 is a new technique that uses changes in electrical conductivity to follow the movement of fluid and gas in teh oesophagus. As yet m11 is available only at research centres in the UK.

Laryngopharyngeal reflux

More to reflux than Acid

Heartburn in Pregnancy