Diagnostic Approach to Globus in GERD

Introduction to Diagnostic Guidelines

The American Gastroenterological Association recommends performing upfront objective reflux testing off medication in patients with isolated extra-esophageal symptoms like globus 1, 4

The patient should undergo upper endoscopy to assess for erosive esophagitis, Barrett's esophagus, and hiatal hernia size, as recommended by the American College of Gastroenterology 2, 4
If endoscopy is normal or shows only LA Grade A esophagitis, prolonged wireless pH monitoring OFF PPI should be performed to objectively confirm whether GERD exists, as suggested by the Clinical Gastroenterology and Hepatology guidelines 3, 5, 2, 4

AET <4.0% on all days indicates no GERD, and the patient should stop PPI therapy, as recommended by the American College of Gastroenterology 3, 6, 7
AET ≥6.0% on ≥2 days confirms GERD, and the patient should optimize therapy, as suggested by the Clinical Gastroenterology and Hepatology guidelines 3, 5

The American College of Gastroenterology recommends verifying compliance and timing of PPI therapy before increasing the dose 2, 4
Personalized adjunctive pharmacotherapy should be considered, including baclofen for regurgitation or belch-predominant symptoms, as suggested by the Clinical Gastroenterology and Hepatology guidelines 5, 1, 8

The American Gastroenterological Association recommends considering pharmacologic neuromodulation with low-dose antidepressants and referral for cognitive behavioral therapy or esophageal-directed hypnotherapy, as suggested by the Clinical Gastroenterology and Hepatology guidelines 7, 4, 5, 6, 7

The American College of Gastroenterology warns against empirically escalating PPI dosing beyond twice-daily without objective confirmation of GERD, as recommended by the Praxis Medical Insights guidelines 2, 4
The Clinical Gastroenterology and Hepatology guidelines advise against continuing long-term PPI without establishing definitive diagnosis through endoscopy and possibly pH monitoring, as suggested by the Praxis Medical Insights guidelines 2, 4