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Is diagnosis all we need?
Submit responseThe systematic review of Numans ME et al. shows that a positive proton pump inhibitors (PPI) test does not support and a negative one does not exclude the diagnosis of GERD as defined according to traditional objective criteria ( that are: upper endoscopy or pH monitorig or symptoms scores). However the authors suggest that a PPI trial might be reasonable in clinical practice. This apparent contradiction raises from regarding PPI test as a diagnostic one. It is not obvious to label a patient in whom PPI relieve symptoms but does not reach a diagnostic symptoms score as a False Positive. Short-term treatment with PPI can be useful for symptomatic patients no matter if they satisfy any formal diagnostic criteria. On the contrary a negative PPI test suggest the need of further investigation. Thus PPI test seems to really assess efficacy of an intervention. Clearly a positive result does not exclude between a placebo effect nor alternative diagnosis ( sensitive to PPI treatment). But in every day practice it seems not so essential to have a precise diagnosis: alternative diagnoses are similar for both prognostic and therapeutic point of view, PPI are relatively safe and inexpensive drugs. In conclusion why should we worry to have a precise diagnosis if patients have no more symptoms? It seems worth while to order further investigations only if alternative diagnoses show quite different prognosis or therapeutic approach : for instance in case of chest pain and nitroglycerin test[1]
REFERENCES 1.. Henrikson C A, Howell E E, Bush D E, Shawn Miles J,. Meininger G R, Friedlander T, Bushnell AC, and Chandra-Strobos N Chest Pain Relief by Nitroglycerin Does Not Predict Active Coronary Artery Disease Ann Intern Med 2003; 139: 979 - 986.
Conflict of Interest:
None declared