Non-erosive and uncomplicated erosive reflux diseases: Difference in physiopathological and symptom pattern (original) (raw)
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Non-erosive reflux disease (NERD) - acid reflux and symptom patterns
Alimentary Pharmacology and Therapeutics, 2003
Background: Recent reports suggest that patients with non-erosive reflux disease (NERD) treated with antireflux medications show lower symptom improvement rates than patients with erosive oesophagitis treated with the same medications. Aim: To determine the acid reflux and symptom patterns of patients with NERD in comparison with those with erosive oesophagitis and Barrett's oesophagus, and to identify different NERD subgroups. Methods: One hundred and forty-nine consecutive patients seen for classic heartburn symptoms were evaluated for the study. Oesophageal mucosal injury was assessed by upper endoscopy and classified by Hetzel-Dent criteria. Patients with Hetzel-Dent grades 0-1 were considered to have NERD. The extent of oesophageal acid exposure was determined by ambulatory 24-h oesophageal pH monitoring. Results: Seventy-one patients were found to have NERD, 36 erosive oesophagitis and 42 Barrett's oesophagus. Compared with patients with erosive oesophagitis (75%) and Barrett's oesophagus (93%), those with NERD (45%) were significantly less likely to have an abnormal pH test (P ¼ 0.0001). Patients with Barrett's oesophagus had the highest mean number of acid reflux events (210 ± 17.7), compared with those with erosive oesophagitis (139.7 ± 15.2) and NERD (95.3 ± 9.4) (P ¼ 0.0001); however, the rate of perceived acid reflux events was similar and very low in all groups (NERD, 3.6%; erosive oesophagitis, 2.9%; Barrett's oesophagus, 2.17%). NERD-positive patients (abnormal pH test) had a similar extent of oesophageal acid exposure to those with erosive oesophagitis. NERD-positive patients were more likely to demonstrate a symptom index greater than 75% than NERD-negative patients (normal pH test) (61.9% vs. 10.5%; P ¼ 0.0001). In the NERD-negative group, those with a negative symptom index reported having heartburn at pH < 4 only 12.7% of the time, compared with 70.7% of the time in those with a positive symptom index, despite a similar mean number of heartburn episodes. Conclusions: Patients with NERD commonly demonstrate a negative pH test. Acid reflux characteristics and symptom patterns suggest a heterogeneous group of patients.
The American Journal of Gastroenterology, 2009
Patients with EE and NERD underwent combined impedance -pH monitoring. Normal values were defi ned on the basis of previously collected data from 48 HVs. We evaluated distal esophageal acid exposure time (AET), number and type of refl ux episodes (acid, nonacid), acid and bolus clearance times, proximal extension of refl ux episodes, and symptom association probability (SAP). RESULTS: Distal AET (percentage time, pH < 4) was higher ( P < 0.01) in 58 EE patients (median 7.4 % , 25 -75th percentile 4.2 -9.9 % ) compared with 168 NERD patients (4.2 % (1.2 -6.4 % )) and 48 HVs (0.7 % (0.2 -1.4 % )). Patients with EE and NERD had a higher ( P < 0.01) number of acid refl ux episodes compared with HVs (51 (37 -66) vs. 34 (22 -51) vs. 17 (8 -31); P < 0.05), but a similar number of nonacid refl ux episodes (22 (15 -39) vs. 23 (15 -38) vs. 18 (14 -26); P = NS). The percentage of refl ux episodes reaching the proximal esophagus was higher ( P < 0.01) in EE patients (57 % (45 -73 % )) than in NERD patients (45 % (36 -60 % )) and HVs (33 % (19 -46 % )). A positive SAP for heartburn or regurgitation was found in 161 of 168 (96 % ) NERD and 54 of 58 (93 % ) EE patients ( P = NS).
Patterns of Gastroesophageal Reflux in Health and Disease
Annals of Surgery, 1976
Twenty-four-hour pH monitoring of the distal esophagus quantitates gastroesophageal reflux in a near physiologic setting by measuring the frequency and duration of acid exposure to the esophageal mucosa. Fifteen asymptomatic volunteers were studied with 24-hour pH and esophageal manometry. The normal cardia was more competent supine than in the upright position. Physiologic reflux was unaffected by age, rarely occurred during slumber, and was the rule after alimentation. One hundred symptomatic patients with an abnormal 24-hour pH record (2 S.D. above the mean of controls) could be divided into three patterns of pathological reflux: those who refluxed only in the upright position (9), only in the supine position (37), and in both positions (54). Upright differed from supine refluxers by excessive aerophagia causing reflux episodes by repetitive belching. Compared to controls, they had excessive post-prandial reflux, lower DES pressure, and less DES exposed to the positive pressure of the abdomen. Supine differed from upright refluxers by having a higher incidence of esophagitis and an inability to clear the esophagus of acid after a supine reflux episode. Compared to controls, they had only a lower DES pressure. Combined refluxers had a higher incidence of esophagitis than supine refluxers. Stricture (15%) was seen only in this group. They were similar to supine refluxers in their inability to clear a supine reflux episode. Compared to controls, they had a lower DES pressure and less DES exposed to the positive pressure of the abdomen. Forty of the 100 patients had an antireflux procedure (4 upright, 8 supine, 28 combined). The most severe postoperative flatus and abdominal distention was seen in the upright refluxers. It is concluded that minimal reflux is physiological. Patients with pathological reflux all have lower DES pressure. Patients with upright reflux have less of their DES exposed to the positive pressure environment of the abdomen. Patients with supine reflux have an inability to clear the esophagus of reflux acid and are prone to develop esophagitis. Patients with both upright and supine reflux have the most severe disease and are at risk in developing strictures. In patients with only upright reflux, aerophagia and delayed gastric emptying may be an important etiological factor.
Gastroesophageal reflux disease: symptoms versus pH monitoring results
Otolaryngology - Head and Neck Surgery, 2003
The reason why some patients with gastroesophageal reflux disease (GERD) have symptoms of upper aerodigestive system irritation, while others mainly have gastroenterologic symptoms, is not well established. This retrospective case series study was designed to examine the existence of a correlation between symptoms and reflux characteristics, based on data obtained from esophageal pH monitoring.
The Turkish journal of gastroenterology : the official journal of Turkish Society of Gastroenterology, 2011
Non-erosive reflux disease and erosive esophagitis are the most common phenotypic presentations of gastroesophageal reflux disease. Recent reports suggest that patients with non-erosive reflux disease treated with antireflux medications show lower symptom improvement rates than patients with erosive esophagitis treated with the same medications. The aim was to assess the acid reflux and symptom patterns of patients with non-erosive reflux disease in comparison with those with erosive esophagitis and to identify different non-erosive reflux disease subgroups. One hundred and twenty consecutive patients (67 male, age: 37.6±12.9 years) seen for classic heartburn symptoms were evaluated for the study. The patients underwent upper endoscopy and 24-hour ambulatory pH monitoring. Erosive esophagitis was identified in 51 patients and nonerosive reflux disease in 69 patients. According to pH metric findings (DeMeester Score >14.72 or Fraction Time >4%), 31.9% of the non-erosive reflux ...
Diagnosis and management of non-erosive reflux disease–the Vevey NERD Consensus Group
2009
diagnosis included: responsiveness to acid suppression therapy, abnormal reflux monitoring or the identification of specific novel endoscopic and histological findings. Functional heartburn was considered a separate entity not related to acid reflux. Proton pump inhibitors are the definitive therapy for NERD, with efficacy best evaluated by validated qualityof-life instruments. Adjunctive antacids or H 2 receptor antagonists are ineffective, surgery seldom indicated. Conclusions: Little is known of the pathobiology of NERD. Further elucidation of the mechanisms of mucosal and visceral hypersensitivity is required to improve NERD management.
Clinical utility of histology in non-erosive gastro-esophageal reflux disease. *Corresponding Author
Background: in the absence of gross oesophageal erosions longterm ph monitoring is the present gold standard for diagnosing gastro-esophageal reflux disease.this method, however, is invasive, time consuming and not generally available. Aim of the study: this study was specifically designed to determine the diagnostic value of histological findings in patients with non-erosive gastro-esophageal reflux disease. Study design: an observational, cross-sectional study. Patients and methods:68 patients (36 males & 32 females) complaining of typical gerd symptoms for at least 12 weeks, not necessarily consecutive, during the previous 12 months were enrolled in this study. They underwent upper gi endoscopy and los angeles classification was used for grading cases with mucosal breaks and biopsies were taken from esophago-gastric junction. 24 hour ph monitoring and esophageal manometry were also performed for each patient.correlation/regression analysis was done on clinical, endoscopic and histological findings. Fifteen apparently healthy subjects (9 males and 6 females) not complaining of any gerd symptoms were recruited as controls. Results:four groups were identified on the basis of symptoms, endoscopy, and ph monitoring: (1) erosive esophagitis (n=24), (2) non-erosive esophagitis with abnormal ph (n=33), (3) non-erosive esophagitis with normal ph (n=11), and (4) controls (n=15).the presence of erosive esophagitis was directly correlated to male gender (p=0.0225) , current smoking (p= 0.0227) and hiatus hernia (p=0.0086).biopsies were assessed for basal cell hyperplasia, papillae elongation, intercellular space dilatation, intraepithelial eosinophils infiltration, intraepithelial neutrophil infiltration and erosions. A global severity score was calculated on the basis of the above parameters and allowed the distinction of patients from controls with 82.4% sensitivity and 86.7% specificity.there global severity score was directly correlated to the frequency of reflux episodes. It was also directly related to the time elapsed below ph 4.0 and the composite ph score. Conclusions:in contrast with previous reports on the marginal role of histology in patients with gerd, our study shows that this technique can be a useful diagnostic tool, particularly in patients With nerd where it may contribute to diagnosis and play a role in the comparative evaluation of different therapies.
Typical GERD Symptoms and Esophageal pH Monitoring Are Not Enough to Diagnose Pharyngeal Reflux
Journal of Surgical Research, 2005
Background. Abnormal pharyngeal reflux of acid (PR) (as measured by pH monitoring) is associated with microaspiration, and is a good predictor of airway symptom response to medical and surgical antireflux therapy. However, in clinical practice the link between airway disease and Gastroesophageal reflux disease (GERD) is still based on the presence of typical symptoms (e.g., heartburn) and/or standard esophageal function testing (manometry and 24-pH monitoring). PR is rarely measured directly. We undertook this study to determine if typical symptoms and standard testing could reliably predict the presence of PR. Methods. The study group consisted of 518 patients with suspected reflux induced airway disease evaluated from December 1998 through January 2002. Each patient completed a standardized symptom questionnaire, underwent esophageal manometry, and 24-h esophageal and pharyngeal pH monitoring. Patients were classified having abnormal pharyngeal reflux (PR؉) if they had >1 episode of PR detected during pH monitoring. Results. One hundred eighty-one patients were PR؉ and 337 were PR؊. The most common symptoms, namely cough (PR ؉73%, PR؊ 68%), hoarseness (PR ؉64%, PR؊ 66%), and dyspnea (PR ؉59%, PR؊ 59%) were present with similar incidence in PR؉ and PR؊ patients. The incidence of heartburn was 54% in the PR؉ and 52% in the PR؊ patients. Logistic regression analysis revealed that abnormal esophageal acid exposure was a predictor of PR؉ (P < 0.001). Neither the presence of heartburn or specific respiratory symptoms, the pressure of the lower esophageal sphincter (LES) or upper esophageal sphincter (UES), or amplitude of esophageal contractions predicted PR؉. There was substantial variability in esophageal length (UES to LES), thus the placement of the distal pH probe from the LES varied considerably (median ؍ 13 cm, 2-20 cm). Using established normal values of acid exposure at multiple levels of the esophagus, 24% of PR؉ patients had normal amounts of esophageal acid exposure. Conclusions. Typical GERD symptoms, such as heartburn, and typical symptoms of aspiration such as hoarseness, cough, or dyspnea are not enough to positively identify PR. While patients with abnormal esophageal acid exposure are three times more likely than those with normal values to have PR, abnormal esophageal acid exposure alone does not identify all patients with PR. Therefore, relying on symptoms and standard diagnostic testing may fail to identify patients with extraesophageal reflux. Pharyngeal pH monitoring should be considered for patients with suspected reflux-induced airway disease.
Neurogastroenterology & Motility, 2011
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.