BL Unfortunately, no. It would be helpful if clinicians could perform appropriate pH testing a hr wireless pH capsule test or a transnasal impedance pH probe and then use parameters on the pH test that would help predict response to therapy. Unfortunately, this is not yet possible. BL At least in my practice, pH testing is indicated in a number of different situations.
The first would be when I think a patient clearly has true GERD, I place the patient on a PPI, and the patient is still experiencing persistent symptoms despite taking the medication appropriately. I would evaluate such a patient with either a transnasal impedance pH probe or a hr wireless pH capsule.
Several studies have now shown that the vast majority of patients with reflux symptoms do not require a double-dose or even higher dose PPI, and I tend to test patients earlier rather than later to show that their acid is controlled on a daily PPI, before treating the patient for months with double-dose therapy that may not be required or be effective. I also perform pH testing when a patient presents with extraesophageal manifestations, such as constant clearing of the throat, vocal cord problems, chronic cough, or asthma symptoms, and the patient reports that these symptoms are not responding to PPI therapy.
This is a frequent referral to our Motility Center in which another provider may have thought that these symptoms represented reflux and put the patient on a PPI. In this situation, I would take the patient off the PPI and examine him or her with a hr wireless pH capsule. BL Especially nowadays when medical costs are rising and budgets are limited, I think that all clinicians need to try to practice medicine as cost-effectively as possible.
Therefore, the following question has often come up: is it more cost-effective to place patients on PPI therapy, often escalating from a daily dose to a twice-daily dose, or is it more cost-effective to measure patients upfront to determine whether acid reflux is the culprit, and then place the patients on the appropriate therapy? This question has come up in part because the symptoms of acid reflux are not very sensitive or specific. Even a well-established, astute clinician can sometimes find it very difficult to determine whether the upper abdominal symptoms described by a patient truly are acid reflux, as opposed to the other conditions previously mentioned, such as functional dyspepsia, ineffective esophageal motility, or eosinophilic esophagitis.
With all of this in mind, my colleagues and I conducted a cost economic analysis several years ago. Using economic modeling, we found that upfront pH testing, using a hr wireless pH capsule test, was more cost-effective than placing patients on long-term PPI therapy.
This concept of upfront testing is important. Gastroenterology ; — Wolfe MM and Sachs G. Acid suppression: optimizing therapy for gastroduodenal ulcer healing, gastroesophageal reflux disease, and stress-related erosive syndrome.
Gastroenterology ; S9—S Sachs G. Proton pump inhibitors and acid-related diseases. Pharmacotherapy ; 22— Herregods TV, et al. Patients with refractory reflux symptoms often do not have GERD. Neurogastroenterol Motil ; — Bytzer P, et al.
Limited ability of the proton-pump inhibitor test to identify patients with gastroesophageal reflux disease. Clin Gastroenterol Hepatol ; — Reimer C. Safety of long-term PPI therapy. Best Pract Res Clin Gastroenterol ; — William JH and Danziger J. Magnesium deficiency and proton-pump inhibitor use: a clinical review. J Clin Pharmacol ; — Oberhuber G and Stolte M. Gastric polyps: an update of their pathology and biological significance. Virchows Arch ; — Jalving M, et al.
Increased risk of fundic gland polyps during long-term proton pump inhibitor therapy. Aliment Pharmacol Ther ; — Cats A, et al. Parietal cell protrusions and fundic gland cysts during omeprazole maintenance treatment.
Hum Pathol ; — Bhatt DL, et al. J Am Coll Cardiol ; — Vaduganathan M, et al. Am J Med ; — Related CE. View More CE. Related Content.
One potential problem is that patients may have self-diagnosed without ever seeing a gastroenterologist and purchased a PPI over the counter. Additional testing, such as an upper endoscopy, may also be needed. Another test is reflux monitoring. The patient keeps a diary of symptoms while the recorder measures the amount of reflux.
Another test attaches an acid monitor temporarily to the inside of the esophagus and wirelessly sends the data to a recorder.
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