The diagnosis of gastro-esophageal reflux disease (GERD) in clinical practice is limited by the sensitivity and specificity of symptoms and diagnostic testing.

Professor Vakil and colleagues from Wisconsin, USA determined if adding histology as a criterion and excluding patients with epigastric pain enhances the diagnosis for GERD.

Patients with frequent upper gastrointestinal symptoms who had not taken a proton pump inhibitor in the previous 2 months, and who had evaluable distal esophageal biopsies were included. 

Epithelial hyperplasia was identified when total epithelial thickness was at least 430 μm. 

The team's investigation-based GERD criteria included presence of erosive esophagitis, pathological esophageal acid exposure, and/or positive symptom–acid association probability. 

The researchers assessed symptoms using the Reflux Disease Questionnaire, and a pre-specified checklist.

Overall, the team found that 55% of the 231 included patients met investigation-based GERD criteria, and 84% met symptom-based criteria. 

Epithelial hyperplasia was present in 89 individuals, of whom 69% met investigation-based criteria, and 93% met symptom-based criteria. 

The researchers noted that adding epithelial hyperplasia as a criterion increased the number of patients diagnosed with GERD on investigation to 67%. 

The proportion of patients with a symptom-based GERD diagnosis who met investigation-based criteria including epithelial hyperplasia was significantly greater when concomitant epigastric pain was absent than when it was present.

Professor Vakil's team comments, "Histology increases diagnosis of GERD, and should be performed when clinical suspicion is high and endoscopy is negative."

"Excluding patients with epigastric pain enhances sensitivity for the diagnosis of GERD."