Diagnostics - A Path with Obstacles

Dear readers,

You will often find that test results are unclear, are assessed differently by doctors and even contradict each other. One gastroscopy shows a small hernia, the next none at all and the one after that even a large one. But in the X-ray of the barium, this has suddenly disappeared again and there is no reflux at all! The MRI shows an unremarkable normal result, the lung function test shows good values, as do the ECG and blood laboratory. So the family doctor also leafs through all the findings and in the end there are more questions than answers.

But the correct diagnosis is always the key to curing a disease! But this "correct diagnosis" is often difficult to make when it comes to diseases of the diaphragm. Why is that?

The diaphragm may be about the size of two A4 sheets of paper, but it is extremely thin, stretches out as a curved membrane in all three planes of the body and constantly changes its position with each breath. As a result, no examination can capture the diaphragm in its entirety, as we know it from the lungs or heart. In addition, many organs such as the heart, stomach, esophagus, liver, lungs and spleen are directly attached to the diaphragm and it is sometimes difficult to clearly define their boundaries. Due to these peculiarities, the diaphragm is more difficult to detect using imaging diagnostics than any other organ: while an MRI can detect even the smallest change in the brain and an ultrasound can detect a gallbladder polyp measuring just 1 mm, a 3cm(!) tear in the diaphragm often goes undetected.

Gastroscopy is still the most important diagnostic tool. Although it cannot look directly at the diaphragm, it can at least indirectly determine the situation in the hiatus based on the displacement of the stomach and the relief of the diaphragm muscles pushing through. That is worth a lot. But it is also prone to errors: A different gas pressure when the stomach is inflated can make a hernia appear different sizes or smaller. The important documentation of findings using photos is increasingly rare. Samples are taken from the wrong place and not from the esophagus. This is particularly critical in the context of Barrett's diagnosis. For a medical discussion of the findings, the patient is always referred to the family doctor for treatment planning, who in turn did not carry out the examination.

Many patients ask me why reflux cannot be clearly identified in an X-ray of a barley swallow? After all, the acid also flows upwards. The X-ray contrast agent should do the same! Here, too, hope is deceptive. The barley swallow examination is only a snapshot, the patients are always fasting and there is only a short time during the X-ray to detect reflux. Patients know very well that acid does not always shoot upwards immediately as soon as they lie down. It may only happen after eating, when bending over or after eating foods that they are intolerant to. None of this is taken into account. In this brief moment of the examination, the X-ray often shows that no contrast agent is rising into the esophagus. Reflux disease is therefore ruled out and the long search for other causes begins.

pH measurement in the esophagus, i.e. measuring acid flowing back over 24 hours using a probe or the "Bravo" capsule in the esophagus, has proven to be a very good measuring instrument in everyday life. This at least gives an indication of whether the closure system is working or not. The evaluation is complicated, devices fail during the measurement or the measuring probes are in the wrong place. As you can see, it is not always easy to collect reliable data.

Measuring the acid in the throat is called a “residual reflux test”. It can be helpful in determining whether there is respiratory or “silent reflux”. However, more important is an ENT examination by colleagues who are familiar with the consequences of reflux disease in the larynx area and the symptoms of gastric laryngitis.

Why is all this so crucial to us?

In the conservative treatment of reflux disease, proton pump inhibitors (PPIs) are prescribed as standard. For this form of therapy, it is ultimately irrelevant whether the hernia is small or large, whether it is an axial or paraesophageal hernia, or whether Barrett's is present or not. It is always the same therapy: PPI medication. If the drug helps, it is good; if not, the dose is increased.

In surgery, things are completely different! The decision to perform reflux surgery has a different dimension than the prescription of an acid blocker. An operation can never be removed from the patient's life. An operation always leaves permanent traces in the body - preferably for the better, but not always! Therefore, these far-reaching consequences, the individual risks and the chances of success of the procedure must be taken into account for each patient. To do this, it is essential that the surgeon bases his decision on well-founded findings and knows how to accurately assess all possible sources of error in preliminary examinations. But these contradictions arise so frequently, especially in diaphragm diagnostics.

We know from our many years of experience that findings undoubtedly provide important clues. But the most crucial diagnostic information we get from the patients themselves. Through their descriptions, the body shows us the exact path to its problem. That is exactly where we need to start.

Yours

Dr. med. Eckhard Löhde