Patterns of reflux in gastroesophageal reflux disease: are they of clinical use?

Abstract

See article on page 1184 The development of intraesophageal pH testing, first stationary and then ambulatory testing led to the suggestion that the acid exposure underlying gastroesophageal reflux disease (GERD) could be divided into two patterns; postprandial upright reflux and nocturnal supine reflux.1 Later, two mechanisms for reflux were proposed; hypotensive basal lower esophageal sphincter (LES) pressure, and the more common transient lower esophageal sphincter relaxation.2 It is possible that postprandial reflux is more commonly related to transient LES relaxations while nocturnal reflux is related to basal LES hypotension. It has also been suggested that supine reflux is more damaging.3 In this issue of the Journal, a presented paper re-evaluates the association between endoscopic esophagitis, esophageal motility and reflux pattern.4 The patients were divided into those with symptoms and a normal endoscopy and pH test, those with a normal endoscopy, but abnormal esophageal acid exposure, and those with erosive esophagitis. There were more hiatal hernias and more symptoms of heartburn, dysphagia and regurgitation in patients with pathological amounts of reflux and in those with erosive esophagitis. Low LES pressure and supine reflux were more common in patients with esophagitis, but not more common in the pathological reflux without esophagitis group. Postural therapy (elevation of the head of the bed and remaining upright after meals) has been advocated as an important adjuvant in the treatment of GERD.5 These recommendations are based on physiological studies that have suggested a decrease in reflux episodes and an improved esophageal acid clearance with the head of the bed elevated by 6–10 inches.6,7 Documentation of a benefit for these maneuvers has been difficult. In a study of 71 patients, raising the head of the bed provided some symptomatic benefit that was additive when combined with ranitidine treatment.8 Another study randomized 284 patients to conservative therapy with the elevated bed head either with placebo or with ranitidine. The ranitidine group did statistically better than placebo, but esophagitis healed in 41% of patients randomized to placebo and conservative therapy.9 There has not been a properly designed and powered trial looking at the head of the bed elevation versus a flat bed in GERD patients. The authors of the study in this issue of the Journal suggest that because only patients with esophagitis have significant supine reflux and low basal LES pressure, postural changes may not be of benefit outside of this group. This is important because the majority of patients with GERD do not appear to have erosive esophagitis. As postural therapy relies on gravity to keep both acid within the stomach and improve esophageal drainage, it is reasonable to assume that patients with a weak LES would benefit most from these interventions. The data from this study support this claim, but a prospective study will be needed to fully answer that question. For example, there are no data that prove that patients with transient LES relaxations do not benefit from postural changes regardless of their basal LES pressure. In addition, peristaltic dysfunction was more common in both the esophagitis (52%) and pathological reflux (44%) groups when compared with the symptomatic-only group (28%). Perhaps postural changes will help control symptoms in patients with peristaltic dysfunction. Where does this leave us in regards to the recommendation of postural therapy for GERD? While I agree with the authors that these maneuvers may actually impair the quality of life in some patients, there are many patients who are quite comfortable and happy with the head of their bed elevated. I would still advocate postural therapy as an adjuvant to medical therapy of reflux, and discuss the possible benefit with most patients. The use of this treatment should be discontinued if it adversely affects the quality of life in an individual patient, and certainly should be reconsidered if it does not seem to be improving symptoms. It is also clear that few patients will have their symptoms and mucosal disease cured with postural therapy alone. Therefore, initial pharmacological management is appropriate in most patients presenting with symptoms of reflux, regardless of the pattern of their reflux.