Editorial: The Milan Score as Supportive Evidence of Gastro‐Oesophageal Reflux Disease. Authors' Reply

We thank Chahuán and Savarino for their editorial on our study validating the Milan Score against 96-h wireless pH monitoring [1, 2]. Their commentary helps us to emphasize the specific role of the Milan Score in patients with inconclusive gastro-oesophageal reflux disease (GERD), which remains one of the most difficult challenges in everyday practice. According to Lyon Consensus 2.0, inconclusive GERD on prolonged wireless reflux monitoring includes a broad spectrum of patients with acid exposure time (AET) between 4.0% and 6.0% on any single day, to pathologic AET (> 6.0%) on only one of the 4 days of the recording [3]. This wide zone of uncertainty is not uncommon in clinical practice, and we agree that complementary tools such as the Milan Score may provide adjunctive evidence. In our cohort, 15 patients (17%) had inconclusive GERD based on one positive AET day on 96-h wireless pH monitoring [2, 3], of whom a full 40% (6 patients) had an abnormal Milan Score (> 137) [4], supporting underlying anti-reflux barrier disruption despite non-diagnostic pH testing. Although patients with and without abnormal Milan Score shared similar reflux monitoring characteristics, five patients (83%) in the positive Milan Score group had good PPI response, compared to only three (33%) in the negative Milan Score group. Although the small cohort prevents strong and generalizable conclusions, these results indicate a role for the Milan Score in inconclusive patients: a clearly positive score increases confidence toward true GERD, while a clearly negative score, especially in the context of a normal endoscopy and low symptom burden, discourages escalation of anti-reflux therapy, as underlined in a previous study from our multicentre group [5]. We fully agree that prospective outcome studies are needed to determine whether the Milan Score can direct management in inconclusive patients and reduce diagnostic delay. Moreover, we believe that a recalibration of the Milan Score parameters, aimed to make the score itself less dependent on a relatively novel metric such as the straight leg raise manoeuvre, may improve its reliability in predicting definitive GERD. Marco Sozzi: conceptualization, writing – original draft, writing – review and editing. Stefano Siboni: conceptualization, writing – review and editing, data curation, writing – original draft. C. Prakash Gyawali: conceptualization, writing – original draft, writing – review and editing, supervision. The authors have nothing to report. The authors declare no conflicts of interest. 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.70697. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.