Esophageal pH-Impedance Reflux Monitoring Interpretation Report

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Ordering Clinician: [Ordering clinician name, credentials]

Interpreting Clinician: [Interpreting clinician name, credentials]

Study Date/Time: [Start date/time] to [End date/time]

Report Date: [Report date]

Facility: [Facility/Institution]

Study Type: Ambulatory catheter-based pH-impedance

Device/Software: [Manufacturer, catheter/model, recorder/model, software/version] (Include components only if known; otherwise state "not provided")

Clinical Context

Primary indication: [Heartburn / Regurgitation / Non-cardiac chest pain / Chronic cough / Globus / Laryngeal symptoms / Pre-surgical evaluation / Post-surgical symptom recurrence / Other: specify]

GERD evidence status at time of testing: [Unproven GERD (no prior conclusive objective evidence) / Proven GERD (prior erosive esophagitis, Barrett's, or abnormal reflux testing)] (If not documented, state "not provided")

Relevant prior studies: [EGD, HRM, prior reflux testing with dates and key findings] (If not provided, state explicitly)

Current acid suppression therapy: [Medication(s), dose(s), frequency, timing relative to meals] (If unknown, state "not provided")

Study Conditions

Test condition: [Off PPI/acid suppression (diagnostic evaluation) / On PPI/optimized therapy (mechanism evaluation in proven GERD)] (Do not infer if not stated)

Acid-suppressing medications around testing:

• PPI: [Name, dose, frequency; last dose date/time] (If applicable; note if adherence uncertain)
• H2RA: [Name, dose, frequency; last dose date/time] (If applicable)
• Adherence information source: [Patient diary / Medication list / Unknown]

Catheter setup:

• LES localization method: [High-resolution manometry / Prior manometry / Stepwise pull-through / Estimated by measurement]
• pH sensor position: [X cm above upper border of LES]
• Impedance configuration: [Number of channels and spacing; distal channel distance(s) above LES]
• Calibration: [Performed per manufacturer instructions / Not documented]

Recording parameters:

• Planned duration: [Hours]
• Actual recorded duration: [Hours:minutes]
• Analyzed duration after exclusions: [Hours:minutes]
• Upright vs supine determination: [Patient diary / Device position sensor / Not documented]
• Meals excluded from analysis: [Yes / No / Partially]
• Symptom logging method: [Patient diary buttons / Paper diary transcribed / Mobile app]
• Symptom buttons programmed: [List symptom labels]

Study Adequacy

• Duration adequacy: [Adequate (≥16–24 hours usable) / Borderline / Inadequate]
• Signal integrity: [No significant drift or dropout / pH drift suspected / Impedance channel dropout at channel(s) / Suspected catheter migration at time]
• Diary quality: Meals recorded [Yes / No]; Supine periods recorded [Yes / No]; Symptoms recorded [Yes / No], count = [N]
• Editing approach: [Auto-detection only / Manual review performed / Manual review with edits] (Describe scope if manual editing performed)
• Unassessed elements: [List any elements that could not be evaluated, or state "None"]

Results

Normative frame used: [Off-therapy thresholds / On-therapy thresholds]

Acid Exposure: (Meals [excluded / not excluded])

• Total AET: [Value] % — [Normal / Borderline / Abnormal]
• Upright AET: [Value] % — [Normal / Borderline / Abnormal]
• Supine AET: [Value] % — [Normal / Borderline / Abnormal]
• Prolonged acid episodes (>5 min): [Count]
• Longest acid exposure episode: [Duration]
• DeMeester score: [Value] — [Normal / Abnormal] (Include only if routinely reported by lab)

Impedance-Defined Reflux Episodes: (Note any editing limitations)

• Total reflux episodes: [Count] — [Within normal range / Elevated]
• By acidity: Acid [Count]; Weakly acidic [Count]; Non-acid [Count] (If available)
• By composition: Liquid [Count]; Gas [Count]; Mixed [Count] (If available)
• Proximal extent: [Count] reaching proximal channel at [distance above LES] (If relevant to clinical question)

Mean Nocturnal Baseline Impedance (MNBI): (Include if calculated)

• Distal channel at ~3 cm above LES: [Value] Ω — [Low / Normal]
• Distal channel at ~5 cm above LES: [Value] Ω — [Low / Normal]
• (Interpret as supportive evidence for or against reflux-related mucosal injury; low impedance may have non-GERD causes)

PSPW Index: [Value] % — [Low / Normal] (Include only if reliably calculated by lab; adjunctive phenotyping metric)

Symptom Association

(Include when symptom events were recorded in adequate number. If no symptom events recorded or diary unusable, omit this section and document in Limitations)

Association tested against: [Acid reflux events only / All impedance-defined reflux events]

• [Heartburn / Regurgitation / Chest pain / Cough / Other]: Total count [N]; SI [Value] % — [Positive (≥50%) / Negative]; SAP [Value] % — [Positive (>95%) / Negative]

(Repeat for each symptom type analyzed. If symptom counts are low, state that association is limited by low frequency. For cough, note potential timing unreliability)

Interpretation

Phenotype classification:

• Off PPI (unproven GERD): [Conclusive GERD / Physiologic (GERD unlikely) / Borderline or inconclusive reflux burden / Reflux hypersensitivity / Functional heartburn phenotype]
• On PPI (proven GERD with persistent symptoms): [Actionable refractory GERD physiology / Adequate reflux control on therapy / Reflux hypersensitivity on therapy]

Severity/phenotype qualifiers: [Severe acid burden / Predominant upright reflux / Predominant supine reflux / High reflux episode frequency / None applicable] (Include only if position data reliable)

Key drivers of interpretation (list 2–4):

• Total AET: [Value] % — [Normal / Borderline / Abnormal]
• Total reflux episodes: [Value per 24h] — [Within normal / Elevated]
• MNBI: [Value] Ω — [Low / Normal]
• Symptom linkage: [Symptom] SAP [Value] % — [Positive / Negative]

Impression

[Study type], [Off PPI / On PPI]; [Adequate / Borderline / Inadequate] recording; meals [excluded / not excluded].

[Primary phenotype diagnosis].

Symptom linkage: [Positive / Negative / Limited] for [symptom type(s)]; based on [acid-only / all reflux] events.

[Important caveats or limitations impacting interpretation] (If applicable)

Recommendations

• Therapeutic: [GERD therapy optimization / Consider anti-reflux intervention referral / Neuromodulator or visceral hypersensitivity strategies / Avoid escalation given physiologic burden / Consider deprescribing unnecessary acid suppression] (Select based on phenotype)
• Diagnostic: [Adjunctive evaluation / Evaluate for alternative diagnoses] (Specify if applicable)
• Adherence and timing: [Confirm PPI timing and adherence] (If on-therapy study)
• Referral: [Specialist referral or shared decision-making items] (If applicable)

(Note if recommendations assume confirmed adherence)

Limitations

• [Incomplete diary entries (meals/supine/symptoms)]
• [Short usable recording time]
• [Suspected catheter migration]
• [pH drift or impedance channel artifact/dropout]
• [Underpowered symptom association due to low symptom frequency]
• [Mismatch between study condition and clinical question]

(List only applicable items. If none, state "No significant limitations identified.")

Signature

Interpreting clinician signature: ________________________________

Name and credentials: [Printed name, credentials]

Date/Time signed: [Date and time]