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Am Fam Physician. 2005;71(3):568-570

The empiric treatment of uncomplicated gastroesophageal reflux disease (GERD) with proton-pump inhibitors (PPI) and lifestyle changes has been endorsed by multiple medical organizations. The use of “the PPI test”—considering a rapid symptom response to a normal dose as validation of the diagnosis—has been widely accepted. Studies confirming this type of diagnostic treatment trial, however, have been inconsistent. Clarification of the reliability of the PPI test would be useful to avoid inappropriate long-term use of PPI treatment and misdiagnosis of GERD-like symptoms. Numans and associates used a meta-analysis of studies looking at response to PPI treatment as a diagnostic test for GERD when compared with standard objective testing.

Fifteen studies (including 2,793 patients) of PPI treatment of presumptive GERD that also included objective testing with a structured symptom score, 24-hour pH monitoring, or endoscopy were included in the meta-analysis. Successful symptom response to the PPI treatment demonstrated the highest positive likelihood association with objective GERD when the latter was defined by an abnormal 24-hour pH monitoring test. Using other standard reference tests, the positive predictive value of response to PPI was close to 1.0, which indicates poor reliability for the diagnosis of GERD.

The authors conclude that a positive response to short-term PPI treatment does not reliably correspond to the diagnosis of GERD as defined by specific objective criteria. Patients with objectively determined GERD also may not respond to normal-dose PPI therapy because of the need for a higher dosage or a longer duration of treatment. Despite these results, empiric PPI treatment for suspected, uncomplicated GERD might still be appropriate and might resolve patient symptoms. The utility of long-term treatment in patients who respond to short-term empiric treatment needs to be individualized until better methods are developed to determine a diagnosis.

Clinical suggestions of severe reflux or other disease, including odynophagias, dysphagia, persistent or progressive symptoms on therapy, immunosuppression, GI bleeding, weight loss, or noncardiac chest pain
Screening for Barrett's esophagus in high-risk patients (white men older than 50 years with chronic symptoms)
Abnormality on esophagram

editor's note: The empiric use of PPIs in patients with symptoms of GERD is becoming standard. PPIs have been shown to be superior to histamine2-receptor antagonists in empiric treatment of typical GERD symptoms, but not necessarily in the treatment of endoscopy-negative reflux disease.1 In the latter group, both drugs work equally well. Most patients with heartburn show no endoscopic abnormalities, but empiric treatment with PPIs without endoscopy is still the most cost-effective management strategy. Some of the more frequent indications for endoscopy that have been recommended by the American Society for Gastrointestinal Endoscopy and/or the American College of Gastroenterology are noted inthe accompanying table. If there is no concern about other diagnoses, there is no evidence to support the use of routine endoscopy in patients with heartburn who respond to medical therapy. —r.s.

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