Diagnostic work up and indications for gastro-esophageal reflux surgery

Gastro-esophageal reflux disease (GERD) has a worldwide prevalence and presents with a broad spectrum of symptoms and various grade of severity: from mild disease to complicated disease in relation with long standing disease. Etiopathology is related to abruption of anti-reflux mechanisms, including anatomical barrier which protects by reflux of gastric content and esophageal peristalsis that cleans the reflux to avoid the exposition of esophageal mucosa to acid. Diagnosis is based primarily on typical symptoms, the presence of atypical symptoms that can be related to GERD needs additional testing, as pH-impedance monitoring and esophageal manometry. These additional tests are necessary to assess the association between pathologic reflux and the symptoms. Lifestyle interventions are recommended; to date, the proton pump inhibitors are milestone of the medical treatment and the 8-week trial is first line therapy and it is considered also as diagnostic mean. Other possible medications include histamine-receptor antagonists and neuromodulators. When medical therapy lacks in relieving symptoms, anti-reflux surgery (ARS) can be suggested after an adequate characterization of disease. The 24-hour esophageal pH-impedance monitoring allows to demonstrate the pathological reflux and the association between acid and not-acid reflux with the symptoms. The high-resolution manometry (HRM) is useful to identify esophageal major motility disorders. These tests are suggested to select patients with better outcome from surgery and to tailor the most suitable procedure for patients.