Classic Gastroesophageal Reflux Disease Symptoms Research Articles

Extra-Esophageal Presentation of Gastroesophageal Reflux Disease: 2020 Update.

Gastroesophageal reflux disease (GERD) is defined by the presence of symptoms induced by the reflux of the stomach contents into the esophagus. Although clinical manifestations of GERD typically involve the esophagus, extra-esophageal manifestations are widespread and less known. In this review, we discuss extra-esophageal manifestations of GERD, focusing on clinical presentations, diagnosis, and treatment. Common extra-esophageal manifestations of GERD include chronic cough, asthma, laryngitis, dental erosions, and gingivitis. Extra-esophageal involvement can be present also when classic GERD symptoms are absent, making the diagnosis more challenging. Although available clinical studies are heterogeneous and frequently of low quality, a trial with proton pump inhibitors can be suggested as a first-line diagnostic strategy in case of suspected extra-esophageal manifestations of GERD.

Barrett’s Esofagus

Gastroesophageal reflux disease (GERD) is a condition commonly managed in the primary care setting. Patients with GERD may develop reflux esophagitis as the esophagus repeatedly is exposed to acidic gastric contents. Over time, untreated reflux esophagitis may lead to chronic complications such as esophageal stricture or the development of Barrett’s esophagus (BE). BE may progress to oesophageal adenocarcinoma. There is currently a rising incidence of BE. The pathogenesis of BE is not well-understood although genetic and environmental factors play significant roles. BE is characterized by the replacement of distal esophageal stratified squamous epithelium by columnar epithelium. It is rare in children and the risk factors may include mental retardation, cerebral palsy, esophageal atresia, etc. As patients with BE can be entirely asymptomatic, it is difficult to screen this population group. BE is present in 10%–20% of patients with GERD and has also been detected in patients who deny classic GERD symptoms and are undergoing endoscopy for other indications.

Can the Reflux Finding Score and Reflux Symptom Index Be Used to Evaluate the Severity of Esophagitis in Children?

Laryngopharyngeal reflux (LPR), a growing issue in ear, nose, and throat (ENT) and pediatric medicine, is the backflow of stomach contents into the laryngopharynx. Patients present with frequent upper and/or lower respiratory tract infections and coughs, associated with acid- and pepsin-mediated injury to the mucosae of the larynx and pharynx. LPR is associated with rhinosinusitis, laryngitis, pneumonia, and asthma. Children with LPR often fail to exhibit classic gastroesophageal reflux disease symptoms, or such symptoms may be intermittent. Only a few studies have sought correlations among symptoms, endoscopic findings, and the results of frequently used diagnostic tests. We sought associations among the Reflux Finding Score (RFS), Reflux Symptom Index (RSI), and the pathological extent of esophagitis. We reviewed data on children who underwent upper gastrointestinal tract endoscopy and showed LPR symptoms, as reported by the ENT department. The RSI was scored by pediatric gastroenterologists and the RFS by ENT doctors, via laryngoscopic examination. The pathological esophageal data were evaluated retrospectively. We treated 52 patients (29 boys) with a mean age of 11.4 ± 4.5 years. On pathological evaluation, one patient exhibited normal esophageal findings, while 28 showed mild esophagitis, 16 esophagitis, and 8 severe esophagitis. Thirteen patients showed esophageal pseudopolypoid lesions secondary to gastroesophageal reflux disease on endoscopic examination, but were human papilloma virus-negative. There was no correlation among the RFS, RSI score, and age, but there was a significant correlation between the pathological data and the RFS (P = 0.010; r = 0.461). The incidence of LPR/esophagitis in children may differ from that in adults. Therefore, ENT specialists should determine esophagitis status in children and, if necessary, consult pediatric gastroenterologists.

GASTROESOPHAGEAL REFLUX DISEASE IN PATIENTS WITH FUNCTIONAL DYSPEPSIA AND CONSTIPATION PREDOMINANT IRRITABLE BOWEL SYNDROME: CLINICAL FEATURES AND EFFICACY OF LACTULOSE AND ITOPRIDE HYDROCHLORIDE

Актуальность. В ряде исследований описано частое сочетание гастроэзофагеальной рефлюксной болезни (ГЭРБ), функциональной диспепсии (ФД) и синдрома раздраженного кишечника (СРК). Цель – изучить особенности клинического течения и диагностики ГЭРБ в сочетании с ФД и СРК с запором (СРК-З) по сравнению с изолированным течением ГЭРБ, а также оценить эффективность терапии лактулозой и итоприда гидрохлоридом. Материал и методы. Обследовано 60 пациентов, страдающих ГЭРБ в сочетании с ФД (Римские критерии III) и СРК-З (Римские критерии III) и 29 больных только с ГЭРБ. Диагноз ГЭРБ устанавливали на основании клинических, эндоскопических и рН-метрических критериев. На протяжении 4 недель 10 больных с сочетанием неэрозивной рефлюксной болезни (НЭРБ), ФД и СРК-З принимали лактулозу, 10 больных – комбинацию лактулозы с итоприда гидрохлоридом. Клиническую симптоматику и показатели рН-метрии оценивали до и через 4 недели после терапии.Результаты. Сочетание ГЭРБ, ФД и СРК-З чаще встречалось у женщин моложе 40 лет с нормальным индексом массы тела (р<0,05). Классических симптомов ГЭРБ не отмечалось у 43,4% больных с коморбидной патологией желудочно-кишечного тракта и у 10,3% – с изолированным течением ГЭРБ (р=0,004). Распространенность жалоб на отрыжку воздухом и тошноту была выше среди пациентов с сочетанием ГЭРБ, ФД и СРК-З, чем среди больных с изолированным течением ГЭРБ (р<0,05). Через 4 недели лечения у пациентов с сочетанием НЭРБ, ФД и СРК-З, получавших лактулозу в комбинации с итоприда гидрохлоридом, наблюдались уменьшение выраженности клинической симптоматики (p<0,05) и нормализация рН-метрических показателей (р<0,001). Заключение. Течение ГЭРБ у больных с ФД и СРК-З сопряжено со следующими особенностями: преобладанием лиц женского пола, отсутствием классических симптомов ГЭРБ почти у половины больных, частым присоединением других функциональных симптомов. Применение комбинации лактулозы и итоприда гидрохлорида позволяет успешно контролировать клинические симптомы ГЭРБ и ФД, а также уровень рН в пищеводе.

Prevalence of Gastroesophageal Reflux Disease (GERD) Symptoms and Proton Pump Inhibitor (PPI) Use in Patients With Crohn Disease (CD) Treated at a Tertiary Care Inflammatory Bowel Disease Center

Introduction: GERD is commonly diagnosed by improvement of upper gastrointestinal (UGI) symptoms on PPI therapy. Similar symptoms are reported in patients with CD and whether this is a manifestation of UGI CD or GERD is unclear. Data on the prevalence of GERD in CD do not exist. A preliminary study of patients with CD has shown gastroduodenal histologic findings of granulomas and focally enhanced gastritis, which are more specific to UGI CD, in 12% of patients with upper endoscopy (Diaz et al, 2015). Given the potential long-term side effects of PPIs, our aim was to evaluate the prevalence of PPI use and reported GERD symptoms in patients with CD. Methods: We performed a retrospective chart review of 499 patients with CD seen between September 2009 to May 2015 and grouped them using the Montreal Classification (MC). Each encounter was evaluated for pyrosis, regurgitation, globus, dysphagia, odynophagia, chest pain, postprandial abdominal pain, early satiety, bloating, and nausea. Use of acid suppressive therapy prior to the first visit and current use were also recorded, as were gastric emptying and pH studies if available. Results: The mean age of our 499 patient cohort was 39 years (range: 17-80), 49% males, mean BMI= 24.7 (range: 13-52). By MC criteria, 186 (37%) were L1, 80 (16%) were L2, 218 (44%) were L3, and 15 (3%) had upper and lower GI CD. Less than 5% of patients had gastric emptying or pH studies. 108 (21.6%) patients were on medications prior to their first visit with indications unknown and 111 (22.2%) patients were on acid suppressive therapy. Of the patients on acid suppressive therapy, 61% were not assessed for pyrosis, 88% were not assessed for regurgitation, and 82% were not assessed for postprandial abdominal pain. Other classic GERD symptoms were not assessed at higher rates (Table 2). Bloating and nausea were reported in 43 and 45% of patients on acid suppressive therapy, respectively.Table 2: Upper GI Symptoms Assessed While on Acid Suppressive TherapyConclusion: Many patients with CD are on PPI therapy without proper symptom screening or existing indications. Nausea and bloating are commonly reported in these patients and whether that is related to UGI CD, dyspepsia, or true GERD is unknown. Given the potential side effects of PPIs and the complications of CD, appropriate screening should be done to minimize PPI use. Further studies should prospectively evaluate CD patients through validated GERD questionnaires and endoscopic biopsies to better analyze which CD patients would benefit from PPI use.Table 1: Baseline Characteristics

Tu1772 Comparison of Proximal and Distal Impedance Episodes in Patients With Classic Versus Extra-Esophageal Symptoms of GERD

Background: Patients are frequently referred for evaluation of extraesophageal (EXT) symptoms (cough, hoarseness, globus sensation) presumably related to gastroesophageal reflux disease (GERD). 24 hour pH/impedance is the most sensitive test for the diagnosis of GERD, however limited data exist in examining the relationship between distal and proximal impedance episodes in patients with EXT symptoms versus classic reflux symptoms. Aim: To compare the number and percentage of proximal impedance episodes in patients with EXT symptoms to those with classic GERD symptoms undergoing 24 hour pH/impedance testing. Patients & Methods: A retrospective review of adult patients undergoing esophageal manometry and 24 hour pH/impedance studies off acid suppressing therapy between 20062011 was performed. Indications for these studies included typical GERD symptoms (heartburn and regurgitation) or atypical symptoms (cough, asthma, hoarseness or globus sensation). GERD was defined using the validated Johnson-DeMeester (JD) score. The results of the esophageal manometry and 24 hour pH/impedance studies between the classic GERD and EXT groups were compared using Chi squared test and students independent t-test. Continuous data is expressed as means (sd). Results: A total of 220 patients were included in the analysis [172 GERD vs. 48 EXT]. GERD and EXT groups were similar in race and gender, however GERD patients were younger than EXT patients [46 (13) years vs. 50 (8) years, p = 0.048]. There was no significant difference between GERD and EXT in the mean number of proximal impedance episodes [33 (22) vs. 28 (22), p = 0.188], the percentage of proximal impedance episodes migrating from the distal esophagus [55 (20) % vs. 50 (17) %, p=0.178), or the mean number of distal impedance episodes [57 (33) vs. 49 (34), p = 0.157]. There was no significant difference between GERD and EXT with regards to mean lower esophageal sphincter pressures [13.3 (11) mmHg vs. 15.3 (7.8) mmHg, p = 0.251] or mean esophageal amplitude [95.4 (44.6) mmHg vs. 84.9 (41.0) mmHg, p=0.146]. Based on 24 hour pH monitoring there was no significant difference between the classic GERD and EXT groups in the JD scores [22.6 (33) vs 17.8 (22), p = 0.358] or percent total time pH ,4 [4.6 (5.3) vs. 4.2 (5.3), p = 0.642]. There was a significant correlation between the number of proximal and distal episodes between the two groups (R = 0.724, p , 0.001). Conclusion: Patients with EXT symptoms are similar to classic GERD patients in the number proximal impedance reflux episodes and percentage of distal episodes migrating to the proximal esophagus. Furthermore, both groups have a similar degree of acid reflux.

White-line: A new finding in laryngopharyngeal reflux objective evaluation

Laryngopharyngeal reflux (LPR) indicates the reflux-induced extra-esophageal disorders. LPR and gastroesophageal reflux disease (GERD) occur by the same mechanism: the escape of gastric contents into the esophagus and beyond. However, the classic GERD symptoms are not typical in LPR disease, which can cause a lot of symptoms none of which is specific, making the diagnosis often elusive. The protective mechanisms present in the esophagus are entirely lacking in the larynx, and more generally in upper aerodigestive tract, making them particularly vulnerable to injury from acidic gastric contents. Since gastric acid backflow can affect supraesophageal structures, even in the absence of heartburn or regurgitation symptoms, an early diagnosis is important to prevent the onset of histological modifications in the supraesophageal mucosa.For this scope clinicians need to use different methods to get a diagnosis. We adopted two validated scoring systems: the reflux symptom index (RSI) for symptom assessing and the reflux finding score (RFS) for sign evaluation. In our experience we detect a new objective endoscopic rhinopharyngeal marker, called “white-line” characterized by mucosal metaplasia, that in a significant proportion of patients lines up to these validated indexes as a further element in the LPR diagnosis.

Gastroesophageal Reflux

Gastroesophageal Reflux

Su1054 Perception About Gastroesophageal Reflux Disease (GERD) and Its Impact on Daily Life in the General Population: Results From a Large Population Based AGA Survey

Dental erosions are increasingly recognized as a possible complication of GERD often not accompanied by classic GERD symptoms. The clinical course of silent or asymptomatic GERD in these patients, as well as the best treatment options, are unknown. Methods: Patients presenting to the Bern University Dental Clinic with advanced dental erosions (Lussi erosion index >1) without symptoms of reflux (less than once per week) and without treatment for GERD were referred for upper GI-endoscopy and 24-hour esophageal impedance pH-metry after exclusion of extrinsic and non-reflux causes of dental erosions. For analysis a pH-threshold of 4 was applied. All patients with abnormal reflux were treated with esomeprazole 40mg daily (20mg bid). Follow-up impedance pH-metry was performed annually 2 weeks after discontinuation of esomeprazole. Results: 231 successive patients (146 males, mean age and range: 34 (9-67yr) were studied. 214 patients (138 males) had increased reflux (pH 4% of the 24h measurement), with a mean time with pH<4 (95% CI) of 14% (10-18). 54 patients (25%) had esophagitis and 52 (24%) had a hiatal hernia. Follow-up pH-monitoring was possible in 88 patients for up to a mean of 3±1.8 years. The % time with pH<4 during the last 24h pH-monitoring period was 11% (8-14). Reflux had returned to normal levels in 29 patients (33%). During esomeprazole treatment further visual progression of dental erosions only occurred in 12 patients (14%). Summary and Conclusions: In patients presenting to a dental clinic with advanced dental erosions significant, silent GERD is common after exclusion of other possible causes. In most patients treated with esomeprazole 40mg daily there is no further progression of dental erosions. A spontaneous regression of reflux to normal values only occurs in a minority of patients after a mean of 3 years, necessitating long-term preventive treatment.

Persistent Reflux Symptoms in the Proton Pump Inhibitor Era: The Changing Face of Gastroesophageal Reflux Disease

Given the widespread use of potent acid suppressive therapies and primary caregivers’ increasing comfort with prescribing these medications at high doses, the patient population presenting to gastroenterologists for symptoms of gastroesophageal reflux disease (GERD) has changed. Whereas previous consultation often revolved around the control of erosive disease and other mucosal manifestations of GERD, and terminated with the prescription of proton pump inhibitor (PPI) therapy, gastroenterologists often now only enter the scene after failure of PPI therapy, for symptoms either resistant or only partially responsive to these medications. Because of the high proportion of subjects with esophagitis who are healed with PPI, 1,2 upper endoscopy of such individuals is low yield, 3 with only a small minority demonstrating erosive disease. The care of such patients is challenging. High-quality evidence supporting useful diagnostic testing or alternative effective therapies is largely lacking. However, the number of subjects with GERD symptoms incompletely or nonresponsive to PPI therapies is high, and their utilization of healthcare resources is substantial. The purpose of this mini-review is to examine the definition and epidemiology of esophageal GERD symptoms incompletely responsive to PPI therapy, the potential pathophysiologic mechanisms behind these symptoms, the differential diagnosis and evaluation of such patients, and current and developing therapeutic options.

Differences in Clinical Characteristics between Patients with Non-Erosive Reflux Disease and Erosive Esophagitis in Korea

Gastroesophageal reflux disease (GERD) is caused by abnormal reflux of gastric contents into the esophagus. GERD can be divided into two groups, erosive esophagitis and non-erosive reflux disease (NERD). The aim of this study was to compare the clinical characteristics of patients with erosive esophagitis to those with NERD. All participating patients underwent an upper endoscopy during a voluntary health check-up. The NERD group consisted of 500 subjects with classic GERD symptoms in the absence of esophageal mucosal injury during upper endoscopy. The erosive esophagitis group consisted of 292 subjects with superficial esophageal erosions with or without typical symptoms of GERD. Among GERD patients, male gender, high body mass index, high obesity degree, high waist-to-hip ratio, high triglycerides, alcohol intake, smoking and the presence of a hiatal hernia were positively related to the development of erosive esophagitis compared to NERD. In multivariated analysis, male gender, waist-to-hip ratio and the presence of a hiatal hernia were the significant risk factors of erosive esophagitis. We suggest that erosive esophagitis was more closely related to abdominal obesity.

Gastroesophageal reflux disease and asthma

Asthma and gastroesophageal reflux disease (GERD) are both common diseases, and hence they often coexist. However, the coexistence of asthma and GERD is far more frequent than chance association. There remains debate regarding the mechanism of this relationship and whether treatment of GERD improves asthma outcomes. Recent data have confirmed the high prevalence of GERD among patients with asthma. Many asthmatic patients with GERD documented by pH probe do not have classic symptoms of GERD and are considered to have 'silent GERD'. On the basis of smaller trials with somewhat conflicting results regarding improved asthma control with treatment of GERD, consensus guidelines recommend a trial of GERD treatment for symptomatic asthmatic patients even without symptoms of GERD. Recently, a large multicenter trial demonstrated that the treatment of asymptomatic GERD with proton pump inhibitors did not improve asthma control in terms of pulmonary function, rate of asthma exacerbations, asthma-related quality of life, or asthma symptom frequency. Asthmatic patients have more GERD than the general population. There is not a clear understanding of why this is true. Current guidelines recommend that physicians consider treating patients who have poorly controlled asthma for GERD, even without GERD symptoms. Recent data suggest that this is not a useful practice for mild-to-moderate asthmatic patients.

Symptom Check: Is It GERD?

Despite the vast number of individuals living with gastroesophageal reflux disease (GERD), establishing a diagnosis can be difficult. Detailed patient history and symptom review are critical. Nurses can play an integral role in gathering information that may lead to a definitive diagnosis. In addition to the classic symptoms of GERD-acid reflux and heartburn-several atypical conditions may also be present. Understanding the diverse and subtle nature of presenting symptoms can assist in establishing a GERD diagnosis. This column examines the atypical presentations of GERD, including laryngopharyngeal symptoms, chronic cough, asthma, and dental erosions.

Effect of Heartburn on Life Expectancy

Effect of Heartburn on Life Expectancy

Laryngopharyngeal Reflux: Beauty is in The Eye of The Beholder

Laryngopharyngeal Reflux: Beauty is in The Eye of The Beholder

Endoluminal gastroplication for treatment of patients with classic gastroesophageal reflux symptoms and borderline 24‐h pH studies

Background: Patients with classic gastroesophageal reflux disease (GERD) symptoms and borderline 24‐h pH studies are not considered to be good candidates for surgical fundoplication. Endoluminal gastroplication (ELGP) is a new endoscopic treatment for patients with GERD. The aim of this study was to evaluate the efficacy of ELGP in these patients. Methods: Patients with heartburn, regurgitation symptoms and a DeMeester score of less than 30 were studied. ELGP involved placement of two or three plications within 2 cm of the gastroesophageal junction. Clinical outcomes measured were heartburn symptom score (HSS), regurgitation frequency score (RFS) and medication use. Results: Twenty‐five patients (11 M, 14 F, mean age of 51 years) had a medication use of 11.5 doses of proton‐pump inhibitors per week prior to ELGP. Average lower esophageal sphincter pressure measured 15 ± 8 mmHg, and average DeMeester score was 18 ± 8. Nine patients had hiatal hernias and 11 had esophagitis. Twenty‐four patients were available for a mean follow‐up of 12 months. HSS significantly decreased from 48 to 17 (P < 0.01) and RFS was reduced from 1.8 to 0.7 (P < 0.01). Proton‐pump inhibitor use was 5.3 doses per week (P < 0.01) post‐ELGP; 12 patients (50%) were off medications, 3 (13%) had a 50% reduction in medication use, and in 9 (37%) there was no change. Complications were bleeding in one patient and aspiration pneumonia in another patient. Conclusions: Endoluminal gastroplication provides symptomatic relief for patients with classic GERD symptoms despite medical therapy and borderline 24‐h pH studies.

Outcomes of Endoluminal Gastric Plication for the Treatment of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is very common in the USA. Although proton-pump inhibitors are effective in alleviating GERD symptoms, many patients do not find relief with medication alone or become dependent on these medications for life. The lifelong cost of such medications can be burdensome. For these reasons, many patients with GERD have undergone invasive procedures including Nissen fundoplication and more recent endoscopic techniques to alter their anatomy enough to prevent the reflux of acid into the esophagus. Newer procedures including endoluminal gastric plication (ELGP) look promising, but long-term follow-up is needed to more thoroughly assess outcomes. We have studied the outcomes of 43 patients who underwent ELGP and analyzed the efficacy of this particular technique in alleviating symptoms and eliminating the need for proton-pump inhibitors. METHODS Patients The study examined patients who underwent ELGP between October 2000 and April 2001. Some who underwent the procedure were referred by their physicians, and others self-referred after hearing about the procedure through the media. To be a candidate for the procedure, the patient had to have reflux symptoms that were relieved or partially relieved by H2 blockers or proton-pump inhibitors. Classic symptoms of GERD were defined as regurgitation of sour material in the mouth or heartburn. The patients also underwent initial diagnostic tests including manometry, 24-hour pH testing, and endoscopy. Patients with Barrett’s esophagus, motility disorders, or large hiatal hernias, as determined by endoscopy, were excluded as candidates. Patients who had documented reflux by pH probe testing with no contra indications to the procedure were candidates. During this time period, 43 patients met the criteria and underwent ELGP. Procedure After consents were obtained, patients were placed in the left lateral decubitus position, and a trained anesthesiologist administered general anesthesia or deep conscious sedation using propofol. An overtube was placed in the patient’s esophagus. The endoscope was then passed through the overtube to the level of the squamocolumnar junction. The suturing device located at the tip of the endoscope was then placed in apposition to the luminal wall, and suction was applied to draw and hold tissue in the suture chamber. Once an adequate amount of tissue was in the chamber, a suture was placed. A second suture was then placed adjacent to the first, and the 2 were tied together to create a plication. This technique was repeated, and all patients received 1 to 3 plications depending on their anatomy and the endoscopic appearance after placement of each suture. Endpoints The goal of this study was to determine the long-term effectiveness of ELGP for the treatment of GERD. To achieve this with a retrospective review of medical records alone, we confined our endpoints to 1 objective outcome: whether patients were taking proton-pump inhibitors or H2 blockers 1 year after the procedure. Follow-up The patients in the study were monitored up to 2 years after their procedure. Initially, each patient had a 3-day and a 3-month follow-up visit with a trained gastroenterologist. The physician’s office also contacted patients by telephone 1 year after the pro cedure. At that time, the patients were asked 2 questions to determine the effectiveness of the procedure. The first question was whether they were on or off their medicines for the treatment of reflux symptoms. If they were still taking medicines, they were asked if the amount of medicine was the same as before the procedure or less. Their answers were recorded, and the information in the charts was reviewed retrospectively. RESULTS All 43 patients were successfully contacted by telephone, and the results were recorded in the charts. When the patients were asked if they were still on medicines, 19 patients (44%) responded yes. Of these patients, 11 responded that they were on less medicine, and 8 replied that they were on the same doses. Twenty-four patients (56%) reported no reflux and no medicines for GERD 1 year after ELGP. There were no major complications in any of the procedures. Minor complications included sore throat and chest pain immediately after the procedure. These symptoms generally resolved within 72 hours.

Radiofrequency energy delivery to the gastroesophageal junction for the treatment of GERD

Background: In this multi-center study, the feasibility, safety, and efficacy of radiofrequency (RF) energy delivery to the gastroesophageal junction (GEJ) for the treatment of gastroesophageal reflux disease (GERD) were investigated. Methods: Forty-seven patients with classic symptoms of GERD (heartburn and/or regurgitation), a daily anti-secretory medication requirement, and at least partial symptom response to drugs were enrolled. All patients had pathologic esophageal acid exposure by 24-hour pH study, a 2 cm or smaller hiatal hernia, grade 2 or less esophagitis, and no significant dysmotility or dysphagia. RF energy was delivered with a catheter and thermocouple-controlled generator to create submucosal thermal lesions in the muscle of the GEJ. GERD symptoms and quality of life were assessed at 0, 1, 4, and 6 months with the short-form health survey (SF-36). Anti-secretory medications were withdrawn 7 days before each assessment of symptoms and pH/motility study. Medication use, endoscopic findings, esophageal acid exposure, and motility were assessed at 0 and 6 months. Results: Thirty-two men and 15 women underwent treatment. At 6 months there were improvements in the median heartburn score (4 to 1, p ≤ 0.0001), GERD score (26 to 7, p ≤ 0.0001), satisfaction (1 to 4, p ≤ 0.0001), mental SF-36 (46.2 to 55.5, p = 0.01), physical SF-36 (41.1 to 51.9, p ≤ 0.0001), and esophageal acid exposure (11.7% to 4.8%, p ≤ 0.0001). Esophagitis was present in 25 patients before treatment (15 grade 1 and 10 grade 2) and 8 had esophagitis at 6 months (4 grade 1 and 4 grade 2, p = 0.005). At 6 months, 87% no longer required proton pump inhibitor medication. There was no significant change in median lower esophageal sphincter pressure (14.0 to 12.0 mm Hg, p = 0.19), peristaltic amplitude (64 to 66 mm Hg, p = 0.71), or lower esophageal sphincter length (3.0 to 3.0, p = 0.28). There were 3 self-limited complications (fever for 24 hours, odynophagia lasting for 5 days, and a linear mucosal injury that was healed after 3 weeks). Conclusion: RF energy delivery significantly improved GERD symptoms, quality of life, and esophageal acid exposure while eliminating the need for anti-secretory medication in the majority of patients with a heterogeneous spectrum of clinical disease severity but with minimal active esophagitis or hiatal hernia. (Gastrointest Endosc 2001;53:407-15.)

Diagnosing Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common condition with a variety of clinical manifestations and potentially serious complications. This article reviews available methods for diagnosing GERD. A clinical history of the classic symptoms of GERD, heartburn or acid regurgitation, is sensitive enough to establish the diagnosis in patients without other complications. Esophagogastroduodenoscopy is the best way to evaluate suspected complications of GERD, but endoscopic findings are insensitive for the presence of pathological reflux, and therefore they cannot reliably exclude GERD. The "gold standard" study for confirming or excluding the presence of abnormal gastroesophageal reflux is the 24-hour ambulatory esophageal pH monitoring test, and this study should be used for the evaluation of refractory symptoms and extraesophageal manifestations of GERD. A formal acid-suppression test is helpful in the evaluation of the atypical GERD symptom of noncardiac chest pain. Optimal use of currently available tests for GERD may allow for more efficient diagnosis and better characterization of the pathological manifestations associated with GERD.