Clinical Use of Esophageal Physiologic Testing

Publication Date: August 12, 2020
Last Updated: March 14, 2022

Recommendations

Testing for obstructive symptoms

We suggest that patients with obstructive esophageal symptoms without a mechanical cause should undergo HRM for evaluation of esophageal motility disorders. (Conditional (weak) “We suggest”, Very low)
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We recommend HRM over conventional line tracing manometry for the diagnosis of esophageal motility disorders in patients with obstructive esophageal symptoms. (Strong “We recommend”, Moderate)
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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. (Conditional (weak) “We suggest”, Low)
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We suggest the inclusion of a barium tablet with a barium esophagram during the evaluation of obstructive esophageal symptoms. (Conditional (weak) “We suggest”, Very low)
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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. (Conditional (weak) “We suggest”, Low)
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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. (Conditional (weak) “We suggest”, Very low)
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Testing for typical reflux symptoms

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. (Conditional (weak) “We suggest”, Very low)
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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. (Conditional (weak) “We suggest”, Very low)
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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. (Conditional (weak) “We suggest”, Very low)
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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. (Conditional (weak) “We suggest”, Low)
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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. (Conditional (weak) “We suggest”, Very low)
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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). (Conditional (weak) “We suggest”, Very low)
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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. (Conditional (weak) “We suggest”, Very low)
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Testing for extraesophageal reflux symptoms and atypical symptoms

We recommend ambulatory reflux monitoring, specifically pH impedance monitoring performed off acid suppression, over laryngoscopy for a diagnosis of extraesophageal reflux. (Strong “We recommend”, Low)
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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. (Conditional (weak) “We suggest”, Very low)
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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. (Conditional (weak) “We suggest”, Low)
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We suggest that for patients with excessive belching, pH impedance monitoring can be used to confirm the diagnosis of supragastric belching. (Conditional (weak) “We suggest”, Very low)
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EGJ, esophagogastric junction; FLIP, functional lumen imaging probe; GERD, gastroesophageal reflux disease; HRM, high-resolution manometry; PPI, proton pump inhibitor.

Recommendation Grading

Disclaimer

Overview

Title

Clinical Use of Esophageal Physiologic Testing

Authoring Organization

Publication Month/Year

August 12, 2020

Last Updated Month/Year

July 10, 2023

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis

Diseases/Conditions (MeSH)

D004935 - Esophageal Diseases

Keywords

esophageal, gastroesophageal reflux disease (GERD), esophageal dysmotility, physiologic tests

Source Citation

Gyawali, C. Prakash MD, MRCP, FACG; Carlson, Dustin A. MD; Chen, Joan W. MD; Patel, Amit MD; Wong, Robert J. MD, MS, FACG (GRADE Methodologist); Yadlapati, Rena H. MD, MSHS ACG Clinical Guidelines: Clinical Use of Esophageal Physiologic Testing, The American Journal of Gastroenterology: September 2020 - Volume 115 - Issue 9 - p 1412-1428 doi: 10.14309/ajg.0000000000000734