In evaluating GERD, which test is considered the GOLD STANDARD?

• A. Esophageal manometry
• B. 24 hr pH monitoring
• C. EGD
• D. Barium swallow study

Answer: (B)

The test that provides the strongest objective evidence of reflux over time is 24-hour ambulatory pH monitoring. It records esophageal acid exposure continuously for a full day and allows you to correlate symptoms with actual acid reflux events, giving a quantitative measure (often summarized as the DeMeester score) to distinguish pathologic reflux from benign episodes. This makes it the most definitive test for confirming GERD, especially when endoscopy is normal or when symptoms persist despite therapy. Esophageal manometry, while useful for assessing motility and LES pressure and for guiding surgical planning, does not prove that acid reflux is occurring. Endoscopy can show erosions or Barrett’s changes but many GERD patients have non-erosive disease, so a normal endoscopy doesn’t exclude GERD. Barium swallow mainly helps identify structural or motility problems and is not sensitive for detecting reflux itself. In current practice, 24-hour pH monitoring remains the gold standard, with impedance-pH monitoring as an even more sensitive option for detecting non-acid reflux when needed.