Early Referral for 24-hour Esophageal Ph Monitoring May Prevent Unnecessary Treatment With Acid-reducing Therapy

David A Kleiman, MD, Matthew J Sporn, BS, Toni Beninato, MD, Thomas J Fahey, Iii, MD, Rasa Zarnegar, MD. New York Presbyterian Hospital – Weill Cornell Medical College

 INTRODUCTION: Gastroesophageal reflux disease (GERD) affects nearly 25% of adults, however an objective diagnosis is rarely established.  We hypothesized that delayed referral for 24-hour pH monitoring (current "gold-standard" for diagnosis) may result in lengthy courses of unnecessary acid-reducing therapy for select patients.

METHODS AND PROCEDURES: A retrospective chart review was performed of all 24-hour esophageal pH monitoring studies performed at our institution between 2004 and 2011. Patients whose medical records lacked adequate historical information were excluded. The records were reviewed for patient age, gender, type of GERD symptoms, and duration/response to prior acid-reducing medications. Patients were labeled “no GERD” if there was a low index of suspicion, “typical GERD” if descriptors such as regurgitation, “heartburn,” and dysphagia were reported, and “atypical GERD” if symptoms such as hoarseness, voice changes, post-nasal drip, or sinusitis were used. Patients were grouped by history of GERD and then also by response to acid-reducing therapy prior to testing. pH monitoring was considered diagnostic of pathological GERD if the DeMeester score was ≥14.7. Statistical analysis was performed using STATA 12.0 (College Station, TX).                                                                                                

¹Values not normally distributed reported as median (range), ²Kruskal-Wallis rank test.

RESULTS: 115 patients were included in this study. 68.7% of the patients had a history of typical GERD, 22.6% had a history of atypical GERD, and 8.7% had no history of GERD. Patients who tested positive for GERD on 24-hour pH monitoring were well-matched compared to those who tested negative except the positive group was significantly older than the negative group (52.5±15.1 years vs. 45.4±15.8, p=0.023). When grouped according to type of GERD history, there were no significant differences in the outcome of the test, DeMeester score, or duration of PPI use prior to testing (Table 1). When grouped according to response to anti-reflux therapy, there were no significant differences in DeMeester scores or test outcomes between the groups. However, there was a significant step-wise increase in duration of anti-reflux therapy prior to testing. Patients with no response to treatment were referred earliest and patients with an initial response but subsequent relapse of symptoms were referred the latest (median 1.3 years vs. 6.0 years, p=0.012) (Table 1). 42.9% of the patients who had a relapse of symptoms had no evidence of GERD on pH monitoring (Table 1).

CONCLUSION: Delayed referral for esophageal pH monitoring occasionally results in lengthy periods of unnecessary treatment with acid-reducing therapy with no therapeutic benefit. Early referral for 24-hour esophageal pH monitoring could potentially avoid unnecessary side effects and expenses for these patients.

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