**6. Diagnosis**

A presumptive diagnosis of GERD is based on typical symptomatology. Empirical proton-pump inhibitor (PPI) treatment, where the patient is prescribed a PPI for a short period of time (usually two months) to see if it resolves symptoms is in the majority of patients sufficient for diagnosis of GERD. In case when symptoms do not improve, or even worsen, when GERD is accompanied with other, atypical symptoms or, in case of suspected complications, there is a need for more invasive diagnostic tests.

While routine endoscope examination of the esophagus is not indicated for patients with typical symptoms, it is advised for patients with complicated GERD and is useful in the detection of erosive esophagitis, presence of Barett's esophagus or hiatal hernia, and other anatomic changes. The absence of esophageal mucosal injury cannot exclude GERD, because more than half of the patients with GERD have nonerosive reflux disease [22]. Routine biopsy is not recommended. The detection rate of abnormal blood vessels and epithelial micro injuries can be improved under endoscopy equipped with narrow banding imaging [22]. Barium esophagography and pH monitoring are useful to evaluate esophageal function. Esophageal manometry

is of limited value but is recommended before considering anti-reflux surgery. Ambulatory reflux monitoring allows the determination of pathologic esophageal acid reflux and its frequency [23]. Blood tests are used to measure H. pylori IgG and H. pylori CagA IgG antibodies.

Standard diagnostic algorithm, which could precisely determine LPR have still not been established. LPR is mostly not recognized, and because of that it is known as a "silent reflux." In a large number of cases diagnostic and therapeutical protocols are inadequate, so proper treatment is usually delayed. Laryngeal symptoms are most common, so patients are usually treated by otolaryngologists. Otolaryngologists have developed a Reflux Symptom Index (RSI), a validated questionnaire given to patients to score the severity of their symptoms. It is based on the importance of certain disease symptoms (the degree of hoarseness, frequency of throat clearing, degree of throat mucus or postnasal drip, dysphagia, coughing after eating or lying down, breathing difficulties, chronic cough, globus sensation, and heartburn). Reflux Finding Score (RFS) is based on frequency of pathological changes observed by laryngoscopy [24]. The laryngoscopic findings associated with LPR include posterior commissure hypertrophy, edema, arytenoid erythema, ventricular obliteration, granulation, oropharyngeal and anterior pilar erythema, coated tongue, uvula, and oropharyngeal posterior wall erythema. Many of them are nonspecific, but laryngoscopy has a very important role in diagnosis of reflux laryngitis; redness, thickness, and swelling located in the posterior parts of the larynx (posterior laryngitis) are important for the diagnosis of LPR.

This part of the larynx is anatomically more disposed to chronic irritation because both arytenoids and the interarytenoid regions are closer to the inlet of esophagus [25]. In some cases, immunoserologic pepsin detection tests are useful and easy to perform. Pepsin is produced only by the chief cells of the stomach and, therefore, the pepsin as a specific marker detected in the larynx can only be derived from refluxing gastric contents [26].
