Esophagogastroduodenoscopy (EGD) with Placement of a Bravo Probe for pH and GERD Symptom Monitoring

Gastroesophageal reflux disease (GERD) is a chronic condition affecting approximately 20% of the western population, with significant impacts on quality of life.¹ Accurate diagnosis and monitoring of GERD are crucial for appropriate patient management and treatment selection. While traditional pH monitoring required transnasal catheter placement for 24–48 hours, causing significant patient discomfort, the wireless Bravo pH monitoring system represents a significant advancement in diagnostic technology.^2,3

The Bravo pH monitoring system utilizes a wireless capsule endoscopically placed on the esophageal mucosa, enabling extended pH monitoring.⁴ The procedure is indicated for patients with persistent reflux symptoms despite medical therapy, atypical GERD symptoms, or those undergoing preoperative evaluation for antireflux surgery.⁵ Contraindications include severe esophagitis, esophageal strictures, varices, and bleeding diatheses.^6,7

This video demonstrates the proper technique for Bravo pH capsule placement during upper endoscopy, highlighting the standardized approach to ensure accurate positioning and secure attachment of the monitoring device.

The procedure begins with a comprehensive upper endoscopy under conscious sedation. The endoscopist performs careful intubation with smooth passage through the posterior pharynx to minimize coughing. During the systematic examination of the upper gastrointestinal tract, attention is paid to the gastroesophageal (GE) junction, which is typically located at 35 cm from the incisors. Narrow-band imaging aids in identifying any irregular areas requiring targeted biopsies. The endoscopist documents the presence and size of any hiatal hernia and assesses the integrity and appearance of the gastroesophageal valve using Hill grade.

The Bravo capsule is then positioned 6 cm proximal to the GE junction, specifically at 29 cm from the incisors. The delivery system creates suction to draw the esophageal mucosa into the capsule well. Following one minute of sustained suction, the release mechanism is activated, embedding the capsule pins securely into the mucosa.

Immediate post-deployment endoscopy confirms proper capsule positioning and mucosal attachment. The system's wireless connectivity is verified, and initial pH readings are obtained to ensure proper functioning.
Patients receive instructions for maintaining their diet diary and recording symptoms using the provided device. The standard monitoring period extends to 96 hours, during which the system continuously records pH levels, reflux episodes, and their correlation with patient-reported symptoms. The capsule naturally detaches during normal mucosal turnover within 7–10 days and passes spontaneously.

This demonstration highlights the advantages of the Bravo wireless system over traditional catheter-based methods for pH monitoring. The procedure proves particularly valuable in post-bariatric surgery patients, as illustrated in this case of a patient with previous sleeve gastrectomy, where GERD symptoms frequently require thorough evaluation. The extended 96-hour monitoring period provides comprehensive data regarding reflux patterns and symptom correlation, facilitating evidence-based decisions about medical or surgical management.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Dr. Charu Paranjape serves as an Editor-in-Chief for the Journal of Medical Insight.