Based on Lyon Consensus 2.0 [1], wireless pH monitoring is the preferred diagnostic method for confirming gastro‐oesophageal reflux disease (GERD) during the evaluation of patients with an unproven diagnosis. However, it is not universally available and may be cost‐prohibitive [1, 2]. In this context, given that high‐resolution oesophageal manometry (HREM) is often performed before 24‐h reflux monitoring to facilitate correct probe placement or as part of the evaluation of oesophageal symptoms [3], HREM tools such as the Milan score [4] have been proposed to corroborate the need of undergoing reflux testing and to support the diagnosis of GERD in patients with inconclusive 24‐h pH monitoring [5, 6, 7].
Siboni et al. evaluated the Milan Score against prolonged (96‐h) wireless pH monitoring in a multicentre cohort. The Milan score achieved good diagnostic performance (AUC 0.812), with particularly high specificity (92.9%) and positive predictive value (90.6%) for conclusive GERD [5]. Importantly, the score remained an independent predictor of GERD after adjustment for body mass index, sex and hiatal hernia, and its performance improved when combined with clinical variables (AUC 0.875). These findings strengthen the biological plausibility of the score, as it captures key components of anti‐reflux barrier dysfunction, including oesophagogastric junction integrity and response to stress manoeuvres, as well as ineffective oesophageal motility [4].
From a clinical perspective, the main value of the Milan score lies in its ability to provide supportive evidence of GERD in settings where diagnostic uncertainty persists. According to Lyon Consensus 2.0, acid exposure time between 4% and 6% remains inconclusive, often requiring prolonged reflux monitoring [1]. In this context, the Milan score may serve as a pragmatic adjunct.
Nevertheless, caution is warranted. The relatively modest sensitivity (60.4%) indicates that a negative Milan score cannot reliably exclude GERD, with a substantial proportion of false negatives. This limitation reflects the heterogeneous pathophysiology of GERD [8], where mechanisms beyond anti‐reflux barrier dysfunction may predominate. Therefore, the Milan score should be interpreted within a multimodal diagnostic framework rather than as a standalone tool.
The study also addresses several prior methodological concerns. The inclusion of multivariable analysis, internal validation through bootstrapping, and subgroup comparisons enhances the robustness of the findings. However, some limitations remain, including the retrospective design, relatively small sample size, and limited comparison with alternative diagnostic scores. While direct comparison with tools such as the Lyon [9] or pHoenix [10] scores is challenging due to methodological differences, future studies should explore the additive value of combining these approaches.
Beyond diagnosis, the Milan score may have broader implications. By providing mechanistic insight into anti‐reflux barrier competence, it could help stratify patients, guide therapeutic decisions and potentially predict response to medical or surgical interventions.
In conclusion, this study reinforces the Milan score as a valuable adjunctive tool in the diagnostic workup of GERD. Its high specificity makes it particularly useful for ‘ruling in’ disease, especially when conventional reflux monitoring is inconclusive or unavailable. Further prospective studies are warranted to define its role within integrated diagnostic pathways and to assess its impact on clinical outcomes.
Author Contributions
Javier Chahuán: conceptualization, investigation, writing – original draft. Edoardo Vincenzo Savarino: conceptualization, investigation, writing – review and editing, project administration.
Funding
The authors have nothing to report.
Conflicts of Interest
Javier Chahuán has nothing to declare. Edoardo Vincenzo Savarino has served as speaker for AbbVie, Agave, AGPharma, Alfasigma, Aurora Pharma, CaDiGroup, Celltrion, Dr. Falk, EG Stada Group, Fenix Pharma, Fresenius Kabi, Galapagos, Janssen, JB Pharmaceuticals, Innovamedica/Adacyte, Malesci, MayolyBiohealth, Omega Pharma, Pfizer, Reckitt Benckiser, Sandoz, SILA, Sofar, Takeda, Tillots and Unifarco; has served as consultant for AbbVie, Agave, Alfasigma, Biogen, Bristol‐Myers Squibb, Celltrion, Diadema Farmaceutici, Dr. Falk, Fenix Pharma, Fresenius Kabi, Janssen, JB Pharmaceuticals, Merck & Co, Nestlé, Reckitt Benckiser, Regeneron, Sanofi, SILA, Sofar, Synformulas GmbH, Takeda and Unifarco; and has received research support from Pfizer, Reckitt Benckiser, SILA, Sofar, Unifarco and Zeta Farmaceutici.
Linked Articles
This article is linked to Siboni et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70668 and https://doi.org/10.1111/apt.70729.
Chahuán J. and Savarino E. V., “Editorial: The Milan Score as Supportive Evidence of Gastro‐Oesophageal Reflux Disease,” Alimentary Pharmacology & Therapeutics 64, no. 3 (2026): 400–401, 10.1111/apt.70697.
Handling Editor: Colin Howden
Data Availability Statement
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.