Table 4.

Strength of the GRADE recommendations for esophageal physiologic testing for extraesophageal reflux symptoms and atypical symptoms

Statement	GRADE quality	Strength of recommendation
We recommend ambulatory reflux monitoring, specifically pH impedance monitoring performed off acid suppression, over laryngoscopy for a diagnosis of extraesophagealreflux	Low	Strong
We suggest up-front ambulatory reflux monitoring off acid suppression over an empiric trial of PPI therapyforextraesophagealrefluxsymptomswithout concurrent typicalreflux symptoms	Very low	Conditional
We suggest HRIM with postprandialmonitoring be used to confirm the diagnosis of rumination if clinically necessary in patients with esophagealsymptoms suspicious for rumination syndrome	Low	Conditional
We suggest that for patients with excessive belching, pH impedance monitoring can be used to confirm the diagnosis of supragastric belching	Very low	Conditional

Please refer to the text for detailed discussion and evidence regarding each of the recommendations.

GRADE, Grading of Recommendations Assessment, Development and Evaluation; HRIM, high-resolution impedance manometry; PPI, proton pump inhibitor.