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Relief of symptoms from proton-pump inhibitor treatment does not necessarily confirm diagnosis of GERD

Proton-pump inhibitors (PPIs), acid suppressive medications, are often selected as first-line therapy for patients with symptoms that suggest uncomplicated gastroesophageal reflux disease (GERD). Indeed, a positive response to PPIs is commonly thought to support the diagnosis of GERD. However, relief of symptoms from PPIs does not confidently confirm a diagnosis of GERD, according to a recent review of studies on the topic that was supported in part by the Agency for Healthcare Research and Quality (HS13328).

The cardinal features of GERD (heartburn and regurgitation) are not always present in all patients who ultimately are diagnosed with GERD. Also, the ability to discriminate GERD from other acid-related disorders is not always straightforward because symptoms may overlap, leading to many false-positive and false-negative diagnoses. Furthermore, 20 to 40 percent of patients who have GERD may not exhibit a response to a short course of treatment with a PPI, possibly because they need a higher dose or longer duration of treatment. Thus, testing for GERD with PPI treatment demonstrates only a weak correlation with objective measures, conclude the researchers.

They reviewed studies that compared patients' clinical response to a short course (1 to 4 weeks) of normal- or high-dose PPI therapy with objective measures of GERD (24-hour pH monitoring, endoscopy findings, and symptom questionnaires). Based on the 15 studies that met inclusion criteria, the positive likelihood of a symptomatic response to PPIs detecting GERD ranged from 1.63 to 1.87. Sensitivity was a mere 0.78 and specificity was only 0.54. Until better methods are available to establish a confident diagnosis, selection of the dose and type of acid-suppressing agents should be individualized on the basis of clinical setting, the response to therapy, and judicious diagnostic testing, suggest the researchers.

See "Short-term treatment with proton-pump inhibitors as a test for gastroesophageal reflux disease," by Mattijs E. Numans, M.D. Ph.D., Joseph Lau, M.D., Niek J. DeWit, M.D., Ph.D., and Peter A. Bonis, M.D., in the April 6, 2004, Annals of Internal Medicine 140(7), pp. 518-527.

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