GERD-Objective Testing — ESEGH MCQ

Correct answer: A — Ambulatory reflux monitoring off therapy

Answer A is correct. A normal endoscopy does not exclude GERD. To confirm whether persistent symptoms despite optimized PPI therapy represent true refractory GERD (abnormal reflux burden) or functional/non-reflux disease (functional heartburn, hypersensitive esophagus), objective diagnostic testing is essential. Ambulatory reflux monitoring (24-hour pH-impedance or 96-hour wireless pH) must be performed **off PPI therapy** to allow reflux to manifest and identify abnormal acid exposure time (>6% distal AET) or excess reflux events (>40). This is mandated by UK BSG and international consensus before consideration of surgical intervention and to guide targeted pharmacological management. Option B is inappropriate: persistent symptoms despite optimized therapy mandate investigation, not escalation of the same class. Option C (barium swallow) has poor sensitivity for non-erosive GERD and does not quantify reflux burden. Option D (H2 blocker) is ineffective and does not confirm diagnosis. Option E (surgery without confirmation) is contraindicated; objective evidence of reflux is required before anti-reflux procedures.

Reference: British Society of Gastroenterology. Modern diagnosis of GERD: the Lyon Consensus. https://www.bsg.org.uk/clinical-resource/modern-diagnosis-of-gerd-the-lyon-consensus/ (2024). Gyawali CP et al. Gut 2018;67:1351–62 (original Lyon Consensus paper). Trudgill NJ, Sifrim D, Sweis R, et al. British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring. Gut 2019;68:1731–50.