The tapestry of reflux syndromes: translating new insight into clinical practice.

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For decades the rationale for treatment of gastro-oesophageal reflux disease (GORD) with acid suppressors, such as proton pump inhibitors (PPIs), was that symptoms were attributable to reflux of acidic stomach contents into the oesophagus. However, recent advances in the understanding of how brain–gut interactions can modulate the perception of visceral stimuli have complicated the concept of GORD.1 It is increasingly evident that altered perception of reflux is an important underlying cause of symptoms.2 A number of syndromes related to visceral hypersensitivity and central nervous system dysregulation are now recognised as ‘functional’ gastrointestinal (GI) disorders, potentially localised to the oesophagus,3 bowel, stomach, duodenum, anorectum, gallbladder, or multiple GI sites in the same patient. These functional syndromes are common; an internet-based health survey of almost 6000 adults in the US, Canada, and the UK found that 35% had symptoms compatible with some functional GI disorder and 7% met diagnostic criteria for a functional oesophageal disorder.4 This could potentially account for a large fraction of the adults with weekly reflux symptoms in population-based assessments (global prevalence ∼13%).5 However, it being impractical to investigate all of these patients, the recognition of altered perception as a major determinant of reflux symptoms has had little impact on management in general practice. To provide guidance for the management of uninvestigated reflux symptoms in primary care, a series of sponsored (Reckitt Benckiser Healthcare Ltd, UK) workshops were held among gastroenterologists, GI surgeons, and GPs. The objective was to translate recent research findings into clinical practice strategies. Epidemiological data suggest that the prevalence of GORD has increased considerably since the mid-1990s. However, wider public awareness of the link between reflux symptoms and oesophageal cancer6 has likely contributed to the increased presentation of symptomatic patients in primary care. Additionally, the more we understand the …