Neto R. M. L., Herbella F. A. M., Schlottmann F., Patti M. G. Does DeMeester score still define GERD? // Diseases of the Esophagus, 2019 May 1;32(5).
Does DeMeester score still define GERD?
R. M. L. Neto1, F. A. M. Herbella1, F. Schlottmann2, M. G. Patti2
2Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, USA.
SUMMARY. Gastroesophageal reflux disease (GERD) clinical presentation may encompass a myriad of symptoms that may mimic other esophageal and extra-esophageal diseases. Thus, GERD diagnosis by symptoms only may be inaccurate. Upper digestive endoscopy and barium esophagram may also be misleading. pH monitoring must be added often for a definitive diagnosis. The DeMeester score (DMS) is a composite score of the acid exposure during a prolonged ambulatory pH monitoring that has been used since 1970s to categorize patients as GERD+ or GERD-. We showed in this review that DMS has some limitations and strengths. Although there is not a single instrument to precisely diagnose GERD in all of its variances, pH monitoring analyzed at the light of DMS is still a reliable method for scientific purposes as well as for clinical decision making. There are no data that show that acid exposure time is superior — or for that matter inferior — as compared to DMS.
KEY WORDS: ambulatory pH monitoring, DeMeester score, gastroesophageal reflux disease.
Address correspondence to: Dr. Fernando Herbella, Rua Diogo de Faria 1087, cj 301, Sao Paulo- SP 04037-003 Brazil. Email: herbella.dcir@ epm.br
Author´s contribution: Data collection or management: Rafael Melillo Laurino Neto, Fernando A. M. Herbella; Data analysis: Rafael Melillo Laurino Neto, Fernando A. M. Herbella; Manuscript writing/editing: Rafael Melillo Laurino Neto, Fernando A. M. Herbella, Francisco Schlottmann, Marco G. Patti; Protocol/project development: Fernando A. M. Herbella.
Conflicts of interest: The authors declare that they have no conflict of interest.
According to the Montreal Consensus, gastroesophageal reflux disease (GERD) is defined as the condition, which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.1 Still according to this Consensus, patients with GERD are grouped based on symptoms in esophageal or extra-esophageal syndromes. This myriad of symptoms may mimic other esophageal and extra-esophageal diseases. This makes the exclusive analysis of symptoms an inaccurate way to diagnose GERD.2
The more recent GERD consensus in Lyon indicates that symptoms may be unreliable and supports a more objective evaluation of patients with suspected GERD, considering its diagnosis only with specific endoscopic findings (severe esophagitis, long segments of esophageal mucosa with intestinal metaplasia or stenosis), or when the time of acid exposure of the esophagus is greater than 6% of the time studied through the 24-hour pH monitoring.3 The same cutoff value for acid exposure time (AET) was adopted by the update on the Porto consensus that included essentially the same panel of experts tough.4 Although AETmay be considered the most reliable parameter to define GERD by these parameters, data are not provided that DMS is an inferior method.
Complete work-up to diagnose GERD that includes manometry and pH monitoring in addition to symptomatic evaluation and endoscopy is mandatory.5 DeMeester score (DMS) has been used since 1970s to categorize patients as GERD+ or GERD- by pH monitoring. However, some criticize the usefulness of the DMS to define reflux as a pathologic condition.
Creation and parameters of the DeMeester score
DMS was first reported in 1974 by Johnson and DeMeester.6 It is a composite score that measures acid exposure during prolonged ambulatory pH monitoring. Acid reflux is defined whenever the pH of the esophagus, measured 5 cm above the upper border of the manometrically determined LES, drops to 4 or less, also defined by Johnson and DeMeester with better discrimination of GERD as compared to pH 5 in their original article.7,8 The mathematical calculation is based on points attributed to each standard deviation above the reference value for 6 parameters obtained from healthy individuals that served as controls. Parameters with a wide range of variation in volunteers, such as the number of episodes of acid reflux, has a weak effect on the final score and those rarely found in healthy individuals, such as supine reflux, leads to increased DeMeester points (Fig. 1). The parameters that constitute the score are: (1) total number of episodes of reflux, (2) % total time esophageal pH < 4, (3) % upright time esophageal pH < 4, (4) supine time esophageal pH < 4, (5) number of reflux episodes ≥ 5 min, and (6) longest reflux episode (minutes) (Table 1).
Fig. 1 Different pH monitoring tracings to show the value of individual DeMeester Score (DMS) parameters. (A) Several episodes of reflux do not result in pathologic reflux due to the short duration of the episodes (DMS = 12). (B) Prolonged nocturnal episodes of reflux result in severe pathologic reflux (DM = 68). (C) The predominance of upright reflux result in pathologic reflux but with a low score (DMS = 21). (D) A patient with poor esophageal clearance leading to a high number of prolonged episodes of reflux, especially in recumbent position resulting in high scores (DMS = 132).
The sum of all parameters allows the diagnosis of pathologic reflux when the threshold value is exceeded and besides that, individual analysis of the parameters allows a more accurate diagnosis of the reflux pattern as well as esophageal clearance. It must be emphasized that DMS encompasses AET plus other parameters.
DeMeester score in health and disease, and its validation
DMS was initially based on the study of 15 volunteers. The authors increased the number of participants after the original publication to confirm the validity of the score and the threshold value of 14.7.8 The score was also validated and compared to the only other current parameter for normality with general acceptance, the % total time esophageal pH < 4 (AET), with similar results.9 Other authors10,11 also validated the findings of the method over time. In pediatric population, Boix-Ochoa Score12 also is a diagnostic tool.
DMS is widely used especially by surgeons.13-17 Gastroenterologists usually prefer AET because they consider it more objective as compared to the DMS where a different weight is given to each parameter.18,19 However, one well-conducted study used receiver operating characteristic curves constructed from 25 asymptomatic healthy subjects and 25 selected patients with other markers of increased esophageal acid exposure to compare DMS and AET.9 This study showed that both methods provide the most efficient interpretation of the test: the composite score has a sensitivity of 96%, a specificity of 100% and accuracy of 98% while the percent total time pH less than 4 has a sensitivity, specificity, and accuracy of 96%. While different studies consistently showed a similarity between DMS and AET to discriminate GERD,20,21 DMS has been repeatedly revalidated to demonstrate that an abnormal DMS is more frequent in patients with endoscopic finding of esophagitis,22 hiatal hernia,23 esophageal dysmotility,23 and an incompetent lower esophageal sphincter.24,25 More interestingly, DMS correlates withmucosal injury severity,26 hiatal hernia size,27 and the presence of Barrett’s esophagus.28 Symptoms have been continually described as unreliable for GERD diagnosis29 and should not be used as markers to validate reflux testing methods.
It should be pointed out here that both parameters (DMS and AET) point to the presence of reflux and not the fact that the symptoms are caused by reflux. DMS diagnoses GERD; however it should be associated with another diagnostic method to establish temporal correlation between symptoms and reflux episodes. This can be accomplished using symptom–reflux association parameters, such as the symptom index (SI), symptom association probability (SAP), symptom senssymptitivity index (SSI), and binomial symptom index (BSI).19 SI is defined as the percentage of symptom events that are related to reflux episodes. The most often used cut-off is 50%.30 SI is a simple method but it may be less accurate when few symptoms are reported, e.g. one patient with 2 episodes of cough with only 1 associated with reflux has equal SI as another patient with 100 episodes of cough and 50 of them associated with reflux. SAP is a statistical parameter that expresses the strength of the relationship between symptom events and reflux episodes during the measurement.31 It calculates the chance of an episode of reflux to be symptomatic. The cutoff for SAP is 95%.32 BSI (also named Ghillebert probability estimate, GPE) is a statistical formula that can express the probability that symptom events and reflux episodes are related.33 BSI and SAP are very strongly related and both could be used interchangeably.34 Symptom–reflux association parameters are very useful to increase the accuracy of the diagnosis of 24 hour pH monitoring, especially in cases of extra-esophageal symptoms of GERD.35,36 It must be remembered that the accuracy of the association is dependent on the correct recording of symptoms log by patients. Instructions must be carefully given and checked.
Curiously, different technology for pH monitoring has been developed, such as wireless capsule-based monitoring,37 and many different manufactures for catheters and pH monitors are commercially available, but DMS remains as a valuable cut off for pathologic versus physiologic reflux.
DEMEESTER SCORE LIMITATIONS
We previously mentioned that GERD diagnosis may be challenging. DMS is as imperfect as others tests as a single tool even though it may already be considered the gold standard test. False negatives may occur due to the method itself, such as changes in life style during the test, hyper-salivation induced by the catheter, and gastric alkalization due to Helicobacter pylori infection; however, this is common to any form of pH monitoring interpretation. Day-to-day variation is also a drawback of reflux testing that is possible to be minimized by prolonged wireless capsulebased pH monitoring for 48 or more hours. Studies using this technology also validated DMS as a sensitive tool for GERD diagnoses.38,39
Despite some criticisms, there are no other parameters to diagnose GERD based on pH monitoring apart from the % total time esophageal pH < 4 that has similar results compared to DMS as previously mentioned.
DMS also attributes different weights according to reflux pattern, with higher scores in supine position. Abnormal supine acid exposure time is observed in different conditions: poor sleep quality, severe erosive esophagitis, Barrett’s esophagus, elevated BMI, and consumption of a late-evening meal.19 Two parameters indirect evaluate esophageal clearance: the number of episodes of reflux lasting longer than 5 minutes and the duration in minutes of the longest reflux episode recorded.7 The clearance is given by the number of episodes longer than 5 minutes, by the longest reflux episode, but mostly by dividing the total time pH is below 4 by the number of reflux episodes. It is noteworthy that the analysis of individual parameters gives important clinical information beyond the diagnoses of pathologic versus physiologic reflux.
Multichannel intraluminal impedance pH (MIIpH) monitoring is claimed by some to improve the sensitivity of the test even though the presence of isolated non-acid reflux is an uncommon finding.19,40 New MII-pH parameters such as mean nocturnal baseline impedance (MNBI) and post-reflux swallowed induced peristaltic wave (PSPW) index41 may add to GERD diagnoses but further studies are necessary.
There is not a single instrument to precisely diagnose GERD in all of its variances. Pieces of a complex puzzles sometimes need to be added to reach a final verdict. pH monitoring analyzed at the light of DMS is a reliable method for scientific purposes as well as for clinical decision making. There are no data that show that AET is superior — or for that matter inferior — as compared to DMS.
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