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    Clinical Use of Esophageal Physiologic Testing (beta)

    Official guideline of the American College of Gastroenterology.

    Strength
    Strong recommendation
    Conditional recommendation
    Evidence
    Moderate quality evidence
    Low quality evidence
    Very low quality evidence

    Obstructive Symptoms

    Obstructive Symptoms
    1. We suggest that patients with obstructive esophageal symptoms without a mechanical cause should undergo HRM for evaluation of esophageal motility disorders.
    2. We recommend HRM over conventional line tracing manometry for the diagnosis of esophageal motility disorders in patients with obstructive esophageal symptoms.
    3. We suggest utilization of supplementary/provocative maneuvers with the HRM protocol to improve the diagnostic yield of esophageal motility disorders in patients with obstructive esophageal symptoms.
    4. We suggest the inclusion of a barium tablet with a barium esophagram during the evaluation of obstructive esophageal symptoms.
    5. We suggest the use of FLIP to complement HRM for the diagnosis of esophageal motility disorders in patients with obstructive esophageal symptoms and borderline HRM findings.
    6. We suggest that the EGJ and gastric cardia anatomy should be inspected endoscopically and/or radiographically to assess for mechanical abnormalities in patients with esophageal symptoms after antireflux surgery.

    Typical Reflux Symptoms

    Typical Reflux Symptoms
    1. We suggest the use of ambulatory reflux monitoring over patient-reported symptoms on GERD questionnaires for a conclusive diagnosis of GERD in patients with esophageal reflux symptoms.
    2. We suggest the use of ambulatory reflux monitoring over the assessment of response to PPI therapy for a conclusive diagnosis of GERD in patients with esophageal reflux symptoms.
    3. We suggest the use of ambulatory reflux monitoring over upper endoscopy alone (if endoscopy is not definitive) for a conclusive diagnosis of GERD in patients with esophageal reflux symptoms not responding to PPI.
    4. We suggest the use of ambulatory reflux monitoring performed off PPI therapy over ambulatory reflux monitoring on PPI therapy for a conclusive diagnosis of GERD in patients with typical reflux symptoms and unproven GERD.
    5. We suggest the use of prolonged wireless pH monitoring over 24-hr catheter-based monitoring for the diagnosis of GERD in adults with infrequent or day-to-day variation in esophageal symptoms.
    6. We suggest the use of ambulatory pH impedance monitoring on PPI therapy over endoscopic evaluation or pH monitoring alone to diagnose persisting GERD in adults with typical esophageal reflux symptoms and previous confirmatory evidence of GERD (proven GERD).
    7. We suggest that for patients with esophageal symptoms being evaluated for antireflux surgery, abnormal acid exposure time be considered a predictor of treatment outcome; reflux symptom association and mean nocturnal baseline impedance provide adjunctive value.

    Extraesophageal Reflux and Atypical Symptoms

    Extraesophageal Reflux and Atypical Symptoms
    1. We recommend ambulatory reflux monitoring, specifically pH impedance monitoring performed off acid suppression, over laryngoscopy for a diagnosis of extraesophageal reflux.
    2. We suggest up-front ambulatory reflux monitoring off acid suppression over an empiric trial of PPI therapy for extraesophageal reflux symptoms without concurrent typical reflux symptoms.
    3. We suggest HRIM with postprandial monitoring be used to confirm the diagnosis of rumination if clinically necessary in patients with esophageal symptoms suspicious for rumination syndrome.
    4. We suggest that for patients with excessive belching, pH impedance monitoring can be used to confirm the diagnosis of supragastric belching.
    What do the icons mean?  
    Research PaperGyawali CP, Carlson DA, Chen JW, Patel A, Wong RJ, Yadlapati RH. Acg clinical guidelines: clinical use of esophageal physiologic testing. Am J Gastroenterol. 2020;115(9):1412-1428.