Gastroesophageal reflux disease(GERD)
Continues to be a challenge to diagnosis.
Classic symptoms– Only 60 %-- Heart-burn and regurgitation.
Achalasia, cholelithiasis, gastritis, peptic ulcer, coronary artery disease –  All mimic typical symptoms with GERD.
Atypical symptoms include chest pain, hoarseness, recurrent sorethroat, dental caries, bronchospasm, wheezing, chronic cough, recurrent chest infection.
Diagnosis include scintiscanning, barium radiography, acid-perfusion or Bernstein test, panendoscopy, present esophagitis.
The introduction of 24-hour esophageal pH monitoring provided a method to quantitate esophageal acid exposure.
Greatest sensitivity and specificity for diagnosis of gastroesophageal reflux –  As the gold standard test.

Three main cause of increase exposure of esophagus to refluxed gastric contents—
 (1) LES defective–  Most.
 (2) Inefficient esophageal clearance as low  peristaltic amplitudes or increase ineffective contractions.
 (3)Gastric abnormal–  Decrease gastric empting.
In early disease, the reflux episode occurred in upright position.
Bipositional reflux suggests more advanced disease and LES is severely impaired.
Pure supine reflux is rare.
Prolong reflux episodes suggest delayed esophageal clearance.

Bernstein test
Acid-perfusion test — Patient sitting with N-G tube 30 cm from nares, infusion normal saline 15 min, 0.1 N HCL at rate of 6 ml/min until symptoms produced.
The test is positive in two successive infusion periods acid induces pain and saline induces relief.
Specificity 89%, sensitivity is low because the pain induced by acid infusion does not correlate with the severity of esophagitis present.

Acid emptying test
Measeure the esophageal emptying capacity.
A bolus 15 ml of 0.1N HCl is introduced into esophagus 10 cm above the pH probe, patient repeat dry-swallows at 30-second intervals.
In normal–  Distal esophagus is cleared of acid within 10 swallows.
Prolonged clearance test indicates an impaired capacity of the esophagus to clear the irritant material.
Lacks sensitivity.

24-hour esophageal pH monitoring
Importance of—to detect an increased esophageal exposure to refluxed acidic gastric contents.
patient with severe symptoms are found mild degree esophagitis in endoscope frequently.
Mucosa injury was greatest in the exposure of pH 0-2.
Normal–  The gastric pH is 1-2, esophageal pH 4-7.
Continuously measured esophageal pH below 4–  Became the commonly used threshold of determing a reflux episode.
False negative—duodenogastric reflux.
Alkaline secretions neutralize gastric acid.
If suspected, a probe measures bilirubin.
Food in stomach can also neutralized gastric acid.
Probe malfunction or misplacement.
Medication use-- particularly proton pump inhibitors.

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