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Gastroesophageal reflux (GER), defined as the passage of gastric contents into the esophagus, occurs on a daily basis as a normal process in infants, children, and adults. Most episodes of physiologic reflux are transient, asymptomatic, and reach only the distal esophagus. Gastroesophageal reflux disease (GERD) is distinguished by reflux into the esophagus resulting in well-defined symptoms or medical problems (see Chapter 12). When children present with atypical complaints or extraesophageal symptoms, testing may be necessary to document the presence or absence of pathologic reflux, or the association between reflux events and specific symptoms.1

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While endoscopy can be helpful in documenting acid damage to the esophageal mucosa in the form of erosions or ulcers, the majority of patients with symptoms of GERD do not have endoscopic or pathologic evidence of esophagitis.2 Tests designed to detect the presence of GER have been developed.

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The first test utilized was esophageal pH monitoring, in which an electrode designed to detect changes in pH is used to assess the frequency and duration of acidic reflux present in the distal esophagus. Over the years the advantages, disadvantages, and limitations of traditional, catheter-based esophageal pH monitoring have become better defined, with a subsequent evolution of newer diagnostic techniques. Wireless methods to detect acidic contents in the esophagus have now become available (Bravo capsule). Additionally, we have seen the development of the technical possibility of measuring both acidic and non-acidic reflux with multichannel intraluminal impedance (MII). In the present chapter we will review the current techniques that are being used for the dynamic detection of reflux episodes.

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Esophageal pH monitoring, which quantifies the frequency and duration of acidic reflux episodes, can be used to confirm abnormal esophageal acid exposure and/or correlate symptoms with acidic reflux episodes. Testing may be especially helpful in patients who present with atypical symptoms, patients with persistent symptoms despite pharmacologic treatment, or patients without evidence of mucosal damage on endoscopy. Other diagnostic approaches, such as barium contrast upper GI series or nuclear scintigraphy, have had variable sensitivity and specificity when compared to esophageal pH monitoring.1 Unacceptably high false-positive and false-negative rates seen with these radiographic tests have made esophageal pH monitoring preferable over barium contrast and scintigraphy studies for the diagnosis of reflux.

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Equipment

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Over the years, the methodology of esophageal pH monitoring in children has become relatively standardized as evidenced by the publication of professional practice guidelines.1,3 In addition to a catheter-based pH sensor, a portable data logger that records intraesophageal pH as well as events during the study such as symptoms, meals, position changes, and activity is required. As technology has improved and as electronic devices have become smaller, pH monitoring is now conducted on an ambulatory basis, even for pediatric patients.

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Electrode Placement

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The catheter-based pH electrode is placed through the nose into the distal esophagus.3 There ...

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