REVIEW ARTICLE

'LDJQRVWLF$SSURDFKWR*DVWURHVRSKDJHDO5HÀX[
Disease: The Role of GERD Questionnaire and PPI Test
Ummu Habibah*, Achmad fauzi**
*Department of Internal Medicine, Faculty of Medicine
University of Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta
**Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine
University of Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta

Corresponding author:
Achmad Fauzi. Division of Gastroenterology, Department of Internal Medicine, Dr. Cipto Mangunkusumo
General National Hospital. Jl. Diponegoro No.71 Jakarta Indonesia. Phone: +62-21-3153957;
Facsimile: +62-21-3142454. E-mail: ppfauzidrgm@gmail.com

ABSTRACT

*DVWURHVRSKDJHDOUHÀX[GLVHDVH*(5'DFFRUGLQJWR$PHULFDQ&ROOHJHRI*DVWURHQWHURORJ\$&*LV

V\PSWRPVRUPXFRVDOGDPDJHSURGXFHGE\DEQRUPDOUHÀX[RIJDVWULFFRQWHQWVLQWRWKHHVRSKDJXV,QPRVW
patients with GERD, showed no abnormalities in the endoscopic picture. This is what underlies the importance
of a diagnostic tool in the form of assessment for the degree of severity of the disease based on symptoms,
response to therapy and effect on the patients’ quality of life. This diagnostic tool is then formulated in the form
of a questionnaire (GERD questionnaire). Response to treatment with proton pump inhibitor (PPI) drugs is also
often used to support the diagnosis of this disease.
Diamond study is a large study which aim to assess the accuration of the questionnaire and use of PPI
WHVW'LDJQRVWLFPHWKRGZLWKTXHVWLRQQDLUHPRGDOLW\DQGIROORZHGE\33,WHVWKDYHVHQVLWLYLW\DQGVSHFL¿FLW\
value, which are relatively similar to the symptoms-based diagnoses performed by general practitioners or
gastroenterologist, as well as when compared to endoscopy and esophageal pH monitoring. Although the
diagnosis by methods of questionnaires and PPI test is not the most ideal test in term of accuracy, but these
tests are not expensive, readily available and worked mainly on primary health care. These test methods are
favored compared to other tests.

Keywords:JDVWURHVRSKDJHDOUHÀX[GLVHDVH*(5'*(5'TXHVWLRQQDLUH*(5'4SURWRQSXPSLQKLELWRU

(PPI) test

ABSTRAK

3HQ\DNLWUHÀXNVJDVWURHVRIDJXVPHQXUXW$PHULFDQ&ROOHJHRI*DVWURHQWHURORJ\$&*\DLWXNHUXVDNDQ

PXNRVD\DQJGLDNLEDWNDQROHKUHÀXNVDEQRUPDOGDULLVLODPEXQJNHHVRIDJXV3HQ\DNLWUHÀXNVJDVWURHVRIDJXV
JDVWURHVRSKDJHDO UHÀX[ GLVHDVH*(5' SDGD VHEDJLDQ EHVDU SDVLHQ WLGDN PHPSHUOLKDWNDQ NHODLQDQ SDGD
gambaran endoskopinya. Hal inilah yang mendasari pentingnya sebuah alat diagnostik berupa penilaian derajat
keparahan berdasarkan gejala, respon terhadap terapi dan pengaruhnya terhadap kualitas hidup pasien. Alat
diagnostik ini kemudian dirumuskan dalam bentuk sebuah kuesioner (GERD questionnaire). Respon terhadap
pengobatan dengan obat-obatan dari golongan inhibitor pompa proton (proton pump inhibitor/PPI) juga sering
digunakan untuk mendukung diagnosis penyakit ini.
Studi Diamond yaitu sebuah studi besar yang dikerjakan untuk menilai akurasi kuesioner dan penggunaan
tes PPI. metode diagnostik dengan modalitas kuisoner dan diikuti oleh PPI test memiliki angka sensitivitas

112 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy

 Diagnostic Approach to Gastroesophageal Reflux Disease: The Role of GERD Questionnaire and PPI Test

GDQVSHVL¿VLWDV\DQJUHODWLIVDPDGHQJDQGLDJQRVLVEHUEDVLVJHMDOD\DQJGLODNXNDQROHKGRNWHUXPXPPDXSXQ
gastroenterologis, begitupun jika dibandingkan dengan pemeriksaan endoskopi dan pemantauan pH esofagus.
Meskipun penegakan diagnosis dengan cara kuesioner dan PPI test bukan merupakan uji dengan akurasi yang
paling ideal, akan tetapi pemeriksaan ini tidak mahal, pilihan yang mudah didapatkan dan dikerjakan terutama
pada pelayanan kesehatan primer. Hal inilah yang diunggulkan dibandingkan pemeriksaan lainnya.

Kata kunci:SHQ\DNLWUHÀXNVJDVWURHVRIDJXVNXHVLRQHUJDVWURHVRSKDJHDOUHÀX[GLVHDVHWHVSURWRQSXPS
inhibitor

INTRODUCTION disease defined as a condition that arises due to

UHÀX[ RI VWRPDFK FRQWHQWV ZKLFK FDXVHG LUULWDWLQJ
Gastroesophageal reflux disease (GERD) is a
symptoms and/or its complications.1 What referred to
gastrointestinal disease which fairly common but the
irritating symptoms are any symptoms that lower the
prevalence very diverse worldwide.1 This disease is
quality of life of patients. These symptoms need to be
very common in Western Countries which occurs in
FRQ¿UPHG LQ RUGHU WR GLIIHUHQWLDWH WKH V\PSWRPV RI
10-30% of population. In Singapore, the prevalence of
JDVWURHVRSKDJHDOUHÀX[GLVHDVHIURPHSLVRGLFEXUQLQJ
JDVWURHVRSKDJHDOUHÀX[GLVHDVH¶VV\PSWRPVLQFUHDVHG
sentation in the chest.
sharply from 1,6% of population in 1994 to 10,6% in
$QRWKHUGH¿QLWLRQRIJDVWURHVRSKDJHDOUHÀX[GLVHDVH
2001.1 In Indonesia, there has been no representative
are based on American College of Gastroenterology
data to describe the incidence of this disease, but data
(ACG), is symptoms or mucosal damage produced by
from Rumah Sakit Cipto Mangunkusumo (RSCM)
DEQRUPDOUHÀX[RIJDVWULFFRQWHQWVLQWRWKHHVRSKDJXV2
showed that there is increased of prevalence from 6%
The latter definition can refer to the findings at
in 1997 to 26% in 2002 on patients which undergone
endoscopy, but it is also need to keep in mind that not
upper gastrointestinal endoscopy. This increasing trend
DOOJDVWURHVRSKDJHDOUHÀX[GLVHDVHUHTXLUHGHQGRVFRS\
is predicted caused by many things, which one of them
is the increased use of endoscopic modalities. 'H¿QLWLRQRIJDVWURHVRSKDJHDOUHÀX[GLVHDVH
The increasing prevalence due to the use of Genval Workshop Report Individuals exposed to the risk
(1999) of physical complications from
endoscopic modalities is very helpful in describing the JDVWURHVRSKDJHDO UHÀX[ RU WKRVH
actual conditions, especially in big cities, but it became ZKRH[SHULHQFHFOLQLFDOO\VLJQL¿FDQW
impairment of health-related well-
a distinctive obstacle for regions with less advanced being (quality of life) because of
health facilities. These conditions need to be addressed UHÀX[UHODWHG V\PSWRPV DIWHU
adequate reassurance of the
with a more simple modalities which able to reach all benign nature of their symptoms
Canadian Consensus 7KH UHÀX[ RI JDVWULF FRQWHQWV LQWR
areas, validated and reliable. Of course, use of gastro- Conference(2004) the esophagus causing symptoms
HVRSKDJHDOUHÀX[GLVHDVHTXHVWLRQQDLUH*(5'4 and VXI¿FLHQW WR UHGXFH TXDOLW\ RI
life or cause injury. Endoscopy
PPI test are expected to solve this problem. This paper QHJDWLYHUHÀX[GLVHDVHDQGQRUPDO
will be presented the role and position of GERDQ and HQGRVFRS\¿QGLQJV
American College of Symptoms or mucosal damage
33,WHVWLQGLDJQRVLVRIJDVWURHVRSKDJHDOUHÀX[GLVHDVH Gastroenterology (2005) SURGXFHGE\WKHDEQRUPDOUHÀX[RI
gastric contents into the esophagus
The purpose of this literature review is to know the 0RQWUHDO'H¿QLWLRQ A condition that develops when
position of GERDQ and PPI test use in the diagnosis UHÀX[ RI JDVWULF FRQWHQWV FDXVHV
troublesome symptoms or
RI JDVWURHVRSKDJHDO UHÀX[ GLVHDVH7KLV EULHI SDSHU complications
also aims to provide a basis for the primary health American 0RQWUHDOGH¿QLWLRQDGRSWHG
Gastroenterological
care providers to not hesitate in diagnosing the Association (2008)
JDVWURHVRSKDJHDOUHÀX[GLVHDVH
)LJXUH'H¿QLWLRQVRIJDVWURHVRSKDJHDOUHÀX[GLVHDVH3

GASTROESOPHAGEAL REFLUX DISEASE

Clinical Menifestations of Gastroesophageal
'H¿QLWLRQRI*DVWURHVRSKDJHDO5HÀX['LVHDVH 5HÀX['LVHDVH

'H¿QLWLRQRIJDVWURHVRSKDJHDOUHÀX[GLVHDVHEDVHG M o s t t y p i cal cl i n i cal m an i fes t at i o n s o f

on the consensus of international experts group which JDVWURHVRSKDJHDOUHÀX[GLVHDVHDUHEXUQLQJVHQVDWLRQ
known as Montreal definition. Gastroesophageal in the chest and regurgitation. Burning sensation in the

Volume 16, Number 2, August 2015 113

Ummu Habibah, Achmad fauzi

FKHVWGH¿QHGDVDEXUQLQJVHQVDWLRQLQWKHUHWURVWHUQDO IRU JDVWURHVRSKDJHDO UHÀX[ GLVHDVH GLDJQRVLV YDOLG

DUHD ZKLOH UHJXUJLWDWLRQ GH¿QHG DV SHUFHSWLRQ RI assessment of symptoms is very important.
ÀRZ RU UHÀX[ RI VWRPDFK FRQWHQWV LQWR WKH PRXWK
or hypopharynx. These two symptoms are assessed Endoscopy
fairly descriptive to diagnose GERD. Dysphagia
(QGRVFRS\LVDGLDJQRVWLFWHVWZKLFK¿UVWFRQVLGHUHG
symptom is generally more often to appears if a
in GERD diagnosis because of its capabilities to showed
burning sensation occurs long enough and in patients
Barret metaplasia, stricture or diagnosis of another
with erosive esophagitis. Dyspeptic symptoms
upper gastroinstetinal diseases in patients.4 However,
mostly can be resolved with the administration of
FRUUHODWLRQEHWZHHQHQGRVFRSLF¿QGLQJVDQGVHYHULW\RI
proton pump inhibitor (PPI). Slowly progressive
symptoms is very weak. Endoscopy must be considered
dysphagia, especially for solid food with obstructive
LQSDWLHQWVZKLFKDOUHDG\KDYHJDVWURHVRSKDJHDOUHÀX[
esophageal obstruction are suggestive for peptic
disease patients for more than 5 years, have alarm signs,
stricture. Symptoms outside the esophagus which can
and to search Barret esophagus.
EHFDWHJRUL]HGDVJDVWURHVRSKDJHDOUHÀX[GLVHDVHDUH
chest pain, sleep disorders, cough, hoarseness and
Esophageal pH Monitoring Examination
asthma.4,5
Esophageal pH monitoring examination are
'LDJQRVLVRI*DVWURHVRSKDJHDO5HÀX['LVHDVH invasive procedure which can be done after endoscopic
and histopatologic examination showed normal result
%DVHGRQ0RQWUHDOGH¿QLWLRQDQGWKHDFFHSWDQFHRI
LQSDWLHQWVZLWKW\SLFDOUHÀX[V\PSWRPV$SSOLFDWLRQV
HPSLULFWKHUDS\WKHUHLVQRVSHFL¿FGLDJQRVWLFWHVWLQWKH
of this examination is varied, probe can be placed
PDQDJHPHQWRISDWLHQWVZLWKJDVWURHVRSKDJHDOUHÀX[
 FP RU  FP IURP JDVWULF V¿QJWHU DQG GXUDWLRQ RI
disease. Diagnostic tools which needed must meet
probe placed also varied (some said it can be done
WKHVHWZRWKLQJV,GHQWL¿FDWLRQRIFRPSOLFDWLRQV
momentarily, but others said 24 hours examination
of the disease; (2) Evaluating patients who have failed
is better). As with endoscopy, this modality also not
to be treated with empiric therapy.2 Signs which make
readily available in primary health care centers so its
health practitioners should evaluated the empirical
use is very limited.
therapy in patients with suspected gastroesophageal
reflux disease called alarm signs. 4 Those alarm
GERD Questionnaire
signs are vomiting, upper gastrointestinal bleeding,
weight loss, dysphagia, anemia, and epigastric mass. Some diagnostic tools have been tried to use in
Nevertheless, the evidence to support this, is very little. helping physicians in diagnose GERD. Dent et al
Another perspective found in a meta-analysis found reported a study entitled “Accuracy of the diagnosis
that alarm signs in patients with upper gastrointestinal of GERD by questionnaire, physicians and a trial
PDOLJQDQF\KDVVHQVLWLYLW\DQGVSHFL¿FLW\ of PPI treatment: The Diamond Study”, the result
This prompted the need of endoscopic examination for LV JDVWURHVRSKDJHDO UHÀX[ GLVHDVH GLDJQRVLV EDVHG
follow-up alarm signs. on symptoms with questionnaire have the same
Endoscopic and 24-hour esophageal pH probe accuracy as diagnosis based on symptoms by a general
examination initially recommended as the gold practitioner or gastroenterologist.6
VWDQGDUGIRUWKHGLDJQRVLVRIJDVWURHVRSKDJHDOUHÀX[
disease.1 However, it is estimated that more than 70% Proton Pump Inhibitor (PPI) Test
of patients with typical symptoms of gastroesophageal This test is one of the modalities to be considered
UHÀX[GLVHDVHKDYHDQRUPDOHVRSKDJHDOPXFRVDZLWK when endoscopic diagnostic resources not available.
endoscopic examination. 24-hour esophageal pH probe Patients with typical symptoms will be given a double
examination is not sensitive enough to be one of the dose PPI for two weeks then the clinical response
diagnosis criteria. One study in China found that 63 assessed. This test usually follow GERDQ or used
of 102 patients with this disease is endoscopically alone as a diagnostic modality in places with limited
positive, and 84 patients of the 115 patients who resources. If this PPI test done after GERDQ, then the
had a positive result on a 24-hour esophageal pH evaluation also use GERDQ. Administration of PPI
probe.1 Futhermore, these two modalities are quite will be continued with the usual doses if the patient
expensive and not readily available in small hospitals had clinical improvement, and the patients will be
or clinics. Because of there are no gold standard FRQVLGHUHGKDYHJDVWURHVRSKDJHDOUHÀX[GLVHDVH4

114 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy

 Diagnostic Approach to Gastroesophageal Reflux Disease: The Role of GERD Questionnaire and PPI Test

ROLE OF GERD QUESTIONNAIRE AND PPI TEST of severity at certain times on individual and group. Of
the three types of the questionnaire, GERDQ expected
GERD Questionnaire
to meet three types.
$VSUHYLRXVO\GHVFULEHGJDVWURHVRSKDJHDOUHÀX[ There are several requirements that must be met for
disease occurs quite often, but most patients do not a good questionnaire, which are: (1) Sensitive to detect
VKRZDEQRUPDOLWLHVLQWKHHQGRVFRSLF¿QGLQJV7KLV GERD patients; (2) Includes data on the frequency and
is what underlies the importance of a diagnostic tool intensity of symptoms of typical and atypical GERD;
based on assessment for the degree of severity of the (3) Multidimensional (not only includes medical
disease based on symptoms, response to therapy and problems); (4) Have psychometric characteristics that
effect on the patients’ quality of life.7 This diagnostic FDQEHSURYHQYDOLGLW\OHYHORIFRQ¿GHQFHUHOLDELOW\
tool is then formulated in the form of a questionnaire (5) Practical and economical; (6) Can be done by the
(GERD Questionnaire). patient itself, without having to be accompanied (self-
In general, symptom based questionnaire can be assesed); (7) Use language that easily understood by
used as a discriminatory, predictive, or evaluative patients; (8) Provide a fast response to a change in the
instrument. Discriminatory instrument is intended short term; (9) Can be used in daily settings to provide
to distinguish this group of patients and to classify assessments during and after therapy; (10) Valid in
patients into a few degrees of severity and frequency different languages, for use on an international scale.11
of the disease. If used as a diagnostic instrument, Some questionnaires have been made to answer some
the discriminatory questionnaire must have very of these requirements. In general, the questionnaires
VSHFL¿F TXHVWLRQV FDQ UXOH RXW RWKHU GLVHDVHV DQG are divided into symptomatology questionnaires (based
has high probability prediction. Questionnaire as a on symptoms), questionnaires based on effect of the
predictive instrument is used if there is a gold standard disease on quality of life, and serta questionnaire that
examination. Evaluative questionnaire with a scale combines both. The grouping of the questionnaires can
used to assess the magnitude of change in the degree be seen in the following table 1.

Tabel 1. Various questionnaires used to aid diagnose GERD11

Symptomatology questionnaires (based on Questionnaires based on effect of the
Questionnaire that combines both
symptoms) disease on quality of life
6SHFL¿FIRU*(5' 6SHFL¿FIRU*(5' Questionnaires by Colwell et al and
*(5'VSHFL¿FHVRSKDJHDOV\PSWRP *DVWURHVRSKDJHDOUHÀX[GLVHDVHKHDOWK Mathias et al
questionnaire related quality of life (GERD-HRQL) HRQoL batteries
*(5'VSHFL¿FTXHVWLRQQDLUHE\0ROGHWDO +HDUWEXUQVSHFL¿FTXDOLW\RIOLIH Domestic/International
*(5'VSHFL¿FTXHVWLRQQDLUHE\5lLKlHWDO instrument (HBQOL) Gastroenterology Surveillance Study
GERD questionnaire *(5'VSHFL¿F4R/TXHVWLRQQDLUHE\ (DIGEST)
,QIDQWJDVWURHVRSKDJHDOUHÀX[TXHVWLRQQDLUH Jasani et al 5HÀX[TXHVWLRQQDLUH5H4XHVW
(I-GERQ) QOL questionnaire in gastroesophageal Nocturnal GERD symptom severity
*DVWURHVRSKDJHDOUHÀX[TXHVWLRQQDLUH*(54 UHÀX[5HÀX[4XDO and impact questionnaire (N-GSSIQ)
GERD Activity Index (GRACI) 5HÀX[TXDOVKRUWIRUP546
*(5'VSHFL¿FTXHVWLRQQDLUHE\&DUOVVRQHWDO Work Productivity and Activity
*(5'VSHFL¿FTXHVWLRQQDLUHE\0DQWHURODHWDO Impairment Questionnaire for GERD
GERD score (WPAI-GERD)
GERD Symptom Assessment Scale (GSAS) QoL questionnaire for patients
GERD screener XQGHUJRLQJDQWLUHÀX[VXUJHU\
Questionnaire used by Vigneri et al (QOLARS)
5HÀX[GLVHDVHGLDJQRVWLFTXHVWLRQQDLUH5'4 GERD-QOL
Chinese GERD Questionnaire (Chinese GERDQ) 6SHFL¿FIRU*DVWURLQWHVWLQDO
Score related to GERD Gastrointestinal quality of life index
Standardized esophageal symptom questionnaire (GIQLI)
Questionnaire by Andersen et al 4XDOLW\RIOLIHLQUHÀX[DQGG\VSHSVLD
Gastrointestinal Symptoms Rating Scale (GSRS) (QOLRAD)
Questionnaire by Ruth et al Patient assessment of upper
Ulcer esophagitis subjective symptoms scale gastrointestinal disorders (PAGI-QOL)
(UESS)
Digestive health status instrument (DHSI)
0RGL¿HGERZHOGLVHDVHTXHVWLRQQDLUH%'4

Volume 16, Number 2, August 2015 115

Ummu Habibah, Achmad fauzi

Tabel 2. Results of systematic review on various GERD questionnaires7

Available in different Psychometrically
Name *(5'VSHFL¿F Multidimensional Self-assessed Daily assessed
languages validated
GERD Score 9 - - - - 9
UESS - 9 9 - - 9
GSAS 9 9 9 - - 9
GSRS - - 9 - 9 9
GRACI 9 - (9)* (9)* - -
*(5'JDVWURHVRSKDJHDOUHÀX[GLVHDVH*5$&,*(5'DFWLYLW\LQGH[*6$6*(5'V\PSWRPDVVHVPHQWVFDOH*656JDVWURLQWHVWLQDOV\PSWRPVUDWLQJ
scale; UESS: ulcer oesophagitis subjective symptom scale

*only parts of the scale

From many questionnaires which successfully The type of PPI used varied, the most common is
documented, no one can be taken as the gold standard omeprazole, so this test once regarded as omeprazole
questionnaire.3 A systematic review conducted in 2004 test. New classes of drugs that are often used for
showed that there are 5 pieces questionnaire that almost research is omeprazole, but its effectiveness was
meets all the criterias of an ideal GERD questionnaire, similar to other drugs, if intended for PPI test. Large
but this study too long that a more contemporary study studies on this test using oral PPI, no one was using
QHHGWREHFRQGXFW7KRVH¿YHTXHVWLRQQDLUHVFDQEH intravenous PPI with consideration of the application
seen in the following table 2. LQWKH¿HOGDQGWKLVUHVHDUFKVXEMHFWVLVLQWHQGHGIRU
The big question is which questionnaire that can be outpatients. The strategy for increasing the role of
widely or generaly used and how to choose the most doctors in primary cares in improving diagnosis of
appropriate questionnaire for the clinical situation in GERD because the scope of this strategy is very simple
Indonesia, and how the actual role of this questionnaire and well tolerated by patients.
LQGLDJQRVLQJJDVWURHVRSKDJHDOUHÀX[GLVHDVH7RDQVZHU Disadvantages of this test is the absence of a
some of these questions, there is a recent large study on the standard test or the definitive gold standard for
role of GERD questionnaire in 2009 which quite helpful diagnosing GERD. In some studies, the PPI test is
to help answering doubts about the use of questionnaires often compared to endoscopy and pH examination,
DV DQ DSSURDFK LQ GLDJQRVLQJ JDVWURHVRSKDJHDO UHÀX[ by the fact that these two examinations also has many
disease. Details of the study will be discussed later. OLPLWDWLRQV%HFDXVHRIWKHVHGLI¿FXOWLHVWKHPHWKRGV
vary between studies, and the populations are different,
Proton Pump Inhibitor (PPI) Test WKHUHIRUHDORWRIUHVHDUFKGDWDGLI¿FXOWWREHFRPSDUHG
Response to treatment with drugs from class of 6HQVLWLYLW\ DQG VSHFL¿FLW\ YDOXH EHFDPH YHU\ ZLGH
proton pump inhibitor (PPI), often used to support the which are 27-89% for sensitivity and 35-73% for
GLDJQRVLVRIJDVWURHVRSKDJHDOUHÀX[GLVHDVH, however specificity. Schindlbeck et al showed that 40 mg
the accuracy of this strategy is often questioned.8 omeprazole per day for 7 days resulted in a sensitivity
Among some of the questions is whether this test can be of 27% and will be increased to 83% when the drug
applied in all cases, and whether this test can be used to dose was increased to 40 mg twice daily. Fass et al
replace other tests that are invasive and uncomfortable. stated that the omeprazole dose lower than previous
Rationalization of the use of high-dose PPI drugs with studies (60 mg); which are 40 mg before breakfast,
a short duration as a diagnostic modality is its effect on 20 mg before dinner; for 7 days will result in 80% for
gastric acid secretion to cope with erosive esophagitis sensitivity of 80%. Study by Fass use 50% symptoms
and improve the symptoms of GERD.9 In general, PPI reduction as a positive limit value, if the value of
drugs can provide the acid suppressive effect within this limit was increased to 75% symptoms reduction
1-28 days, because it is used to help diagnosis, then (clinical improvement) then the sensitivity value will
high dose of PPI is used to boost the effects supresinya increased to 86% with 91% positive predictive value
and immediately improve patient complaints. The and accuracy of 81%.10
high doses expected to give effect before 28 days. A large study in India who studied algorithms
The dose used in several large studies are double- GLDJQRVLVRIJDVWURHVRSKDJHDOUHÀX[GLVHDVHVWDWHGWKDW
dose PPI, which are 40-80 mg omeprazole, 30-60 mg combination of a PPI test, endoscopy and histology
lansoprazole, and 40 mg rabeprazole.10 Duration which examination can identify all cases of gastroesophageal
ZLGHO\XVHGLVGD\V7KHUHLVQRGH¿QLWHVWUDWHJ\ UHÀX[GLVHDVHLQWKHVWXG\EXWQRWLIWKHWKUHHWHVWVVWDQG
regarding this test procedure. on their own.11 From the previous decription, it can be

116 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy

 Diagnostic Approach to Gastroesophageal Reflux Disease: The Role of GERD Questionnaire and PPI Test

FRQFOXGHGWKDWWKH33,WHVWSURYLGHVUHDOEHQH¿WVLQ
diagnosing GERD, especially if the test is combined
with other diagnostic.
Economic analysis test has also been used to
determine the position of the PPI test in terms of
HI¿FLHQF\ RI KHDOWK FRVW (FRQRPLF DQDO\VLV KDYH
stated that this test proven to reduce the cost of
health expenditure because it can prevent the use of
other diagnostic methods which are more expensive
ZLWKKLJKVHQVLWLYLW\DQGVSHFL¿FLW\WKDWLVQRWPXFK
different. This test saves 64% expenditure when
compared to endoscopy, and saves 53% expenditure
when compared to the 24-hour pH measurement.10

Figure 4. Corelations PPI test with frequency of symptoms

DIAMOND STUDY AND ITS APLICATION IN

INDONESIA

In 2009, there is a large study was done to assess

the accuracy of the questionnaire and the use of PPI
test, which expected to help the problem in diagnosing
JDVWURHVRSKDJHDOUHÀX[GLVHDVHV5HSRUWRIWKLVVWXG\
was released in 2010, and often used as a basis for
adopting a new questionnaire which easier, simpler and
validated in various countries, including in Indonesia.
This study was named the Diamond study.
Diamond study was conducted in many centers in
Figure 3. Position of PPI test at GERD diagnosis algorithm with
various countries, which Germany, Sweden, Canada,
non-cardiac chest pain symptoms Denmark, Norway, and the United Kingdom. This
sudy 73 family physicians, 22 specialist clinics and
308 patients. Patients who entered the inclusion criteria
The algorithm showed above was proposed in
UHTXHVWHGSUHYLRXVO\WR¿OORXWWKUHHTXHVWLRQQDLUHV
clinical review conducted in 2008. The main approach
ZKLFKKDYHEHHQYDOLGDWHGZKLFKDUHUHÀX[GLVHDVH
RIWKHGLDJQRVWLFÀRZLVSDWLHQWVZLWKV\PSWRPVRIZLWK
questionnaire (RDQ), gastrointestinal symptom rating
symptoms of heartburn or non-cardiac chest pain which
VFDOH*656DQGJDVWURRHVRSKDJHDOUHÀX[GLVHDVH
is a classic symptom of GERD beside regurgitation.
impact scale (GIS).12 Based on input from these three
This algorithm showed that the position of the PPI test
questionnaires, some questions which are considered
LVTXLWHXVHIXODQGHFRQRPLFDOO\HI¿FLHQW
best describes the symptoms and the effect on quality
The diagnostic algorithm illustrated above can
of life are made. These set of questions compiled in
also describe the role of PPI test in everyday clinical
D TXHVWLRQQDLUH NQRZQ DV JDVWURHVRSKDJHDO UHÀX[
SUDFWLFHV 7KH PRUH VSHFL¿F V\PSWRPV WKH SDWLHQW
disease questionnaire (GERDQ). This study also
complained of, and if accompanied by signs of alarm,
combined the questionnaire with PPI test to assess
then the possibility of erosive esophagitis pathological
its role in assisting the diagnosis and simultaneously
features can be found is more likely. If the histological
HYDOXDWLQJ SDWLHQWV ZLWK RI JDVWURHVRSKDJHDO UHÀX[
features is so clear then PPI test is not needed, but on
disease symptoms.
WKHFRQWUDU\WKHPRUHXQVSHFL¿FV\PSWRPVRI*(5'
the PPI test is more necessary to help establish the
diagnosis.

Volume 16, Number 2, August 2015 117

Ummu Habibah, Achmad fauzi

Table 3 . GERDQ from result of Diamond study

Frequency score (points) for
Question symptom
0 day 1 day 2-3 days 4-7 days
1. How often did you 0 1 2 3
have a burning feeling
behind your breastbone
(heartburn)?
2. How often did you have 0 1 2 3
stomach contents (liquid
or food) moving upwards
to your throat or mouth
(regurgitation)?
3. How often did you have 3 2 1 0
a pain in the centre of
the upper stomach?
4. How often did you have 3 2 1 0
nausea?
5. How often did you have 0 1 2 3
GLI¿FXOW\ JHWWLQJ D JRRG Figure 5. GERD diagnostic algorithm according to the ACG
night’s sleep because
of your heartburn and/or
regurgitation? Table 5. GERDQ in Indonesian have been proven to be valid
6. How often did you take 0 1 2 3 dan reliable
additional medication for Frequency score (points) for symptom
your heartburn and/or Questions in last 7 days
regurgitation, other than 0 day 1 day 2-3 days 4-7 days Point
what the physician told 1. How often did you 0 1 2 3 +
you to take? (such as have a burning
Tums, Rolaids, Maalox? feeling behind
your breastbone
(heartburn)?
2. How often did you 0 1 2 3 +
Eventually, this study mentioned that the sensitivity have stomach
contents (liquid
and specificity of gastroesophageal reflux disease or food) moving
diagnosis based on symptoms by questionnaire are upwards to your
throat or mouth
DQGLI¿OOHGRXWE\SDWLHQWVDQGLI (regurgitation)?
¿OOHGRXWE\IDPLO\SK\VLFLDQVDQGLI¿OOHG 3. How often did you
have a pain in
3 2 1 0 +

out gastroenterologist, 54% and 65% if followed by the centre of the

upper stomach?
PPI test for two weeks.12 Therefore, it can be concluded 4. How often did you 3 2 1 0 +
that the diagnostic method with questionnaire modality have nausea?
5. How often did
which followed by PPI test has the sensitivity and \RXKDYHGLI¿FXOW\
VSHFL¿FLW\ ZKLFK UHODWLYHO\ VLPLODU ZLWK V\PSWRPV getting a good
night’s sleep
based diagnosis which done by general practicioners because of your
heartburn and/or
and gastroenterologist, as well as when compared with regurgitation?
endoscopy and esophageal pH monitoring examination. 6. How often did you 0 1 2 3 +
take additional
Although GERD diagnosis with questionnaire and medication
PPI test are not tests with the most ideal accuracy, for your
heartburn and/
but these tests are not expensive, readily available or regurgitation,
other than what
options and can be done especially in primary health the physician told
care centers. These tests are favored compared to more you to take? (such
as Tums, Rolaids,
invasive and uncomfortable examinations, especially Maalox?
LQ FDVHV RI JDVWURHVRSKDJHDO UHÀX[ GLVHDVH ZLWKRXW
any alarm sign.
CONCLUSION
In Indonesia alone, the two diagnostic methods
have been incorporated into the diagnostic algorithm *DVWURHVRSKDJHDOUHÀX[GLVHDVHLVRQHRIWKHPRVW
RIJDVWURHVRSKDJHDOUHÀX[GLVHDVH*(5'4LQ(QJOLVK common gastrointestinal diseases. Prevalences of this
have been translated into Indonesian and validation test disease are varied, while in Indonesia there has been
have been done. This validation test is done in 2009, no representative data to describe the magnitude of the
and named as Virginia study.1 Result from this study problem in this disease. Diagnostic modality which
is all questions in GERD questionnaire are valid and known to be very helpful in diagnose gastroesophageal
reliable in Indonesian GERD patients. UHÀX[ GLVHDVH LV XSSHU JDVWURLQVWHVWLQDO HQGRVFRS\
Weakness of this modality is the incapabilities to

118 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy

 Diagnostic Approach to Gastroesophageal Reflux Disease: The Role of GERD Questionnaire and PPI Test

H[SODLQ WKH FRUUHODWLRQ RI DEQRUPDO ¿QGLQJV ZLWK 3. /DF\%(:HLVHU.&KHUWRII-)DVV53DQGRO¿QR-(5LWFKHU

degree of severity of symptoms which affected -(HWDO7KHGLDJQRVLVRIJDVWURHVRSKDJHDOUHÀX[GLVHDVH
The Am J Med 2010;123:583-92.
patients’ quality of life and this examination is
4. Patti MG. Advances in diagnostic testing for gastroesophageal
not readily available in all health care centers in UHÀX[GLVHDVH:RUOG-*DVWURHQWHURO
peripehral areas. Initially, this examination became 5. Moore JM, Vaezi M. Extraesophageal manifesations of
diagnostic gold standard of GERD, but because of its JDVWURHVRSKDJHDOUHÀX[GLVHDVHUHDORULPDJHG&XUU2SLQ
weakness until now there is no diagnosis standard in Gastroenterol 2010;26:389-94.
6. Tae HO. Accuracy of the diagnosis of GERD by questionnaire,
JDVWURHVRSKDJHDOUHÀX[GLVHDVH
physicians, and trial of PPI treatment: the Diamond study. J
Some modalities which introduced recently Neurogastroenterol Motil 2011;1:17.
are GERD questionnaire and PPI test. These two 7. Stanghellini V, Armstrong D, Monnikes H, Bardhan KD.
modalities usually simulatenously used, but sometime Systematic review: do we need a new gastro-oesophagel
reflux disease questionnaire? Aliment Pharmacol Ther
used separatedly. Some studies have shown similar
2004;19:463-79.
validities when used by general practitioners or 8. Numans ME, Lau J, Wit NJ, Bonis PA. Short term treatment
gastroenterologist. However, these test also have many with proton-pump inhibitor as a test for gastroesophageal
limitations. Translation of questionnaire must be done UHÀX[GLVHDVHDPHWDDQDO\VLVRIGLDJQRVWLFWHVWFKDUDFWHULVWLFV
carefully and the questionnaire must be revalidated Ann Intern Med 2004;140:518-27.
9. Mace F, Mace P. The proton pump inhibitor test and the
at every place it was translated.1 However, these two GLDJQRVLV RI JDVWURHVRSKDJHDO UHÀX[ GLVHDVH ([SHUW 5HY
modalities very helpful to diagnose GERD, especially Gastroenterol Hepatol 2010;4:423-7.
in remote areas. 10. Gasiorowska A, Fass R. The proton pump inhibitor (PPI)
test in GERD: does it still have a role? J Clin Gastroenterol
2008;8:867-74.
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7KH JDVWURHVRSKDJHDO UHÀX[ GLVHDVH TXHVWLRQQDLUH XVLQJ
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