ACG issues guidelines for esophageal physiologic tests

Issue: September 2020

ByMonica Stonehill

The American College of Gastroenterology developed clinical guidelines for esophageal physiologic tests, published in the American Journal of Gastroenterology.

The Grading of Recommendations Assessment, Development and Evaluation process was used to describe performance characteristics and clinical value of esophageal physiologic tests. Investigators then created recommendations for esophageal physiologic tests use in routine clinical practice.

Among the recommendations for patients with obstructive esophageal symptoms without a mechanical cause are:

Patients should undergo high-resolution esophageal manometry for assessment of esophageal motility disorders

For patients with obstructive esophageal symptoms, high-resolution manometry should be used over conventional line tracing manometry for the diagnosis of esophageal motility disorders; supplementary/provocative maneuvers with the manometry protocol should be used to improve the diagnostic yield of esophageal motility disorders and include a barium tablet with a barium esophagram

For diagnosis of gastroesophageal reflux disease in patients with esophageal reflux symptoms, use ambulatory reflux monitoring over patient-reported symptoms on GERD questionnaires and over the assessment of response to proton-pump inhibitor therapy

Use ambulatory reflux monitoring performed off antisecretory therapy for diagnosis of GERD in patients with typical reflux symptoms and unproven GERD

Use ambulatory reflux monitoring over upper endoscopy alone (if endoscopy is not definitive) for diagnosis of GERD in patients with esophageal reflux symptoms not responding to PPI

Use prolonged wireless pH monitoring over 24-hour catheter-based monitoring for diagnosis of GERD in adults with infrequent symptoms or day-to-day variation in esophageal symptoms

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

Esophagogastric junction and gastric cardia anatomy should be inspected endoscopically and/or radiographically to assess mechanical abnormalities in patients with esophageal symptoms after acute radiation syndrome

Ambulatory reflux monitoring should be used over laryngoscopy for a diagnosis of extraesophageal reflux

Use pH-front ambulatory reflux monitoring off acid suppression over an empiric trial of PPI therapy for extraesophageal reflux symptoms without concurrent typical reflux symptoms

Use high resolution impedance manometry with postprandial monitoring to confirm the diagnosis of rumination if clinically necessary in patients with esophageal symptoms suspicious for rumination syndrome

In patients with excessive belching, pH impedance monitoring should be used to confirm the diagnosis of supragastric belching.

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Sources/Disclosures

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Source:

Gyawali CP, et l. Am J Gastroenterol. 2020;doi:10.14309/ajg.0000000000000734.

Disclosures: Gyawali reports teaching and consulting for Medtronic and Diversatek and consulting for Ironwood and Iso-thrive. Please see the full study for all other authors’ relevant financial disclosures.

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ACG issues guidelines for esophageal physiologic tests

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