Modern Approach to Reflux Testing: When, Which, and How?

Modern reflux monitoring technology provides for both prolonged wireless and 24-hour catheter-based testing options. Wireless pH monitoring offers the advantages of patient comfort and prolonged assessment for up to 96 hours to account for day-to-day variation of GERD, but only distal acid reflux is measured. pH-impedance monitoring detects all reflux episodes regardless of acidity, characterizes refluxate content, identifies proximal extent, and measures baseline mucosal impedance which reflects mucosal integrity as well as longitudinal reflux-related injury, but the indwelling catheter causes patient discomfort and limits monitoring to 24 hours. Metrics from reflux monitoring and findings from endoscopy, together with adjunctive tests such as high-resolution manometry, can provide conclusive and/or supportive evidence for or against pathologic reflux, utilizing the Lyon Consensus 2.0 framework. Selection of optimal testing strategy should depend on presenting symptom phenotypes, clinical indications and scenarios, local testing options, and patient tolerance. Testing should be performed off acid suppressive therapy for patients with unproven GERD, while those with proven GERD and persistent symptoms despite optimized anti-reflux therapy should undergo pH-impedance monitoring on acid suppression. If endoscopy is indicated, wireless monitoring can be performed at the same setting, especially for typical perceptive (heartburn, chest pain) symptoms. pH-impedance monitoring is preferred for primary regurgitation and belching, while both modalities are options for atypical symptoms. Reflux monitoring may be indicated for assessing symptoms after foregut interventions, although no consensus on post-operative thresholds or optimal testing methodology has been established. Reflux monitoring is a valuable tool for evaluating and directing management of esophageal symptoms.