Expert Advice for Difficult GERD Cases
FROM ACG 2025
PHOENIX – , said Kristle L. Lynch, MD, in a presentation at the American College of Gastroenterology (ACG) 2025 Annual Scientific Meeting.
Patients with persistent GERD who have cough and asthma, as well as those with hoarseness, globus, or other ear, nose, and throat concerns, may first undergo workup by other clinicians, said Lynch, who is a professor of clinical medicine and director of the Physiology and Motility Laboratory at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.
With these patients, “given the low pretest probability of an acid reflux source, it makes sense to bypass a trial of acid-suppressing medication if symptoms persist and instead move on to consideration of upper endoscopy,” she said.
“If negative for damage or sequelae of reflux, this test is often followed by advanced reflux testing and high-resolution manometry, to help diagnose the cause of reflux and swallowing problems,” she noted.
For patients with heartburn, regurgitation, or noncardiac chest pain (and no other concerning symptoms), moving to an empiric trial of antisecretory therapy before endoscopy can be reasonable, Lynch said. But if symptoms persist, an endoscopy should be done before any advanced pH testing.
Advanced pH Testing Options
Advanced reflux testing options for persistent GERD after an endoscopy include catheter-based pH-impedance testing and wireless pH testing, said Lynch.
“Wireless pH monitoring offers improved patient comfort by eliminating the need for a nasal catheter, allowing individuals to maintain normal daily activities and diet during testing,” Lynch told GI & Hepatology News.
“It also enables extended monitoring periods of up to 96 hours, enhancing the detection of intermittent acid reflux episodes,” she said. “However, unlike pH-impedance catheter-based testing, wireless pH measures only acid exposure and cannot identify nonacid reflux events.”
In addition, the wireless capsule may detach prematurely or cause mild chest discomfort, and its endoscopic placement adds procedural complexity with the need for anesthesia, as well as additional cost, she noted.
Catheter-based pH-impedance testing involves sedation-free catheter placement while the patient is awake, followed by monitoring for 24 hours, and involves assessment of bolus movement in tandem with pH measurements, Lynch said. The catheter monitors levels of acid refluxing into the esophagus and transmits this information to the smartphone-sized computer worn by the patient over the 24-hour period.
Unlike wireless testing, impedance testing allows for adjunctive measures of mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic waves (PSPW), the latter of which is shown to predict response to proton pump inhibitor (PPI) therapy in patients with reflux.
Logistics include a concurrent manometry for the lower esophageal sphincter to optimize location, followed by a transnasal placement. Challenges associated with the catheter-based test include potential catheter migration and patient discomfort, she added.
Assessing pH Testing Results
After pH testing of either type, abnormal acid exposure time (AET) when the pH in the lower esophagus is greater than 6% supports a diagnosis of GERD; AET between 4% and 6% is considered borderline GERD; and AET less than 4% is considered normal and outside the bounds of pathologic reflux, as per the Lyon Consensus, Lynch explained.
Treatment for patients meeting the GERD criteria based on AET includes not only diet and lifestyle changes but also potential pharmacologics, including acid suppressants, alginates, gamma-aminobutyric acid agonists, and prokinetics. In some cases, anti-reflux surgery may be considered, such as magnetic sphincter augmentation, transoral incisionless fundoplication, or Roux-en-Y gastric bypass, Lynch said.
But not all heartburn in patients with persistent GERD is acid-related, she said. Functional heartburn and reflux hypersensitivity can be seen in these cases.
Patients not meeting the criteria for GERD on advanced pH testing and diagnosed with reflux hypersensitivity or functional heartburn may be treated with neuromodulators or nonpharmacologic therapies such as hypnosis, diaphragmatic breathing, cognitive-behavioral therapy, or acupuncture, said Lynch in her presentation.
Overall, “advanced pH testing should be assessed within the framework of other investigations and the patient as a whole,” she emphasized.
Challenges in the Clinic
One of the biggest mistakes while diagnosing a patient with persistent GERD symptoms despite PPI therapy is always assuming their symptoms are driven by ongoing pathologic acid exposure, said Michael Kingsley, MD, a gastroenterologist specializing in gastrointestinal motility disorders and a clinical assistant professor of medicine at the University of Pittsburgh, Pittsburgh, in an interview.
He agreed with Lynch that patients with reflux hypersensitivity or functional heartburn are more likely to benefit from interventions other than a PPI, such as a neuromodulator.
But managing GERD in the clinic also requires making time to assess whether patients are taking PPI correctly and to counsel them on lifestyle modifications, he noted.
One of the current biggest challenges in GERD is how best to manage a patient who falls into the inconclusive range of not definitely normal or abnormal on pH testing, Kingsley told GI & Hepatology News.
“As alluded to in this talk, MNBI and PSPW are emerging metrics, both of which require a pH-impedance study (as opposed to a wireless pH study),” he said. “Further elucidating the ideal application and cutoffs of these metrics may provide additional tools for best treating patients who fall into the “inconclusive” range with standard metrics.”
Lynch and Kingsley disclosed no financial conflicts of interest.
A version of this article appeared on Medscape.com .