Comparison of transnasal esophagoscopy and sedated esophagogastroduodenoscopy in the assessment of laryngopharyngeal reflux.

OBJECTIVE: Transnasal esophagoscopy (TNE) in the awake patient and esophagogastroduodenoscopy (EGD) in sedation are both used in the assessment of laryngopharyngeal reflux (LPR). The objective of this study was to compare these two endoscopic methods in contributing to the diagnosis of LPR. METHODS: This study included 54 patients presenting with signs and symptoms suspicious for LPR, which were examined both by TNE and EGD. The contribution of each method to the diagnosis of LPR was evaluated separately and then compared with each other. RESULTS: In detecting LPR, TNE showed a significant higher sensitivity (94% vs. 60%) and accuracy (93% vs. 59%) than EGD, but their specificity was equal (50% each). The most common pathologic findings in both methods were a hiatal hernia (70% vs. 48%) and gaping cardia (69% vs. 24%), followed by peptic esophagitis (41% vs. 24%). CONCLUSION: The value of EGD is limited in the workup of LPR, as sedation tends to mask the subtle findings in this kind of reflux disease.

Ineffective esophageal motility assessment in patients with and without pathological esophageal acid reflux.

ABSTRACT: Ineffective esophageal motility (IEM), defined as minor esophageal motility disorder, is also the most common esophageal motility disorder. The relationship between gastro-esophageal reflux disease is still controversial. Our aim in this study is to evaluate whether there are differences in terms of demographic, endoscopic, or motility findings between IEM patients with pathological esophageal acid reflux and physiological reflux.Patients diagnosed with IEM according to the Chicago classification v3 with high-resolution manometry (HRM) before acid monitoring constituted the study group of our investigation. The patients were divided into 2 groups as patients with pathological esophageal reflux and patients with physiological reflux according to 24-hour acid monitoring. Demographic data, endoscopic findings, and HRM findings were compared between 2 groups.A total of 62 patients who were diagnosed with IEM according to the Chicago classification v3 were included in the study. Patients in the physiological reflux group were 7 years younger on average than the pathological reflux group. Esophagitis rates were significantly higher in the pathological reflux group (P = .033). Lower esophageal sphincter resting pressure, integrated relaxation pressure, and the presence of hernia were found to be similar in the 2 groups (P = 392, P = 182, P = 657, respectively). The rate of severe IEM was also similar between the 2 groups (P = .143).The fact that the physiological reflux patient group is younger may suggest that the IEM develops in the early period and then reflux accompanies the picture with advancing age.

Adam, Eve and the reflux enigma: age and sex differences across the gastro-oesophageal reflux spectrum.

INTRODUCTION: We present demographic differences across the gastro-oesophageal reflux disease (GORD) spectrum in a UK District General Hospital. PATIENTS AND METHODS: Data were prospectively collected over 37 years. At endoscopy patients were categorized as: erosive oesophagitis (EO), Barrett's oesophagus (BO) or nonerosive reflux disease (NER). Analysis 1: comparison of EO, BO and NER 1977-2001 when the database for GORD without BO closed. Analysis 2: demographic differences in oesophageal adenocarcinoma (OAC) in total BO population diagnosed 1977-2011. RESULTS: GORD 1977-2001 (n=11 944): sex, male predominance in EO and BO but not NER; male : female ratios, 1.81, 1.65, 0.87, respectively (P<0.0001); mean age at presentation, EO 54 years, BO 62 years, NER 50 years; women were older than men by 10, 7 and 6 years, respectively.BO 1977-2011: prevalent OAC, 87/1468 (6%); male : female ratio, 4.1 (P<0.0001); incident OAC, 54/1381 (3.9%); male : female ratio, 3.5 (P<0.0001). Among all BO, more men developed OAC (3 vs. 0.9%). Within each sex, proportion of OAC higher among men (4.9 vs. 2.3%); at OAC diagnosis women were slightly but not significantly older (69.9 vs. 72.3 years, P=0.322). CONCLUSION: Two views may explain our findings. First, women have either milder reflux, or reduced mucosal sensitivity hence reflux remains silent for longer. Alternatively, women genuinely develop reflux later, that is, are more protected and for longer from developing GORD and its complications. Early evidence is emerging that female sex hormones may indeed have a protective role in GORD during the reproductive period. We suggest reflux and its consequences may be an example of 'protection' conferred on Eve.

Heartburn and regurgitation have different impacts on life quality of patients with gastroesophageal reflux disease.

AIM: To investigate the impact of heartburn and regurgitation on the quality of life among patients with gastroesophageal reflux disease (GERD). METHODS: Data from patients with GERD, who were diagnosed according to the Montreal definition, were collected between January 2009 and July 2010. The enrolled patients were assigned to a heartburn or a regurgitation group, and further assigned to an erosive esophagitis (EE) or a non-erosive reflux disease (NERD) subgroup, depending on the predominant symptoms and endoscopic findings, respectively. The general demographic data, the scores of the modified Chinese version of the GERDQ and the Short-form 36 (SF-36) questionnaire scores of these groups of patients were compared. RESULTS: About 108 patients were classified in the heartburn group and 124 in the regurgitation group. The basic characteristics of the two groups were similar, except for male predominance in the regurgitation group. Patients in the heartburn group had more sleep interruptions (22.3% daily vs 4.8% daily, P = 0.021), more eating or drinking problems (27.8% daily vs 9.7% daily, P = 0.008), more work interferences (11.2% daily vs none, P = 0.011), and lower SF-36 scores (57.68 vs 64.69, P = 0.042), than patients in the regurgitation group did. Individuals with NERD in the regurgitation group had more impaired daily activities than those with EE did. CONCLUSION: GERD patients with heartburn or regurgitation predominant had similar demographics, but those with heartburn predominant had more severely impaired daily activities and lower general health scores. The NERD cases had more severely impaired daily activity and lower scores than the EE ones did.

Endoscopic assessment of reflux esophagitis concurrent with hiatal hernia in male Japanese patients with obstructive sleep apnea.

OBJECTIVE: The pathogenetic relationship underlying the high prevalence of gastroesophageal reflux disease (GERD) in patients with obstructive sleep apnea (OSA) remains unclear. In addition, GERD has not been adequately assessed by endoscopy in patients with OSA. The purpose of this study was to use endoscopy to investigate potential interactions among reflux esophagitis, hiatal hernia (HH) and OSA. MATERIAL AND METHODS: A total of 243 consecutive male Japanese participants who underwent both overnight ambulatory polygraphic monitoring and esophagogastroduodenoscopy were retrospectively evaluated in a cross-sectional study. The prevalence and severity of HH and reflux esophagitis were assessed according to the Los Angeles classification and the Makuuchi classification, respectively. Associations among reflux esophagitis, HH and OSA were examined by univariate and multivariate analyses. RESULTS: OSA was diagnosed in 98 individuals (40.3%). Endoscopy-confirmed esophagitis (p = 0.027) and HH (p < 0.001) were significantly more prevalent among patients with OSA. Multivariate regression model analysis adjusted for age, body mass index, visceral obesity represented by waist circumference, presence of OSA, concurrence of OSA and HH, smoking, and alcohol consumption yielded OSA as the only variable significantly associated with HH (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.35-4.99; p = 0.004), while concurrence of OSA and HH was related to reflux esophagitis (OR, 3.59; CI, 1.87-6.92; p < 0.001). CONCLUSIONS: OSA was associated with HH and concurrent OSA and HH with reflux esophagitis in male Japanese patients with OSA. Our results support the hypothesis that complicating HH may link reflux esophagitis to OSA.

UPPER GASTROINTESTINAL ENDOSCOPY FINDINGS IN PATIENTS REFERRED WITH UPPER GASTROINTESTINAL SYMPTOMS IN ELDORET, KENYA: A RETROSPECTIVE REVIEW.

BACKGROUND: Dyspepsia is one of the major indications for upper gastrointestinal endoscopy. Other indications include dysphagia, odynophagia and gastrointestinal bleeding. Endoscopy is an expensive procedure that is out of reach of many patients in resource constrained region such as western Kenya. We reviewed endoscopy records from both public and private health institutions spanning ten years. OBJECTIVE: To determine the pattern of referral and endoscopy diagnoses in patients referred for upper gastrointestinal endoscopy in Eldoret, Kenya. DESIGN: Retrospective chart review. SETTING: Moi Teaching and Referral Hospital, private hospitals and private clinics in Eldoret, Kenya. SUBJECTS: One thousand six hundred and ninety (1690) Patients who underwent upper GI endoscopy from 1993 to 2003 were reviewed after obtaining clearances from the respective institutions. Information on age, sex, symptoms, and endoscopy diagnosis were extracted and subjected to statistical analysis. RESULTS: The most common symptom was dyspepsia in 1059 (62.7%) followed by dysphagia in 224 (13.3%). Others were referred with diagnosis of cancer of the stomach or oesophagus. Common endoscopy diagnoses were cancer of the oesophagus in 199 (11.8%) and duodenal ulcer in 186 (11.0%). The majority of the patients (30.4%) had normal endoscopy findings. Of the 1059 patients with dyspepsia, only 154 (14.5%) had duodenal ulcer and 34 (3.2%) had gastric ulcers, the majority, 37.2% had normal endoscopy findings. CONCLUSION: Dyspepsia was main reason for referral, but the majority of such patients had normal findings. Cancer of the oesophagus was the main diagnosis in patients with dysphagia. In view of the cost of endoscopy, only those with dyspepsia and alarm symptoms be referred for the procedure.

Use of acid suppressive therapy more than 10 years after the endoscopic diagnosis of reflux esophagitis with specific emphasis to trademark and generic proton pump inhibitors.

BACKGROUND AND AIM: Reflux esophagitis needs maintenance therapy. Data on comparison between trademark and generic medications are not available. Complaints and use of acid-suppressive therapy 10 years after diagnosis were determined. METHODS: A total of 672 patients with esophagitis between 1998 and 2000 were reviewed. Patients received a questionnaire regarding the use of acid-suppressive therapy, dosage, compliance and satisfaction. The use of trademark and generic medications was assessed. The presence of reflux complaints was assessed via a questionnaire, and a symptom score was calculated using a five-point Likert scale. RESULTS: A total of 208 patients returned the questionnaire, of whom 161 (78%) used acid-suppressive therapy. Of the patients still on therapy, 72% (n = 116, group 1) had reflux complaints, while the remaining 45 patients (28%, group 2) were in remission. There was no difference in sex, age, or severity of the initially diagnosed reflux esophagitis. Patients in group 1 were significantly less compliant and satisfied compared to patients from group 2 (73% vs 96% and 83% vs 100%, P < 0.001, respectively). An equal number of patients in both groups used trademark and generic medications (P = not significant). The presence of reflux complaints, as well as the symptom score, showed no difference between users of trademark or generic medication. CONCLUSION: More than 10 years after the diagnosis, 22% of patients stopped using acid-suppressive therapy. Only a minority (28%) were in clinical remission, associated with significantly higher satisfaction and compliance to therapy, as compared to their symptomatic counterparts. There was no difference in effect and usage of trademark versus generic medication preparations.

The use of frequency scale for the symptoms of GERD in assessment of gastro-oesophageal reflex symptoms in asthma.

In adult asthmatics the incidence of gastro-oesophageal reflux disease (GERD) reportedly ranges from 34% to 89%. Oesophageal pH monitoring and endoscopy are not required in the patient with typical GERD symptoms before the initiation of a therapeutic trial. Diagnosis of GERD on the basis of history is the simplest and quickest method, placing no demand on patients. Recently, a new questionnaire (FSSG; Frequency Scale for the Symptoms of GERD) was produced to evaluate the severity and the therapeutic response of GERD. The FSSG (F-scale) was used to assess the GERD in subjects with persistent moderate to severe asthma treated with anti-inflammatory asthma medication. In the present study, 27.4% of the patients with asthma had symptoms suggestive of GERD. There is significant correlation between GERD symptom (F-scale score) and severity of cough and sputum. The observations suggested that reflux symptoms, not gastric dysmotility symptoms, significantly associated with severity of cough, not of sputum. It is the first such study to use a FSSG as incidence of GERD symptoms in asthmatics and examine the relationship between F-scale score and asthmatic symptoms.

Comparison of endoscopic findings with symptom assessment systems (FSSG and QUEST) for gastroesophageal reflux disease in Japanese centres.

BACKGROUND AND AIM: We compared endoscopic findings of the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG), a written questionnaire developed in Japan, to that for the questionnaire for the diagnosis of reflux esophagitis (QUEST) for the diagnosis of reflux esophagitis. METHODS: We registered 475 patients with untreated symptoms of upper abdominal pain (male/female: 252/223, average age 52.4 +/- 17.8 years). Subjects were assessed first with the FSSG and QUEST questionnaires, then by endoscopy, before allocation to a gastric ulcer (GU), duodenal ulcer (DU), gastroesophageal reflux disease (GERD) or functional dyspepsia (FD) group. RESULTS: On the basis of the endoscopic findings the diagnoses for the 475 subjects were as follows: FD 52.2%, DU 7.6%, GU 7.8%, and GERD 32.4% (Grade M 10.1%, Grade A + B 20.2%, Grade C + D 2.3%). There was no difference between the FSSG and QUEST in sensitivity, specificity or accuracy for any condition. The FSSG score rose with increasing endoscopic severity of GERD, but there was no correlation between the QUEST score and endoscopic severity. The FSSG total score was inferior to QUEST in terms of distinguishing GERD from other conditions, but when only the questions relating to reflux symptoms were used, the FSSG was able to distinguish GERD from other conditions as well as QUEST. CONCLUSIONS: The FSSG score reflects the severity of the endoscopic findings of GERD.

Capsule endoscopy for the detection of oesophageal mucosal disorders: a comparison of two different ingestion protocols.

OBJECTIVE: To assess the accuracy of a new ingestion protocol for capsule endoscopy (CE) in evaluating patients with gastro-oesophageal reflux disease (GORD). METHODS: Oesophago-gastroduodenoscopy (OGD) was performed 1 week prior to CE. The first 28 subjects swallowed the capsule following the original ingestion protocol (OIP) and the subsequent 30 subjects following a simplified ingestion protocol (SIP). CE videos were reviewed by two independent investigators who were blinded to the OGD findings. RESULTS: Of 48 patients included, 24 were diagnosed with reflux oesophagitis (67% male, mean age 49.5+/-13 years) and 24 with Barrett oesophagus (BO) (88% male, 55.6+/-10 years) by OGD. In addition, 10 asymptomatic healthy controls (50% male, 45.8+/-7.1 years) were included. Oesophageal transit time was faster in patients using the SIP compared to the OIP (126+/-26 s versus 214+/-33; p=0.04). Complete evaluation of the Z-line was possible in 19/28 (68%) of the OIPs compared to 28/30 (93%) of the SIPs (p=0.04). Sensitivity for detecting any oesophageal abnormality was higher in the SIP group than in the OIP group (97% versus 89%; p=0.11). Overall, CE detected oesophagitis in 22/24 patients (sensitivity, 92%; specificity, 88%) and BO in 23/24 patients (sensitivity, 96%; specificity, 91%). Furthermore, 41/44 (93%) preferred CE over OGD and experienced less discomfort and pain during CE. CONCLUSION: CE is an accurate method for detecting mucosal oesophageal abnormalities. The new ingestion protocol improves the visualization of the Z-line, which is likely to increase the diagnostic yield of CE.

[Financial restrictions in health care systems could affect treatment quality of GERD-patients]. / Wachsender Kostendruck im Gesundheitswesen kann zu einer Beeinträchtigung der Behandlungsqualität bei Refluxpatienten führen.

AIMS: To directly compare the efficacy and safety of pantoprazole 40 mg VS. omeprazole 20 mg in patients with gastroesophageal reflux disease (GERD). MATERIAL AND METHODS: 915 Patients suffering from symptomatic GERD B-D (Los Angeles classification) were included in a double-blind randomized multicenter clinical trial and treated with either pantoprazole 40 mg od or omeprazole 20 mg od for six weeks. Primary efficacy criterion was the first time to reach normal symptoms as assessed by the questionnaire ReQuest-GI. RESULTS: Compared to omeprazole 20 mg, pantoprazole 40 mg achieved a significantly faster rate of symptom relief (p = 0.0298). Thus, as assessed with the ReQuest questionnaire, patients treated with pantoprazole 40 mg experienced relief from the 7 leading GERD symptoms 2 days earlier than those treated with omeprazole 20 mg. Long-lasting sustained relief from symptoms was also achieved earlier with pantoprazole than with omeprazole; in patients treated with pantoprazole, the daily symptom load was lower than in those treated with omeprazole. After 6 weeks of treatment, over 90 percent of patients were free from symptoms in both treatment groups (93.7 % in the pantoprazole, vs. 91.8 % in the omeprazole group, PP). Both medications were well tolerated. CONCLUSIONS: GERD patients treated with pantoprazole 40 mg experience a significantly faster relief from their leading symptoms than those treated with omeprazole 20 mg.

Comparison between subjective and objective assessment of the long-term results after the Heller-Dor operation in patients affected by oesophageal achalasia.

INTRODUCTION: Nowadays the subjective assessment of Health-Related Quality of Life after surgery for achalasia is often associated with the instrumental methods in order to evaluate long-term results of therapy. AIMS: To assess the long-term objective and subjective results of the surgical treatment of achalasia and to study the correlation between clinical-instrumental methods and those based on the patient's self-assessment and on Health-Related Quality of Life questionnaires. METHODS: One hundred and twenty-four patients consecutively submitted to trans-abdominal Heller-Dor operation were periodically followed up with clinical examination, endoscopy, barium swallow and manometry. The Health-Related Quality of Life was assessed using the 36 item short form (SF-36) and the Psychological General Well-Being Index questionnaire. The statistical comparison between the results of the self-assessment questionnaires and the long-term clinical-instrumental result was calculated by means of linear regression analysis. RESULTS: Over the years, 123 patients underwent at least one complete clinical-instrumental check-up and filled the self-assessment questionnaires. Mean follow-up was 105 months (range 12-288) with a median of 82.5 months. The result of the surgery was considered satisfactory in 93.5% of the patients, while the reflux oesophagitis observed in 6.5% of the cases was the main cause of failure. Clinical scores for dysphagia and for gastro-oesophageal reflux symptoms were significantly reduced after surgery. The results of the SF-36 and Psychological General Well-Being Index questionnaires were in our population very high and clinical correlation (p<0.05) emerged in physical function, in role physical, in mental health and in vitality domains of SF-36 questionnaire, and in self-control and general health scales of Psychological General Well-Being Index questionnaire. CONCLUSIONS: Health-Related Quality of Life questionnaires can be considered valid aids in evaluating surgical results, but the clinical-instrumental evaluation remains the cardinal point of every long-term assessment in order to diagnose complications, the disease-related conditions of the patient and to acquire reliable data on which scientific discussion can be based.

[Prognostic factors for response to treatment and recurrence of uncomplicated symptomatic gastroesophageal reflux in ambulatory care medicine]. / Facteurs pronostiques de la réponse au traitement et de la récidive du reflux gastro-oesophagien symptomatique non compliqué en médecine ambulatoire.

OBJECTIVE: To investigate the prognostic factors of symptom resolution or failure and relapse in patients presenting with symptomatic gastroesophageal reflux (GERD) and treated in the usual conditions of primary care. METHOD: Controlled, non-comparative study consisting of a 4-week treatment phase (omeprazole 10 mg/day) and a 12-week follow-up phase. Initial symptom resolution was defined as no heartburn in the week preceding the assessment at the end of treatment. Following initial symptom resolution, relapse was defined as the occurrence of moderate or severe heartburn and/or acid regurgitation, and/or ingestion of antisecretory agents or prokinetics, or the existence of symptoms justifying upper gastrointestinal endoscopy. The prognostic factors were investigated using a step-by-step multivariate regression logistics, taking into account all the demographic, clinical and therapeutic parameters available. RESULTS: The rate of symptom resolution was of 58% (2775 patients assessed in the intent-to-treat analysis). Failure was associated with the following factors: administration of non-steroid antiinflammatories before/during the study (Odds Ratio [OR] = 1.42, p = 0.015), initial severity of heartburn (OR = 1.37, p < 0.001), previous anti-secretory treatment (OR = 1.32, p = 0.001) and initial severity of acid regurgitation (OR = 1.18 p = 0.002). The relapse rate Owas of 26% (2214 patients assessed) with the following associated factors: previous anti-secretory treatment (OR = 1.98, p < 0.001), duration of GERD history (OR = 1.55, p < 0.001), previous administration of prokinetics (OR = 1.46, p < 0.001), distribution of GERD pain throughout the 24 hr period, body mass index and age of patients, with lower Odds Ratio; these last three factors inciting more reserve as to the results. CONCLUSION: In the presence of these factors, assessment of GERD permits adaptation of the initial management and the eventual relay to a maintenance treatment in patients at risk of failure or relapse.

Medical treatment of gastro-oesophageal reflux disease.

Gastro-oesophageal reflux disease is common and is a chronic recurring condition. In view of our improved knowledge about the pathogenesis and complications of gastro-oesophageal reflux, the therapy should be individualized and a cost-effective approach should be attempted in its management.

Diagnostico endoscopico vs diagnostico histologico: correlacion en la valoracion de los pacientes con esofagitis por reflujo / Correlation between endoscopic and anatomopathological findings in the diferent grades of esophagitis in the gastroesophageal reflux disease

En la actualidad, existen muy pocos estudios en la literatura medica que nos hablen de la correlacion entre los diagnosticos endoscopicos y los anatomopatologicos, en lo concerniente a los diferentes grados de esofagitis por reflujo gastroesofagico (RGE). Objetivo: Estudiar la correlacion entre la endoscopia digestiva alta y la anatomia patologica para el diagnostico de esofagitis por reflujo gastroesofagico patologico. Materiales y metodos: Como parte del estudio, tomamos a todos los pacientes que se sometieron a endoscopia digestiva alta en Video Medicina Endoscopica VIME y que, en uno de sus diagnosticos, tuvieran el de Esofagitis. En total, se incluyeron en el estudio a 65 pacientes, 32 hombres y 33 mujeres. A todos se les realizo la estadificacion endoscopica de la lesion esofagica por RGE, segun la clasificacion modificada de Savary-Miller (Figura 1). Posteriormente, se procedio a tomar biopsias de las zonas lesionadas para el informe histologico. Luego, procedimos a comparar los informes de biopsia con los de endoscopia. Resultados: Encontramos que 42,8 por ciento de los pacientes diagnosticados como esofagitis grado I en la endoscopia, tenian el mismo estadiaje anatomo-patologico; 60 por ciento de los pacientes con esofagitis grado II tenian dicha correlacion; igualmente, 37,5 por ciento de los pacientes con esofagitis grado III y todos los pacientes con esofagitis grado IV la mostraron (100 por ciento); y, 44,4 por ciento de los inicialmente diagnosticados como esofago de Barret, fueron avalados por el estudio histologico...

The usefulness of a structured questionnaire in the assessment of symptomatic gastroesophageal reflux disease.

BACKGROUND: The diagnosis of gastroesophageal reflux disease (GERD) rests primarily on recognition of symptom patterns that are classical for reflux disease, but little attention has been paid to the use of a formal questionnaire for identifying such symptom patterns. METHODS: A self-administered questionnaire was developed which has seven items that focus on the nature of the symptoms and the precipitating, exacerbating, and relieving factors. The diagnostic validity of the questionnaire was tested against endoscopy and 24-h pH monitoring. A further evaluation was undertaken in patients with symptoms suggestive of GERD and in patients with non-ulcer dyspepsia, to identify factors that might predict symptom relief during treatment with omeprazole. RESULTS: When endoscopic esophageal mucosal breaks and 24-h pH data were used as criteria for the diagnosis of GERD, the questionnaire had a sensitivity of 92% but a very low specificity of 19%. Symptom relief during treatment with omeprazole was predicted by the presence of heartburn, described as 'a burning feeling rising from the stomach or lower chest up towards the neck' (P = 0.004), and 'relief from antacids' (P = 0.02). In non-ulcer dyspepsia a positive response to omeprazole was confined to the subgroup of patients who identified their main discomfort as heartburn as described above. CONCLUSION: The present questionnaire using descriptive language usefully identified heartburn in patients presenting with upper abdominal symptoms, and this symptom predicted symptom resolution during treatment with omeprazole.

Diagnostic assessment of gastroesophageal reflux disease: what is possible vs. what is practical?

The diagnosis of gastroesophageal reflux disease (GERD) entails the identification of patients with esophagitis and its complications as well as patients who have symptoms but no mucosal disease. Endoscopy is mandatory to establish a diagnosis of reflux esophagitis, to exclude other esophageal disease and to permit directed biopsy if columnar metaplasia, dysplasia or carcinoma is suspected. The lesions of reflux esophagitis--erosions, ulceration, stricturing and metaplasia--should be identified and graded independently, using a classification system such as the recently described "MUSE" (Metaplasia, Ulcer, Stricture, Erosions) system. Fluoroscopy can identify associated structural changes such as stricturing or esophageal shortening. Measures of esophageal acid exposure time may be used to quantify reflux before and after treatment; however, if the patient has typical symptoms but no esophagitis, a temporal association between symptoms and episodes of esophageal acidification should be sought. Ambulatory 24-hour esophageal pH-monitoring with accurate event-marking provides recordings suitable for an objective statistical analysis, which was evaluated prospectively in 14 patients. Computerized analysis of 24-hour esophageal pH recordings diagnosed 5 patients as having acid-related symptoms although only 3 of 5 patients fulfilling the criteria for pathological reflux had pH-related chest pain. This finding was confirmed by 5 experts who analyzed all recordings visually, unaware of the result of the computer analysis. The Bernstein test should be reserved for patients whose symptoms are too infrequent to permit an objective assessment of symptom occurrence during pH monitoring. In conclusion, i) endoscopy is the test of choice for the diagnosis of esophagitis but it should be supplemented by a standardized and reliable scoring system for disease severity; ii) ambulatory esophageal pH recording with accurate event-marking is the test of choice for the diagnosis of GER-related symptoms, but it should be supplemented by an objective assessment of the temporal relationship between symptoms and esophageal pH; and iii) esophageal manometry is the test of choice for evaluating esophageal peristalsis and LES (lower esophageal sphincter) function but, in the context of GERD, its main indication is the assessment of GERD patients who are being considered for surgery. The widespread use of other tests for clinical purposes must await a better understanding of the pathophysiological mechanisms which can lead to the development of GERD.