Does Symptom Response Diagnose Gastroesophageal Reflux Disease?

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The summary below is from the full report titled "Short-Term Treatment with Proton-Pump Inhibitors as a Test for Gastroesophageal Reflux Disease. A Meta-Analysis of Diagnostic Test Characteristics." It is in the 6 April 2004 issue of Annals of Internal Medicine (volume 140, pages 518-527). The authors are M.E. Numans, J. Lau, N.J. de Wit, and P.A. Bonis.

What is the problem and what is known about it so far?

Gastroesophageal reflux disease (GERD) is a backflow (reflux) of stomach contents into the esophagus. It happens when the valve between the esophagus and stomach opens or relaxes. The reflux of stomach contents causes symptoms such as heartburn, indigestion, and sour- or bitter-tasting fluids in the throat or mouth. Diagnosing GERD can be difficult because symptoms may be similar to those seen in other digestive disorders. Standard diagnostic tests include measuring the amount of stomach acid in the esophagus over a 24-hour period (pH monitoring), visually examining the esophagus by using an instrument passed through the mouth (endoscopy), or completing a checklist for GERD symptoms. Doctors often prescribe medicines called proton-pump inhibitors (PPIs) to reduce stomach acid and symptoms of GERD. They sometimes assume that a patient has GERD if the PPIs eliminate symptoms. Is this assumption correct?

Why did the researchers do this particular study?

To compare patients' responses to short-term treatment with a PPI as a diagnostic test with other, more established procedures for diagnosing GERD.

Who was studied?

More than 2750 patients with suspected GERD who took PPIs and also had tests for GERD.

How was the study done?

Rather than doing a new study, the authors searched the medical literature from January 1980 through July 2003. They found 15 studies that involved patients with suspected GERD who received PPI treatment. Treatment with a PPI was short-term, lasting from 1 to 4 weeks. All of the patients also received tests for GERD, including pH monitoring, endoscopy, or standardized questionnaires. The researchers combined the results of the studies to see whether patients whose symptoms improved with PPI treatment had GERD and whether patients whose symptoms did not improve with PPI treatment did not have GERD.

What did the researchers find?

About 50% to 70% of the patients in the studies reported that PPIs reduced symptoms. Tests, such as pH monitoring and endoscopy, showed that many of these patients did not have GERD. Also, about 20% to 40% of the patients who had positive test results for GERD reported that PPIs did not reduce symptoms.

What were the limitations of the study?

Studies defined "successful" reduction of GERD symptoms differently. Also, there was too little information with which to evaluate whether different doses of PPIs and length of treatment with PPIs made a difference in diagnosing GERD.

What are the implications of the study?

Symptomatic response to short-term treatment with a PPI does not confidently diagnose GERD.

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Is diagnosis all we need?

Agostino Colli, et al.

Annals Online, 20 Jul 2004 [Full text]