For Recalcitrant GERD Symptoms, Order 24-h pH/Imepdance Study

A 35-year-old man is referred for the evaluation of GERD symptoms. His primary symptom is regurgitation, although he occasionally experiences heartburn as well. He was started on once daily PPI for 2 months and only experienced mild relief in symptoms. His dosage was increased to twice daily for an additional month without much improvement. He denies any dysphagia, weight loss, early satiety, or melena. He is otherwise healthy and takes no other medications. Which of the following would be recommended?

A. Ambulatory 24-hour pH/impedance study
B. Upper endoscopy
C. Barium esophagram
D. Switch PPI to H₂ receptor antagonist

Answer: A.

This patient with GERD symptoms has a partial and suboptimal response to PPI therapy. The symptom of regurgitation is generally less responsive to acid suppressants than heartburn. This may be a result of PPIs not directly affecting the mechanisms of reflux, rather these medications change the acidity of the refluxate. As this patient is without red flag signs (weight loss, dysphagia, melena), an upper endoscopy is not warranted. The preferred testing would be ambulatory pH monitoring. This study would be able to assess (1) whether he has adequate acid suppression on PPI; (2) whether his symptoms correlate with reflux; and (3) determine if his symptoms may be attributed to non-acid reflux, which occurs in up to one-third of patients whose symptoms persist despite PPI therapy. A barium swallow is not a good screening test for GERD. Changing acid suppressants is unlikely to improve his symptoms.