Adlrrrn~cMu?qloelsnwr Dr. R. Cuomo, Dipartimanto di Medicina Clinics e Sperimantale, UnitA di Gastroenterologia, Universit& dagli Studi “Fedatico II”, via S. Pansini 5, 60 13 1 Nap& ltely. E-mail: r.cuomo@unina. it Gastro-oesophageal reflux disease (GORD) is perhaps the most prevalent condition seen in the primary care setting. Heartburn and acid regurgitation are classical symptoms of GORD and occur, either alone or together at least weekly in 19.8% of the population and occasionally in 58.7% ‘. The diagnostic approach to the patient with possible reflux oesophagitis is often confusing. In the case of a patient with the typical symptoms attributable to GORD, such as heartburn and regurgitation, little additional information is required to establish a presumptive diagnosis and initiate therapy. If the patient presents various extra-oesophageal or atypical manifestations, additional diagnostic investigations are usually appropriate. To evaluate the status of a patient with definite or possible GORD, a variety of tests and procedures are available. Each can be classified according to its ability to answer some specific questions (for example: is abnormal reflux present? is there reflux injury? are the symptoms due to reflux?). Evaluation begins with a thorough medical history focusing both on oesophageal and extra-oesophageal symptoms. Heartburn and acid regurgitation have the highest specificity for GORD when elicited by an experienced gastroenterologist *. However, the severity of heartburn does not correlate with the presence or severity of oesophagitis and this symptom may also be minimal in patients with Barrett’s oesophagus or with extraoesophageal manifestations of GORD 3. In addition, regurgitation may be more prominent in patients with aspiration and other extra-oesophageal (in particular pulmonary) manifestations A. The first question regarding the most suitable strategy to treat patients with GORD is: should endoscopy be performed routinely in all patients or is an empirical therapy applicable? Some authors support the hypothesis of empirical therapy in the treatment of patients with typical dominant symptoms, if the patient is young and there are no alarm symptoms (dysphagia, bleeding or weight loss). Indeed, sound evidence in support of this criterion comes from a study on more than 700 cases of malignancy of the upper gastrointestinal tract, among whom only 13 patients were under 45 years of age and all had alarm symptoms s. Moreover, since heartburn and regurgitation are so frequent, it is not practical or even feasible to perform an endoscopy in all; indeed, only 30-40% of patients undergoing this procedure for troublesome heartburn has evidence of mucosal breaks h. In common practice, endoscopy is performed: a) to exclude other diseases or complications in patients whose symptoms are not clearcut or who have alarm symptoms, such as signs of bleeding, dysphagia, or weight loss; b) to screen for Barrett’s oesophagus in patients with long-standing symptoms; c) to diagnose and grade the severity of oesophagitis; d) to attempt direct therapy and predict a chronic disease state j. Therefore, the lack of an approved and standardized classification system of oesophagitis grading ’ and the poor role of oesophageal biopsy in the evaluation of patients with endoscopy-negative reflux disease 8, represent a consistent problem in the endoscopic procedure. The primary care physician often performs barium upper gastrointestinal series. This test may be particularly helpful if the patient has severe or persistent gastro-oesophageal reflux. It will also help to rule out complications