Non-erosive reflux disease: the real problem in gastro-oesophageal reflux disease

Endoscopic Advances in the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is one of the most common diseases that occurs secondary to failure of the antireflux barrier system, resulting in the frequent and abnormal reflux of gastric contents to the esophagus. GERD is diagnosed in routine clinical practice based on the classic symptoms of heartburn and regurgitation. However, a subset of patients with atypical symptoms can pose challenges in diagnosing GERD. An esophagogastroduodenoscopy (EGD) is the most common initial diagnostic test used in the assessment for GERD, although half of these patients will not have any positive endoscopic findings suggestive of GERD. The advanced endoscopic techniques have improved the diagnostic yield of GERD diagnosis and its complications, such as Barrett's esophagus and early esophageal adenocarcinoma. These newer endoscopic tools can better detect subtle irregularities in the mucosa and vascular structures. The management options for GERD include lifestyle modifications, pharmacological therapy, and endoscopic and surgical interventions. The latest addition to the armamentarium is the minimally invasive endoscopic interventions in carefully selected patients, including the electrical stimulation of the LES, Antireflux mucosectomy, Radiofrequency therapy, Transoral Incisionless Fundoplication, Endoscopic Full-Thickness plication (GERDx™), and suturing devices. With the emergence of these advanced endoscopic techniques, it is crucial to understand their selection criteria, advantages, and disadvantages.

Alcohol accumulation promotes esophagitis via pyroptosis activation

Gastroesophageal reflux impairs the mucosal barrier in the distal esophagus, allowing chronic exposure of the squamous epithelium to multitudinous stimulations and inducing chronic inflammation. Esophagitis is a response to inflammation of the esophageal squamous mucosa. Our study clarified that alcohol accumulation could aggravate the progress of esophagitis by inducing pyroptosis; however, Ac-YVAD-CMK, an inhibitor of caspase-1, could effectively suppress the expression of IL-1β and IL-18 both in vivo and in vitro, reducing the inflammatory response, which is promised to be an agent to inhibit the progression of esophagitis. Additionally, caspase-1-derived pyroptosis is involved in esophageal cancer.

i-Scan detection of minimal change esophagitis in dyspeptic patients with or without Gastroesophageal Reflux disease

Background

The association of minimal change esophagitis (MCE) with GERD is controversial. i-Scan endoscopy (SE) provides high resolution and modulation of images that may improve minimal change lesion (MCL) detection. We aimed to assess the efficacy of SE in detecting MCL in dyspeptic patients with GERD compared with patients without GERD by GerdQ or by endoscopy with 24-h pH monitoring (PHM) and in normal volunteers.

Methods

This is a cohort study conducted at a tertiary center. All dyspeptic patients were prospectively recruited. All patients completed a validated Thai version of GerdQ and then underwent endoscopy. Forty normal volunteers as a control group were recruited for endoscopy. The distal esophagus was examined by high definition endoscopy and SE sequentially. All had PHM done. GERD was diagnosed by Los Angeles classification A-D and/or by a positive PHM. MCE was diagnosed when MCL or combination of MCL was present.

Results

Of 174 patients, 144 completed the study protocol. After the exclusion of 6 patients, 138 remained for analysis. Overlapping GERD symptoms were found in 44.2 % and 26.8 % had confirmed GERD. Group A was comprised of 61 patients with a positive GerdQ and 77 patients in group B had a negative GerdQ. Twenty-four in group A, 28 in group B and 7 in the control group had MCE that was not significantly different. MCE in GERD was significantly higher (51.45 %) than in non-GERD (32.7 %) (p = 0.047) and in the control group (20.58 %) (p = 0.007). The sensitivity, specificity, positive predictive value, and negative predictive value of SE were 51.35 %, 67.33 %, 36.54 % and 79.06 %, respectively.

Conclusion

In dyspeptic patients, SE detected more MCE in GERD than in non-GERD patients and in the control group.

Trial registration

ClinicalTrials.gov number NCT01742377

Overlap of functional dyspepsia and GERD--diagnostic and treatment implications

GERD and functional dyspepsia are the two most prevalent upper gastrointestinal disorders. Gastro-oesophageal reflux is most commonly diagnosed using the cardinal symptoms of heartburn and regurgitation. Patients might also be diagnosed using a questionnaire, after empiric treatment with an acid suppressant, after upper endoscopy or by pH testing. Functional dyspepsia is best diagnosed using symptoms outlined by the Rome committee in conjunction with a normal upper endoscopy. Theoretically, distinguishing these two populations should be easy for all health-care providers. In reality, however, carefully separating out these two populations can be quite difficult, as substantial overlap exists epidemiologically, symptomatically and even diagnostically. This overlap renders precise diagnosis a challenge; given the limited treatment options, the primary goal is to identify those patients who will respond to acid suppressive therapy. Despite the frequency with which functional dyspepsia and GERD overlap, remarkably few studies have investigated this overlap. Most recommendations are based on data derived from separate studies of functional dyspepsia and GERD. A further limitation of existing studies is their failure to differentiate between the various diagnostic categories into which the individual presenting with heartburn might belong.

Impedance baseline and reflux perception in responder and non-responder non-erosive reflux disease patients

BACKGROUND

It was recently shown that GERD patients have lower impedance baseline (IB) values than healthy controls and, that the esophageal acid exposure time (AET) correlates with IB levels.

GOALS

To explore the sensitivity of IB measurements in NERD patients, responders and non-responders to PPIs, when compared with pH-impedance (MII-pH) variables, and to evaluate whether this variable could represent a marker of GERD symptoms. Reproducibility and inter-observer agreement of IB measurement were also assessed. Study. MII-pH tracings from 44 NERD responders and 22 non-responders were analysed. Ten healthy volunteers underwent the same protocol. IB values were measured at the distal and proximal esophagus. IB was also analysed in a subgroup of patients and in controls with two methods and by two blinded operators.

RESULTS

Mean IB values at the distal esophagus were significantly lower in NERD patients than in controls. IB values did not differ between responders and non-responders. Of the 8 responders with negative AET and symptom association probability (SAP), 3 (37.5%) showed IB values lower than controls. IB values in responders with positive and negative SAP were similar (1832 (1596-2068) Ω vs 1667 (1361-1973) Ω, p: n.s.). No differences were found between the IB values measured with the two methods and the inter-observer agreement was good.

CONCLUSIONS

IB is a promising and easy to calculate MII-pH variable and appears to increase the sensitivity of MII-pH monitoring. IB values cannot predict PPI response and are not associated with reflux perception in NERD patients.

Increased frequency and enhanced perception of reflux in non-erosive reflux disease patients non-responders to proton pump inhibitors

BACKGROUND

The unsatisfactory response to medical treatment in non-erosive patients is becoming a real challenge for gastroenterologists. Non-responder patients, evaluated under treatment, present symptoms which are related to non-acidic, mixed and proximal reflux episodes.

METHODS

To elucidate the reflux pattern and mechanisms related to persistence of symptoms despite treatment, oesophageal pH-impedance was performed in 55 non-erosive responder and 24 non-responder patients, studied off therapy. Ten responder and 10 non-responder patients underwent a repeated study during proton pump inhibitor treatment.

RESULTS

Non-responders were characterised by a higher overall number and larger proportion of symptomatic reflux episodes. Non-responders were also characterised by an enhanced sensitivity to acidic, mixed and proximal refluxes. Weakly acidic reflux accounted for 29% of symptomatic refluxes in non-responders and 34% in responders. Proportions of acidic and weakly acidic reflux episodes were comparable both in responders and non-responders when analysed off and on treatment.

CONCLUSIONS

An increased overall number of reflux episodes and enhanced sensitivity to reflux are strongly associated with treatment failure. Treatment strategies aimed at decreasing transient lower oesophageal sphincter relaxations, pain modulators or anti-reflux surgery should be considered in non-responders in whom a significant relationship between symptoms and reflux has been confirmed.

Nonerosive gastroesophageal reflux disease and mild degree of esophagitis: comparison of symptoms endoscopic, manometric and pH-metric patterns

BACKGROUND

Our aim in the present study was to compare patients presenting with gastroesophageal reflux disease in the presence or absence of mild-grade esophagitis (grade I or II according to the Savary-Miller classification).

METHODS

Between 2005 and 2007, 215 patients with gastroesophageal reflux disease (67 with reflux associated with grade I or II esophagitis and 148 without esophagitis) were evaluated at the Department of Surgery, University Hospital Tor Vergata, Rome, and were included in the present study. The evaluations consisted of clinical interviews, endoscopy of the high digestive tract, esophageal manometry and pH monitoring.

RESULTS

There was no significant difference between the two groups with regard to age, sex or symptoms. The incidence of heartburn associated with noncardiac chest pain was greater in the esophagitis group than in the dysphagia group. The incidence of hiatal hernia was similar in both groups. Although the motor pattern was similar in both groups, the length of the abdominal esophagus was greater in patients without esophagitis (1.6 cm vs 1.1 cm; P < 0.05). The reflux pattern was nearly identical in both groups.

CONCLUSIONS

Gastroesophageal reflux without esophagitis must be regarded not as a milder form of the disease but as part of a single disease. Furthermore, these patients often demonstrate lower rates of symptom improvement after antireflux treatment in comparison with patients with erosive esophagitis. Therefore, further trials to assess the treatment algorithm for these patients are warranted.

Pathophysiology of functional dyspepsia

Functional dyspepsia is a highly prevalent and heterogeneous disorder. Functional dyspepsia involves many pathogenic factors, such as gastric motility disorders, visceral hypersensitivity, psychological factors, Helicobacter pylori infection, and excessive gastric acid secretion. The present article provides an overview of pathogenetic factors and pathophysiologic mechanisms.

Measurement of acid exposure of proximal esophagus: a better tool for diagnosing non-erosive reflux disease

BACKGROUND

The sensitivity of 24-h pH monitoring is poor in non-erosive reflux disease (NERD). In NERD patients, the proximal extent of acid reflux is one of the main determinants of reflux perception. The present study was aimed to compare the diagnostic accuracy of acid exposure time (AET), at 5 cm above the lower esophageal sphincter, with those at 10 cm and at 3 cm below the upper esophageal sphincter as well as the reproducibility of these parameters.

METHODS

A total of 93 consecutive NERD patients, with typical symptoms responsive to proton pump inhibitor treatment, and 40 controls underwent esophageal manometry and multi-channel 24-h pH-test; 13 patients underwent the same study on two occasions. Symptom association probability (SAP) values were evaluated at each esophageal level.

KEY RESULTS

The ROC curve indicates that the area under the curve was 0.79 at distal (SE=0.039), 0.87 (SE=0.032) at proximal (P=0.029 vs distal), and 0.85 (SE=0.033) at very proximal esophagus (P =0.148). AET showed a reproducibility of 61% (Kappa 0.22) at distal esophagus, 77% (Kappa 0.45) at proximal and 53% (Kappa 0.05) at very proximal esophagus. The percentage of patients with a positive SAP was not significantly different when assessed at the distal compared with the proximal esophagus.

CONCLUSIONS & INFERENCES

In NERD patients, the diagnostic yield of the pH test is significantly improved by the assessment of AET at the proximal esophagus. As this variable seems to be less affected by the day to day variability, it could be considered a reliable and useful diagnostic tool in NERD patients.

Disease progression in non-erosive reflux disease (NERD): impact of initial esophageal acid exposure

We investigated the 5-year clinical course in a cohort of patients with typical reflux symptoms and negative endoscopy. Prospective follow-up was conducted in patients with non-erosive reflux disease (NERD) for at least 5 years after initial evaluation with esophageal pH monitoring and upper gastrointestinal endoscopy. Within the last year of follow-up, reflux symptoms occurred in 27 of the 30 patients (90%). Twenty-five of twenty-seven symptomatic patients (93%) were on acid suppression therapy. The majority of our patients (70%) remained unchanged regarding their endoscopic status over 5 years. Progression to erosive esophagitis occurred in four patients with Los Angeles (LA) A (13%), three patients with LA B (10%), and two patients with LA C (7%). The presence of pathological acid exposure did not alter the presence of reflux symptoms over 5 years. Disease progression to erosive esophagitis occurred more frequently in patients with pathological acid exposure than those without pathological acid exposure (P= 0.025). Most NERD patients have symptoms and require acid suppression therapy 5 years after their initial diagnosis. Initial pathological acid exposure does not influence the use of acid suppression; however, it does influence the progression of NERD within 5 years of follow-up.

Increased TRPV1 gene expression in esophageal mucosa of patients with non-erosive and erosive reflux disease

BACKGROUND

Transient receptor potential channel vanilloid subfamily member-1 (TRPV1) may play a role in esophageal perception. TRPV1 mRNA and protein expression were examined in the esophageal mucosa of non-erosive reflux disease (NERD) and erosive esophagitis (EE) patients and correlated to esophageal acid exposure.

METHODS

Seventeen NERD patients, eight EE patients and 10 healthy subjects underwent endoscopy after a 3-week washout from proton pump inhibitors or H2 antagonists. Biopsies, obtained from the distal esophagus, were used for conventional histology, for Western blot analysis and/or quantitative real-time polymerase chain reaction (qPCR). Overall 13 NERD patients, four EE patients and five controls underwent ambulatory pH-testing.

KEY RESULTS

TRPV1 expression was increased in all NERD and EE patients, as measured by Western blot analysis (0.65 +/- 0.07 and 0.8 +/- 0.05 VS 0.34 +/- 0.04 in controls; P < 0.01) and by qPCR (1.98 +/- 0.21 and 2.52 +/- 0.46 VS 1.00 +/- 0.06; P < 0.01). Neutrophilic infiltration, in the mucosa, was detected only in EE patients.

CONCLUSIONS & INFERENCES

Non-erosive reflux disease and EE patients presented increased TRPV1 receptors mRNA and protein, although no correlation with acid exposure was demonstrated. Increased TRPV1 in the esophageal mucosa may contribute to symptoms both in NERD and EE patients and possibly account for peripheral mechanisms responsible for esophageal hypersensitivity in NERD patients.

The prokinetic effect of mosapride citrate combined with omeprazole therapy improves clinical symptoms and gastric emptying in PPI-resistant NERD patients with delayed gastric emptying

BACKGROUND

Previous studies have shown that non-erosive reflux disease (NERD) patients are less sensitive to proton pump inhibitor (PPI) treatment than patients with erosive reflux disease. The aim of this study was to investigate whether treatment with prokinetics in addition to omeprazole therapy would improve clinical symptoms, gastric emptying and esophageal peristalsis in PPI-resistant NERD patients with or without delayed gastric emptying.

METHODS

Subjects were 64 consecutive patients presenting with typical symptoms of PPl-resistant NERD (n = 44) and 20 healthy volunteers. PPI-resistant NERD patients underwent mosapride citrate (15 mg/day) and omeprazole (20 mg/day) co-therapy for 12 weeks. We evaluated the clinical symptoms as well as gastric emptying and esophageal manometry before and after combined therapy. We measured both acylated- and des-acylated plasma ghrelin levels by the ELISA method. The primary endopoint was to investigate whether co-administration of mosapride citrate and omeprazole would improve clinical symptoms and gastric emptying in PPI-resistant NERD patients with delayed gastric emptying.

RESULTS

T (max) value in PPI-resistant NERD patients was significantly higher than in healthy volunteers. Combination therapy with the prokinetic agent mosapride citrate and omeprazole significantly improved reflux symptoms and T (max) value in T (max) > 65 min NERD patients. Co-therapy also significantly reduced des-acylated-ghrelin levels in NERD patients with delayed gastric emptying.

CONCLUSIONS

Administration of mosapride citrate in addition to omeprazole improved gastro-esophageal reflux and gastric emptying in PPI-resistant NERD patients with delayed gastric emptying.

Factors influencing intercellular spaces in the rat esophageal epithelium

AIM: To evaluate the effect of acute stress, hydrochloric acid, ethanol, aspirin, and prednisolone on the intercellular spaces of the esophageal epithelium.

METHODS: Part I, male Sprague-Dawley rats were randomly divided into eight groups and treated with the damaging or control factors. The esophagus of each rat was macroscopically inspected. Histological changes in mucosal biopsies were examined by light microscopy, and the widths of intercellular spaces were determined by transmission electron microscopy (TEM). Part II, in part I, we found that acute stress and aspirin induced dilated intercellular spaces (DIS) of the esophageal epithelium. Therefore, the effect of acid suppression pretreatment with esomeprazole on esophageal epithelial DIS induced by water immersion and restraint stress (WRS) and aspirin was further investigated to determine the association of DIS with acid reflux. After administration of 0.9% sodium chloride solution or esomeprazole solution orally for five days, rats underwent WRS or intragastric administration of aspirin solution. Esophageal epithelial intercellular spaces were investigated by TEM.

RESULTS: (1) The five damaging factors produced no lesions or inflammation in esophageal mucosa of rats under either gross or routine histological inspections. Esophageal epithelial intercellular space diameters in stress and aspirin groups were significantly greater, nearly three or two-fold respectively, than those in their corresponding control groups (stress model: 0.38 ± 0.05 μm vs 0.13 ± 0.02 μm, P < 0.01; aspirin model: 0.32 ± 0.12 μm vs 0.19 ± 0.05 μm, P < 0.01). Neither intragastric administration of hydrochloric acid or ethanol, nor hypodermic injection of prednisolone produced DIS compared with their corresponding control groups (hydrochloric acid model: 0.24 ± 0.03 μm vs 0.19 ± 0.05 μm, P > 0.05; ethanol model: 0.25 ± 0.10 μm vs 0.19 ± 0.05 μm, P > 0.05; prednisolone model: 0.20 ± 0.03 μm vs 0.14 ± 0.03 μm, P > 0.05); and (2) No significant difference in the intercellular space diameters was observed between the group pretreated with esomeprazole and the control group, in both the stress and aspirin models (stress model: 0.35 ± 0.05 μm vs 0.37 ± 0.05 μm, P > 0.05; aspirin model: 0.24 ± 0.02 μm vs 0.27 ± 0.03 μm, P > 0.05).

CONCLUSION: Acute stress and aspirin can induce DIS of the esophageal epithelium in rats, and it is not correlated with acid reflux.

Outcome of nonerosive gastro-esophageal reflux disease patients with pathological acid exposure

AIM: To assess the management and outcome of nonerosive gastro-esophageal reflux disease (NERD) patients who were identified retrospectively, after a 5-year follow-up.

METHODS: We included patients with gastro-esophageal reflux disease (GERD) symptoms who had a negative endoscopy result and pathological 24-h esophageal pH-monitoring while off therapy. We interviewed them after an average period of 5 years (range 3.5-7 years) by means of a structured questionnaire to assess presence of GERD symptoms, related therapy, updated endoscopic data and other features. We assessed predictors of esophagitis development by means of univariate and multivariate statistical analysis.

RESULTS: 260 patients (137 women) were included. Predominant GERD symptoms were heartburn and regurgitation in 103/260 (40%). 70% received a maintenance treatment, which was proton pump inhibitor (PPI) in 55% of cases. An average number of 1.5 symptomatic relapses per patient/year of follow-up were observed. A progression to erosive gastro-esophageal reflux disease (ERD) was found in 58/193 (30.0%) of patients undergoing repeat endoscopy; 72% of these were Los Angeles grade A-B.

CONCLUSION: This study shows that progression to ERD occurs in about 5% of NERD cases per year, despite therapy. Only two factors consistently and independently influence progression: smoking and absence of PPI therapy.

The prevalence of and risk factors for Barrett's esophagus in a Korean population: A nationwide multicenter prospective study

OBJECTIVE

The aim of this study was to evaluate the prevalence of Barrett's esophagus (BE) in the general Korean population by evaluating screening esophagogastroduodenoscopy. In addition, the risk factors for BE were identified.

METHOD

An esophagogastroduodenoscopy examination was performed in 25,536 subjects who had upper endoscopy screening from January 2006 to July 2006.

RESULTS

Two hundred and fifteen subjects were confirmed to have BE by pathology, thus the prevalence of BE was calculated to be 0.84%. The endoscopic findings were subdivided into 2 groups: BE without reflux esophagitis (RE), which included 167 (77.7%), and BE with RE, which included 48 (22.3%). The analysis of symptoms showed that only 60.1% of the subjects with BE had reflux symptoms. Chest pain [odds ratio (OR): 1.48, 95% confidence interval (CI): 1.04-2.11] and epigastric soreness (OR: 1.42, 95% CI: 1.05-1.93) were found more frequently in the subjects with BE compared with the normal subjects. The multivariate analysis showed that the risk factors for all subjects with BE were a male sex (OR: 1.82, 95% CI: 1.32-2.50), nonsteroidal anti-inflammatory drug use (OR: 2.02, 95% CI: 1.28-3.20), hiatal hernia (OR: 5.66, 95% CI: 3.70-8.66), and an age > or = 60 compared with an age < 40 (OR: 1.81, 95% CI: 1.07-3.09). There was no significant difference associated with RE.

CONCLUSIONS

The prevalence of BE in Korean patients presenting for a routine health check-up was 0.84%, lower than reported in Western countries. Among the subjects with BE 77.7% did not have endoscopic erosions and there were no reflux symptoms in 39.9%. These results suggest that regular endoscopic screening with a high index of suspicion is necessary for the diagnosis of BE.

Regional oesophageal sensitivity to acid and weakly acidic reflux in patients with non-erosive reflux disease

The mechanisms underlying symptoms in non-erosive reflux disease (NERD) remain to be elucidated. Non-erosive reflux disease patients appear to be more sensitive to intraluminal stimula than erosive patients, the proximal oesophagus being the most sensitive. In order to assess regional oesophageal changes in reflux acidity and sensitivity to reflux, according either to the acidity or the composition of the refluxate, combined multiple pH and multiple pH-impedance (pH-MII) was performed in 16 NERD patients. According to multiple pH-metry, 29% and 12% of reflux events reached the middle and proximal oesophagus respectively, and 35% and 19% according to conventional pH-MII (P < 0.05). The per-individual analysis confirmed the difference between the two techniques. According to combined distal and proximal pH-MII, approximately 30% of distal acid reflux became weakly acidic at the proximal oesophagus. In all patients, the frequency of symptomatic refluxes, both acid and weakly acidic, was significantly higher at the proximal, compared with distal oesophagus (25 +/- 8%vs 11 +/- 2% for acid reflux and 27 +/- 8%vs 8 +/- 2% for weakly acidic reflux; P < 0.05). Compared with multiple pH-metry, pH-MII shows a higher sensitivity in the detection of proximal reflux. As approximately 30% of acid reflux becomes weakly acidic along the oesophageal body, to better characterize proximal reflux, in clinical practice, combined proximal pH-impedance monitoring should be used. In NERD patients, the proximal oesophagus seems to be more sensitive to both acid and weakly acidic reflux.

Intercellular space diameters of the oesophageal epithelium in NERD patients: head to head comparison between light and electron microscopy analysis

BACKGROUND

Dilation of intercellular space diameters of oesophageal epithelium detected at transmission electron microscopy morphometry is a marker of tissue injury in non-erosive reflux disease patients. Semi-quantitative evaluation of intercellular space diameters using light microscopy seems to provide promising results.

AIM/METHODS

To comparatively evaluate intercellular space diameters in the same patients, by means of morphometry and semi-quantitative analysis, both on light microscopy and transmission electron microscopy microphotographs, biopsies were taken in 29 non-erosive reflux disease patients at distal and proximal oesophagus. Twelve asymptomatic controls underwent the same protocol.

RESULTS

Morphometric analysis on transmission electron microscopy microphotographs showed mean intercellular space diameter values of patients, at distal and proximal oesophagus, 3- and 2-fold, respectively, higher than those in controls (p<0.001). On light microscopy microphotographs, mean intercellular space diameter values of patients at distal oesophagus were higher than those in controls, an overlap between patients and controls being observed. The semi-quantitative score was positive in 79% of patients and in 25% of controls at distal esophagus.

CONCLUSIONS

Intercellular space diameter morphometric analysis at light microscopy is widely available, allows intercellular space diameter to be quantitatively measured with good sensitivity and specificity and could represent a useful tool in non-erosive reflux disease diagnosis. Despite satisfactory sensitivity, the semi-quantitative score at light microscopy is hampered by much lower specificity than transmission electron microscopy- and light microscopy-morphometry.

Heterogeneity of endoscopy negative heartburn: Epidemiology and natural history

It has now become clear that only about 40% or less of patients with heartburn and/or regurgitation have esophagitis, and that the majority of them lack visible distal esophageal mucosa breaks. These subjects are referred to as non-erosive gastroesophageal reflux disease (NERD) patients. It has been estimated that in the Western world at least one tenth of the general population has at least weekly heartburn. This proportion seems to be lower in Asia, while prevalence is rapidly increasing. Although it would be extremely useful to have prospective information regarding the fate of such patients, the natural history of NERD is largely unknown, and very few studies in the literature have addressed this issue. These studies are for the greater part old, not well conducted, and suffer from methodological drawbacks including ill-defined entry criteria. However, a review of these studies indicates that a consistent minority of NERD patients may develop erosive disease at an approximate rate of about 10% per year.

Clinical significance of minimal change lesions of the esophagus in a healthy Korean population: a nationwide multi-center prospective study

BACKGROUND AND AIM

At least half of the patients with typical reflux symptoms have non-erosive reflux disease (NERD). Minimal change lesions are commonly seen in the screening endoscopic examinations for individuals without clinically significant symptoms. We evaluated the correlation between minimal changes and symptoms in individuals visiting the hospital for routine health check-up by a nationwide survey in 2006.

METHODS

Upper gastrointestinal endoscopic examinations as a health check-up were performed for 25,536 patients. Among them, symptom questionnaires were given in 23,350 patients without mucosal break or Barrett's esophagus. Endoscopic findings of the lower esophagus were divided into normal or minimal changes. Minimal changes in the present study included white turbid discoloration and Z-line blurring.

RESULTS

Among a total of 25,536 subjects, reflux esophagitis was found in 2019 subjects (7.91%) and 3043 patients (11.9%) were classified as having minimal changes. History of gastroesophageal reflux disease (GERD) was more commonly found in individuals with minimal changes. Among the reflux-related symptoms, heartburn, acid regurgitation, globus sensation, and epigastric soreness were related to the minimal changes of the esophagus. Especially, individuals with globus sensation or epigastric soreness were more likely to have minimal changes compared to individuals without respective symptoms. Male gender, current smoker, history of H. pylori eradication, frequent stooping at work, hiatal hernia, and atrophic/metaplastic gastritis were found to be risk factors for minimal changes.

CONCLUSION

The minimal changes were closely related with upper gastrointestinal symptoms and had similar risk factors for GERD, suggesting that minimal changes could be considered as early endoscopic findings of GERD.

Correlation between oesophageal acid exposure and dyspeptic symptoms in patients with nonerosive reflux disease

BACKGROUND & AIMS

Oesophageal acidification induces dyspeptic symptoms in healthy individuals. This study aimed to evaluate the correlation between oesophageal acid exposure and dyspeptic symptoms in patients with nonerosive reflux disease.

METHODS

A total of 68 patients with dominant symptoms of heartburn, negative upper gastrointestinal endoscopy and concomitant dyspeptic symptoms participated in the study. The severity of dyspepsia and reflux-related symptoms was evaluated, and 24-h gastro-oesophageal pH-monitoring study was performed in all patients at baseline and after 4 weeks of therapy with esomeprazole 40 mg.

RESULTS

Oesophageal basal acid exposure was pathological in 43 patients and normal in 25 patients, with a similar prevalence and severity of individual dyspeptic symptoms in the two groups. A significant correlation between reflux and dyspepsia scores was observed in the subgroup of patients with normal, but not in those with abnormal pHmetry (r=0.4, P=0.04 and r=0.2 P=0.07, respectively). After esomeprazole, a reduction in severity of dyspepsia (>or=50% with respect to baseline) was observed, independent of improvement of reflux-associated symptoms. Improvement in dyspepsia was, however, similar in patients with normal and abnormal basal acid exposure (14/25 vs. 33/43, respectively, P=NS).

CONCLUSION

Dyspeptic symptoms coexist in a subset of nonerosive reflux disease patients, but prevalence and severity of the symptoms seems to be independent of oesophageal acid exposure.

Screening for esophagitis and Barrett's esophagus with wireless esophageal capsule endoscopy: a multicenter prospective trial in patients with reflux symptoms

BACKGROUND AND AIM

Esophageal capsule endoscopy (ECE) is a new technology that allows noninvasive investigation of the esophagus. Our aim was to evaluate prospectively the diagnostic yield of ECE in patients with chronic reflux symptoms.

PATIENTS AND METHODS

Eighty-nine patients (40 men, mean age 54 yr) referred to five endoscopic centers for esophagogastroduodenoscopy (EGD) were enrolled. Patients first underwent ECE, then EGD; endoscopists who performed the EGD were blind to the ECE data that were interpreted separately by two independent readers. The Los Angeles, Prague, and Montreal classification systems were used to describe endoscopic findings.

RESULTS

Seventy-seven patients completed the study. Esophagitis and endoscopically suspected esophageal metaplasia (ESEM) were present in 24 and 10 patients, respectively. Columnar lining was histologically confirmed in seven patients (3 with specialized intestinal metaplasia and 4 with gastric metaplasia). The kappa values for interobserver agreement regarding the diagnosis of esophagitis and ESEM were 0.67 (0.49-0.85) and 0.49 (0.17-0.81), respectively. The diagnostic yields of ECE to detect esophagitis and ESEM were as follows: sensitivity 79% and 60%, specificity 94% and 100%, positive predictive value (PPV) 83% and 100%, negative predictive value (NPV) 92% and 95%, respectively.

CONCLUSION

As a screening tool in patients with reflux symptoms, ECE has an excellent specificity and NPV for the diagnosis of esophagitis and ESEM. However, its sensitivity for the diagnosis of ESEM is not optimal. Further studies are necessary to improve the procedure, and to compare the cost-effectiveness of strategies using ECE or EGD.

The prevalence of and risk factors for erosive oesophagitis and non-erosive reflux disease: a nationwide multicentre prospective study in Korea

BACKGROUND

Prospective nationwide multicentre studies that have evaluated endoscopic findings and reflux symptoms using a well-designed questionnaire are very rare.

AIM

To compare the prevalence rates of and risk factors for erosive oesophagitis and non-erosive reflux disease (NERD) in the Korean population.

METHODS

A gastroscopic examination was performed on 25 536 subjects who visited 40 Healthcare Centers for a health check-up. A gastro-oesophageal reflux questionnaire and multivariate analysis were used to determine the risk factors for erosive oesophagitis and NERD.

RESULTS

2019 (8%) and 996 subjects (4%) had erosive oesophagitis and non-erosive reflux disease, respectively; only 58% of subjects with erosive oesophagitis had reflux symptoms. Multivariate analysis showed that the risk factors for erosive oesophagitis and NERD differed, i.e. those of erosive oesophagitis were male, a Helicobacter pylori eradication history, alcohol, body mass index > or =25 and hiatal hernia. In contrast, the risk factors for NERD were female, age <40 and > or =60 vs. 40-59 years, body mass index <23 and a monthly income <$1000, glucose > or =126 mg/dL, smoking, a stooping posture at work and antibiotic usage.

CONCLUSIONS

The prevalence rates of erosive oesophagitis and NERD were 8% and 4%, respectively, in Korean health check-up subjects. The risk factors for erosive oesophagitis and NERD were found to differ, which indicates that their underlying pathogeneses are distinct.

Sleep dysfunction in patients with GERD: erosive versus nonerosive reflux disease

BACKGROUND

Sleep disturbance has been observed in patients with gastroesophageal reflux disease (GERD), but very few studies have further characterized sleep quality in patients with nonerosive esophageal reflux disease (NERD). This study was undertaken to investigate whether there are differences in sleep quality among patients with erosive esophagitis, NERD, and control subjects.

METHODS

We performed symptom severity scoring and upper GI endoscopy in 20 healthy control subjects and 35 GERD patients, including 17 with NERD and 18 with erosive esophagitis. Sleep quality was measured by using Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Sleep disturbance was noted in 11 of 17 NERD patients and 12 of 18 patients with erosive esophagitis (P = NS) but none of healthy control subjects. The patient groups, erosive esophagitis and NERD, had greater PSQI scores compared with healthy control subjects (both P < 0.05). Both groups had similar median PSQI score (5.5 vs 6.0; NERD vs erosive esophagitis; P = NS). There was no significant correlation between reflux symptom severity score and PSQI score.

CONCLUSIONS

Despite no difference in sleep quality between erosive esophagitis and NERD, NERD can have a significant impact on sleep comparable to erosive esophagitis. It is suggested that NERD should be treated aggressively and at least similarly to erosive esophagitis.

Gastric motor dysfunction: is eosinophilic mural gastritis a causative factor?

Delayed gastric emptying caused either by gastric motor dysfunction or by gastroparesis is a profoundly debilitating disorder. When unresponsive to medical therapy, patients may undergo radical surgery including near-total gastro-oesophageal, with varied symptomatic improvement. We describe two patients who presented with symptoms consistent with gastro-oesophageal reflux, unresponsive to medical management. After fundoplication both developed symptoms of profound gastric motor dysfunction and subsequently proceeded to near-total gastro-oesophageal with symptomatic improvement. Histological examination of both excised gastric specimens revealed eosinophilic mural gastritis. To our knowledge, these are the first cases to demonstrate the association of mural eosinophilia and symptomatic gastric motor dysfunction. We propose that patients with gastric motor dysfunction, refractory to medical management, progress to laparoscopy and mural biopsy before gastrectomy. This would allow histological analysis of the gastric wall, and in the event of a positive finding of mural eosinophilic gastritis would allow a trial of medical therapy that could include an eosinophilic stabilizer such as the leukotriene D4 receptor antagonist montelukast or intravenous corticosteroid therapy, which may alleviate the symptoms.

Air swallowing can be responsible for non-response of heartburn to high-dose proton pump inhibitor

Intraluminal electrical impedance is a novel technique, which is able for the first time to provide a qualitative assessment of refluxed material moving from the stomach to the oesophagus. In other words, the presence of air can be differentiated from that of liquid, because the former is characterised by high and the latter by low impedance compared with baseline. Moreover, the combined measurement of electrical impedance and pH-metry permits to distinguish acid from non-acid liquid reflux. One of the most important clinical applications of this method is to assess the reasons for poor response of GORD patients to high-dose proton pump inhibitors. This case report describes the results of impedance in the evaluation of a young woman, who did not respond to twice-daily doses of rabeprazole. She continued to complain of heartburn as major symptom and impedance allowed us to clarify that it was not related to acid or non-acid reflux, but to air swallowing. Therefore, this technique identified aerophagia to be responsible for persistent heartburn despite high-dose proton pump inhibitor and prevented the adoption of more aggressive, but probably unuseful therapies, such as the surgical one.

Gastric fullness, physical activity, and proximal extent of gastroesophageal reflux

OBJECTIVES

Proximal extent of gastroesophageal reflux (PER) is relevant for symptoms in GERD patients. It has been suggested that PER is determined by the volume of the refluxate that, in turn, might depend on the degree of gastric fullness. Abdominal straining, during ambulation, increases the likelihood of gastroesophageal reflux. We assessed the influence of gastric fullness and ambulation on proximal extent of reflux.

METHODS

PER was assessed in 37 patients with GERD undergoing ambulatory pH impedance monitoring. In 14 controls and 19 GERD patients, esophageal pH impedance and gastric emptying were also studied simultaneously in stationary conditions. We compared PER during fasting, early postprandial (before half emptying), and late postprandial periods in ambulatory and stationary conditions.

RESULTS

More reflux episodes reached the proximal esophagus in the postprandial period compared to fasting (60%+/-4 vs 29%+/-3, p<0.05). In stationary conditions, early postprandial reflux reached higher proximal extent than late postprandial reflux (15+/-3% vs 8+/-4%, p<0.05). The proportion of reflux events reaching the proximal esophagus was significantly higher in ambulatory than in stationary conditions (29+/-5% vs 15+/-3%, p<0.05).

CONCLUSION

Compared to fasting, reflux episodes occurring after the meals are more likely to reach higher proximal extent, particularly so during the early postprandial period. The highest proportion of postprandial proximal reflux occurred in ambulatory condition. These findings suggest that reducing meal volumes and early postprandial physical activity might contribute to decrease proximal extent of reflux and postprandial GERD symptoms.

Dilated intercellular spaces of esophageal epithelium in nonerosive reflux disease patients with physiological esophageal acid exposure

OBJECTIVES

It has been demonstrated that dilation of intercellular spaces of esophageal epithelium is a marker of tissue injury in GERD patients with a pathological esophageal acid exposure time. To evaluate the relationship among ultrastructural changes, acid esophageal exposure, and GERD symptoms, intercellular space diameters have been assessed in nonerosive reflux disease (NERD) patients with/without abnormal acid exposure time.

METHODS

Following a pharmacological wash-out, 20 NERD patients underwent upper endoscopy, esophageal manometry, and 24-h pH monitoring. Biopsies were taken at 5 cm above the lower esophageal sphincter and intercellular space diameters were measured on transmission electron microscopy photomicrographs. Seven asymptomatic controls underwent the same protocol.

RESULTS

Acid exposure time was in the normal range in all controls and in 11 patients (NERD pH-negative); it was abnormal in 9 patients (NERD pH-positive). Mean intercellular space diameter in NERD pH-negative and in NERD pH-positive patients was three times greater than in controls (1.45 and 1.49 microm vs 0.45, p < 0.001). Mean values of maximum intercellular spaces in all NERD patients were greater, two-fold or more, than those in controls (p < 0.001). No difference in mean and maximal space diameters was observed between NERD pH-positive and pH-negative patients.

CONCLUSIONS

Dilation of intercellular spaces is a feature of NERD patients, irrespective of esophageal acid exposure, and can be considered an objective, structural marker of GERD symptoms. Impaired esophageal mucosal resistance, even to small amounts of acid refluxate, plays a key role in the pathophysiology of NERD.

Laparoscopic Nissen fundoplication in patients with nonerosive reflux disease. Long-term quality-of-life assessment and surgical outcome

BACKGROUND

It is known that laparoscopic antireflux surgery (LARS) can achieve an excellent surgical outcome including quality of life improvement in patients with erosive gastroesophageal reflux disease (GERD; EGD-positive). Less is known about the long-term surgical outcome in GERD patients who have no evidence of esophagitis (EGD-negative) before surgery. The aim of this study was to evaluate the surgical outcome in a well-selected group of EGD-negative patients compared to that of EGD-positive patients.

METHODS

From a large sample of more than 500 patients who underwent LARS, 89 EGD-negative patients (mean age, 51 +/- 6 years; 56 males) were treated surgically because of persistent reflux-related symptoms despite medical therapy. In all cases, preoperative 24-h pH monitoring showed pathological values. To perform a comparative analysis, a matched sample of EGD-positive patients (mean age, 54 +/- 10 years; 58 males) was selected from the database. Surgical outcome included for all patients objective data (e.g., manometry and pH data and endoscopy), quality of life evaluation [Gastrointestinal Quality of Life Index (GIQLI)] symptom evaluation, as well as patients' satisfaction with surgery. The data of a complete 5-year follow-up are available.

RESULTS

There were no significant differences in symptomatic improvement, percentage of persistent surgical side-effects, or objective parameters. In general, patients' satisfaction with surgery was comparable in both groups: 95% rated long-term outcome as excellent or good and would undergo surgical treatment again if necessary, respectively. Quality of life improvement was significantly better (p < 0.05) in the EGD-negative group because of the fact that GIQLI was more impaired before surgery (preoperative GIQLI, 81.7 +/- 11.6 points/EGD-negative vs 93.8 +/- 10.3 points/EGD-positive). Five years after surgery, GIQLI in both groups (121.2 +/- 8.5 for EGD-negative vs 120.9 +/- 7.3 for EGD-positive) showed comparable values to healthy controls (122.6 +/- 8.5).

CONCLUSION

We suggest that LARS is an excellent treatment option for well-selected patients with persistent GERD-related symptoms who have no endoscopic evidence of esophagitis.

Review article: gastric emptying in functional gastrointestinal disorders

Although delayed gastric emptying has been described in several functional gastrointestinal disorders, and appears to be especially common in functional dyspepsia, the relationship of this finding to symptoms and basic pathophysiology is difficult to define. The delineation of the interactions between delayed gastric emptying, on the one hand, and symptom pathogenesis, on the other, has been hampered by several factors. These include the limitations of the methodology itself, the extent of overlap between the various functional disorders and the sensitivity of gastric emptying to factors external to the stomach, be they elsewhere within the gastrointestinal tract, in the central nervous system or in the environment. In many instances, delayed gastric emptying is an epiphenomenon, reflecting the overlap between inadequately defined functional syndromes, shared pathophysiology or the activation of physiological interactions between the various organs of the gut. In others, it may imply a truly diffuse motor disorder. The disappointments attendant on attempts to alleviate symptoms through approaches designed to accelerate gastric emptying should therefore not come as a surprise. Pending the definition of the true significance of delayed gastric emptying in all functional gastrointestinal disorders, caution should be exerted in the interpretation of this finding in a patient with functional symptoms.

Treatment of gastro-oesophageal reflux disease with rabeprazole in primary and secondary care: does Helicobacter pylori infection affect proton pump inhibitor effectiveness?

BACKGROUND

The presence of the gastric pathogen, Helicobacter pylori influences acid suppression by proton pump inhibitors and treatment outcome in patients with gastro-oesophageal reflux disease.

AIM

To determine the influence of H. pylori infection on effectiveness of rabeprazole in primary and secondary care patients with gastro-oesophageal reflux disease.

METHODS

Patients from primary and secondary care centres with uninvestigated gastro-oesophageal reflux disease (based on symptoms only) and investigated gastro-oesophageal reflux disease (endoscopically confirmed oesophagitis or endoscopy-negative reflux disease) were tested for H. pylori and treated with rabeprazole 20 mg once daily for 4-8 weeks in a non-randomized, multicentre, open-label study. Primary end-point for treatment effectiveness was complete resolution of both heartburn and acid regurgitation at 4-8 weeks; secondary end-point was quality of life as registered with the Psychological General Well-being Index.

RESULTS

Data of 1787 patients could be analysed; mean duration of treatment was 36.3 days. At the evaluation visit 76.9% were heartburn-free, 77.7% regurgitation-free and 71% had complete symptom resolution. Overall Psychological General Well-being Index scores improved accordingly. Treatment was equally effective in patients with or without H. pylori infection, but more effective in patients with oesophagitis when compared with symptomatic gastro-oesophageal reflux disease.

CONCLUSIONS

The effectiveness of rabeprazole in gastro-oesophageal reflux disease is not affected by the presence of H. pylori infection.

Functional dyspepsia (FD) and non-erosive reflux disease (NERD): overlapping or discrete entities?

As the incidence of both gastric cancer and peptic ulcer disease have declined, that of gastro-oesophageal reflux disease (GORD) and non-ulcer, or functional dyspepsia (FD) have reached virtually epidemic proportions. As we come to appreciate the expression of these disorders in the community, the real spectrum of each disease has become evident. FD and non-erosive reflux disease (NERD), the most prevalent manifestation of GORD, frequently overlap. Where then does GORD end and FD begin? Is it realistic, or even clinically relevant, to attempt a clear separation between these entities? These are more than issues of mere semantics; therapeutic options may be dictated by the classification of the patient as one or the other. Recent work indicates clearly that NERD is a heterogeneous disorder incorporating some patients who may well harbour subtle manifestations of oesophagitis and others who have entirely normal 24-hour pH studies. These differences may be crucial to the concept of NERD/FD overlap. While evidence in support of this concept is far from complete, it would appear that this overlap is most relevant to those NERD patients who do not exhibit abnormal esophageal acid exposure. These patients truly belong in the spectrum of functional gastrointestinal disorders rather than in GORD; attempts to shoe-horn these individuals into the spectrum of GORD will result in therapeutic disappointment and surgical disaster.

Gastroesophageal reflux disease: a typical spectrum disease (a new conceptual framework is not needed)

Gastroesophageal reflux disease (GERD) is a common GI disorder, particularly frequent in the primary care setting, with a high direct and indirect economic burden on society. Despite the high prevalence and costs of the disease, the epidemiology and natural history of GERD have not been fully elucidated. It has recently been suggested to abandon the current model of GERD as a "spectrum" disease and to adopt a new conceptual framework, e.g., categorizing GERD into three unique groups of patients: nonerosive reflux disease, erosive esophagitis, and Barrett's esophagus. In the present review we present arguments against this proposal, and argue that the concept of a single disease, potentially progressing from mild nonerosive forms toward metaplasia and neoplasia (adenocarcinoma), still holds true and may in fact help us in planning the diagnostic and therapeutic approach as well as in allocating financial resources much better than the proposed model of a "tripartited" disease. Independently from the conceptual model adopted, however, more data on the natural history of patients with GERD are eagerly needed.

Natural history of gastro-oesophageal reflux disease without oesophagitis (NERD)--a reappraisal 10 years on

BACKGROUND AND AIM

Ten years ago we published a study describing the 6-month outcome of 33 outpatients with typical gastro-oesophageal reflux disease symptoms and pH-metry proven excess gastro-oesophageal reflux but without endoscopical evidence of oesophagitis, currently referred to as patients with gastro-oesophageal reflux disease without oesophagitis. We now present an update of that report concerning morbidity, drug consumption and quality of life of the original patients 10 years after the initial diagnosis.

METHODS

The study consisted of the retrieval and revision of all clinical and instrumental records concerning the cohort of 33 above-mentioned patients. Data are available regarding annual intervals within the first 5 years from original diagnosis and, subsequently, with a follow-up ranging from 7 to 14 years (median 10 years). The records of these 33 patients were reviewed, including the results of clinical visits at the outpatients department, of oesophagogastroduodenoscopies and pH- metries. Finally, a telephonic interview was conducted by means of a structured questionnaire, aiming at evaluating present symptoms, actual therapy if any, health-related quality of life and other information regarding any gastro-oesophageal reflux disease symptoms.

RESULTS

Of the original 33 patients, 31 are still alive and 2 were lost to follow-up. Of the 29 remaining, only 1 is definitively not complaining of any gastro-oesophageal reflux disease-related symptoms. Within 5 years of the first diagnosis, oesophagitis was found in all but one of the 18 subjects who underwent repeated endoscopy. At the latest follow-up check, after a median of 10 years, out of the 28 still complaining of gastro-oesophageal reflux disease symptoms, 21 (75%) were presently taking antisecretory drugs (proton pump inhibitors and H-2 receptor antagonists) because of gastro-oesophageal reflux disease symptoms/lesions, 12 of whom intermittently or on demand and the remaining 9 continuously. Two patients (2/28) underwent antireflux surgery, but despite this were still taking antisecretory drugs (in one case H2-RA; in the other proton pump inhibitor). The health-related quality of life, self-evaluated by the patient by means of a VAS scoring from 0 (worst possible) to 10 (best possible) increased significantly from 3.2 to 6.5 from baseline (before therapy) to present time, possibly due to the positive effect of present therapy.

CONCLUSIONS

Our study conducted on a cohort of endoscopy-negative patients with pH-metry-confirmed reflux disease has shown that after a median time of 10 years following the original diagnosis, the majority of patients have, in fact, developed reflux oesophagitis and are on prolonged antisecretory therapy because of recurrent gastro-oesophageal reflux disease symptoms/lesions. The study confirms that gastro-oesophageal reflux disease without oesophagitis, as well as gastro-oesophageal reflux disease at large, is a chronic disease characterised by increasing severity with time, which requires protracted medical therapy in a vast proportion of patients. Absence of endoscopic oesophagitis at presentation does not represent a positive prognostic factor.

Unsolved problems in the management of patients with gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease is a common problem that brings large numbers of patients to physicians every day. It lowers the quality of life of affected individuals and exposes them to potentially dangerous complications. An increasing awareness exists among patients, doctors and authorities about the relevance of this pathological condition. Despite an improved understanding of many aspects of gastro-oesophageal reflux disease, clinical management of several cases is still unsatisfactory. Atypical cases with extra-oesophageal manifestations often defy diagnosis. Even typical symptoms are often misunderstood and considered to be part of the poorly defined area of dyspepsia by both patients and doctors. As a consequence, management remains uncertain for too many cases. If correctly diagnosed, gastro-oesophageal reflux disease can be efficaciously treated with proton pump inhibitors (PPIs). Although standard doses of PPIs can heal mucosal lesions and provide symptom relief in the vast majority of oesophagitis patients, non-oesophagitis symptomatic individuals and those with extra-oesophageal manifestations may fail to respond to similar regimens. Antireflux surgery is a possible alternative to PPI therapy, but it is hampered by complications in a substantial percentage of cases and by sporadic casualties even when performed by experienced surgeons. The high prevalence of gastro-oesophageal reflux disease in the general population and the relatively high management costs should prompt any doctor to seek the best possible therapeutic approach.

Intra-oesophageal distribution and perception of acid reflux in patients with non-erosive gastro-oesophageal reflux disease

BACKGROUND

The majority of patients with gastro-oesophageal reflux disease do not present with erosive oesophagitis and make up a heterogeneous group. Patients with non-erosive gastro-oesophageal reflux disease are less responsive than patients with oesophagitis to acid-suppressive therapy.

AIM

To assess the role of acid reflux in gastro-oesophageal reflux disease symptoms.

METHODS

The spatio-temporal characteristics of reflux events were analysed and related to reflux perception in 45 patients with non-erosive gastro-oesophageal reflux disease and 20 patients with erosive oesophagitis.

RESULTS

Compared with healthy controls, all patients showed a higher intra-oesophageal proximal spread of acid, which was prominent in patients with non-erosive gastro-oesophageal reflux disease (> 50% of events lasting for 1-2 min). Irrespective of mucosal injury, the risk of reflux perception was very high when acid reached proximal sensors (odds ratio, 7.6; 95% confidence interval, 4.6-12.5), being maximal in patients with non-erosive gastro-oesophageal reflux disease with normal acid exposure time (odds ratio, 11; 95% confidence interval, 5.2-22.3).

CONCLUSIONS

Patients with non-erosive gastro-oesophageal reflux disease are characterized by a significantly higher proportion of proximal acid refluxes and a higher sensitivity to short-lasting refluxes when compared with patients with oesophagitis. The highest proximal acid exposure and highest perception occurred in patients with non-erosive gastro-oesophageal reflux disease presenting with a normal pH-metric profile. The assessment of acid distribution and its perception in the oesophageal body can better identify reflux patients who should benefit from acid-suppressive treatment.

New developments in the pathophysiology of gastro-oesophageal reflux disease (GERD): implications for patient management

The spectrum of gastro-oesophageal reflux disease (GERD) has expanded; indeed the majority of individuals with symptomatic GERD do not have erosive reflux disease (ERD); this group has been referred to as nonerosive or negative-endoscopy reflux disease (NERD). There may be important differences between NERD and ERD in terms of pathophysiology and management. Thus, NERD patients appear relatively resistant to proton pump inhibitors and may not be good surgical candidates. The clinician caring for patients with GERD must therefore be aware of the full spectrum of GERD and of the pathophysiological and therapeutic implications of NERD. Recent twin studies have revealed that genetic factors play a role in GERD and form the basis for future studies on the role of inheritance in the various manifestations of GERD. Several recent investigations have reaffirmed the primacy of acid reflux in the pathogenesis of GERD and have also provided insights into the pathophysiology of postprandial heartburn. Transient lower oesophageal sphincter relaxations and hiatal hernias have emerged as major and interacting factors in the genesis of reflux events and in the potentiation of acid exposure; the former are attracting considerable attention as a potential therapeutic target. Nocturnal acid breakthrough, which has been implicated in the failure of some patients to respond to high doses of proton pump inhibitors, appears, on further examination, to be a gastric rather than an oesophageal phenomenon, and may not be of clinical or therapeutic importance.

Factors that influence therapeutic outcomes in symptomatic gastroesophageal reflux disease

The term "symptomatic gastroesophageal reflux disease" (GERD) refers to those patients who present with the typical GERD symptoms of heartburn and regurgitation, yet do not have endoscopic evidence of esophagitis. The primary goals of managing symptomatic GERD are to control symptoms and improve quality of life. A clinical assessment of the GERD patient can identify important clinical features, such as atypical and extraesophageal symptoms for which acid-suppressive agents tend to be less effective. Performing an endoscopy can further identify the patient as having nonerosive reflux disease, erosive esophagitis, or Barrett's esophagus-diagnoses which can help determine treatment but may not prove predictive of therapeutic response. Determining acid exposure through pH testing can predict therapeutic response, with those revealing an abnormal acid exposure time being more responsive to acid-suppressive therapy. However, the performance of an endoscopy and pH testing on each patient is clearly not practical. Whereas the natural history of symptomatic GERD is still largely undefined, acid-suppressive therapy appears to be the best approach available for both the short-term and long-term management of this disease.

Circadian pattern of intragastric acidity in patients with non-erosive reflux disease (NERD)

BACKGROUND

Most patients with gastro-oesophageal reflux disease have non-erosive reflux disease. Proton pump inhibitors are less effective than expected in these patients, but no previous study has measured their 24-h gastric pH values.

AIMS

To evaluate whether there are differences in 24-h intragastric acidity between reflux patients with and without oesophagitis and controls. The influence of Helicobacter pylori on the gastric pH of reflux patients was also assessed.

METHODS

Sixty-three consecutive patients with gastro-oesophageal reflux disease symptoms who agreed to undergo endoscopy and 24-h pH-metry were recruited. Twenty-five (39%) had erosive oesophagitis and 38 (61%) did not. H. pylori was diagnosed by CLO test, histology and 13C-urea breath test. Gastric pH was also measured in 30 controls without digestive symptoms.

RESULTS

H. pylori was found in seven of the 25 (28%) patients with oesophagitis and 14 of the 38 (37%) patients with non-erosive reflux disease. Oesophageal pH-metry was abnormal in 21 of the 25 (84%) patients with oesophagitis and in 32 of the 38 (84%) patients with non-erosive reflux disease. The median gastric pH did not differ between patients with and without oesophagitis or between them and controls during the 24 h (P = 0.8) and other time intervals (P = 0.2-0.4). The gastric pH did not differ between infected and non-infected patients with oesophagitis (P = 0.2-0.4) or non-erosive reflux disease (P = 0.3-0.8).

CONCLUSIONS

The circadian pattern of intragastric acidity does not differ between patients with non-erosive reflux disease and oesophagitis. Moreover, the study confirms that H. pylori infection does not affect the gastric pH in either group of reflux patients.