Different patterns of oesophageal acid exposure distinguish complicated reflux disease from either erosive reflux oesophagitis or non‐erosive reflux disease

Frazzoni, Marzio; Micheli, Enrico De; Savarino, Vincenzo

doi:10.1046/j.1365-2036.2003.01768.x

Cited by 76 publications

(77 citation statements)

References 46 publications

(69 reference statements)

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“…This correlates with the observation that the severity of esophagitis correlates with amount of acid exposure 33 and similar findings have been reported by others. 25 The composite (DeMeester) score, which includes all the acid reflux measures in a weighted calculation of reflux severity, discriminated most clearly between the different GERD stages in this and a similar study. 34 We have presented the findings without applying a correction for multiple comparisons; thus, one explanation is that they are false positive results due to chance alone.…”

Section: Discussionsupporting

confidence: 51%

“…It is well recognized that hiatal hernia is present in most patients with BE, and a lower frequency of hernia in patients with NERD has been reported. 4,24,25 In a large case control study, the presence and size of hernia was strongly associated with risk of developing high grade dysplasia or adenocarcinoma in patients with BE. 26 Hiatal hernia has also be identified as an important factor for the development of ERD in patients with NERD.…”

Section: Discussionmentioning

confidence: 99%

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Hiatal Hernia, Lower Esophageal Sphincter Incompetence, and Effectiveness of Nissen Fundoplication in the Spectrum of Gastroesophageal Reflux Disease

Lord

DeMeester

Peters

et al. 2009

Journal of Gastrointestinal Surgery

115

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Background and Aims Gastroesophageal reflux disease (GERD) is a spectrum of disease that includes nonerosive reflux disease (NERD), erosive reflux disease (ERD), and Barrett's esophagus (BE). Treatment outcomes for patients with different stages have differed in many studies. In particular, acid suppressant medication therapy is reported to be less effective for treating patients with NERD and Barrett's esophagus. The aims of this study were to investigate (1) the role of mechanical factors including hiatal hernia and lower esophageal sphincter (LES) competence in the spectrum of GERD and (2) outcomes of Nissen fundoplication. Methods From the records of patients who had undergone laparoscopic Nissen fundoplication after an abnormal pH study, we identified 50 symptomatic consecutive patients with each of the GERD stages: (1) NERD, (2) mild ERD, defined as esophagitis that was healed with acid suppression therapy, (3) severe ERD, defined as esophagitis that persisted despite medical therapy, and (4) BE. Exclusion criteria were normal distal esophageal acid exposure, esophageal pH monitoring performed elsewhere, antireflux surgery less than 1 year previously or previous fundoplication, and a named esophageal motility disorder or distal esophageal low amplitude hypomotility. Patients who could not be contacted for the study were also excluded. All patients completed a detailed preoperative questionnaire; underwent preoperative upper gastrointestinal endoscopy, stationary manometry, and distal esophageal pH monitoring; and were interviewed at least 1 year after operation. Results One hundred sixty patients meeting the entry criteria were studied. The mean follow-up period was 36.7 months. The only significant preoperative symptom difference was that patients with BE had more moderately severe or severe dysphagia compared to patients with NERD. Patients with severe ERD or BE had a significantly higher prevalence of hiatal hernia, lower LES pressures, and more esophageal acid exposure. Hiatal hernia and hypotensive LES were present in most patients with severe ERD or BE but in only a minority of patients with NERD or mild ERD. Surgical therapy resulted in similarly excellent symptom outcomes for patients in all GERD categories. Conclusions Compared to mild ERD and NERD, severe ERD and BE are associated with significantly greater loss of the mechanical antireflux barrier as reflected in the presence of hiatal hernia and LES measurements. Restoration of the antireflux barrier and hernia reduction by laparoscopic Nissen fundoplication provides similarly excellent symptom control in all patients.

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Section: Discussionsupporting

confidence: 51%

Section: Discussionmentioning

confidence: 99%

Hiatal Hernia, Lower Esophageal Sphincter Incompetence, and Effectiveness of Nissen Fundoplication in the Spectrum of Gastroesophageal Reflux Disease

Lord

DeMeester

Peters

et al. 2009

Journal of Gastrointestinal Surgery

115

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“…A tendency for NERD+ patients to have a higher mean LES pressure than ERD patients has also been reported in other studies, although the difference failed to reach statistical significance [14,20] . Findings for esophageal body motility did not differ significantly between patients with NERD+ and those with ERD, apart from a slight tendency for the distal wave amplitude to be greater in the first group.…”

Section: Physiopathological Patternsupporting

confidence: 74%

“…In particular, the fact that the mean age of the ERD group was similar to that of the NERD+ patients (around 50 years old in both cases) seems to contradict the claim that patients with- out esophagitis tend to be younger and can be expected to progress towards a picture of full-blown esophagitis as they grow older [12,13] . Other authors reported individuals with complicated reflux disease being older than patients with NERD+, although the latter were actually much the same age as the group with ERD, as in our population [14] . We also found no gender-related differences in our two patient groups despite the literature reporting a tendency to find more females among NERD patients than among cases of esophagitis [12,15,16] .…”

Section: General Considerations: Study Populationsupporting

confidence: 54%

“…Hiatal hernia is currently assumed to be one of the physiopathological factors contributing to the onset of GERD by reducing LES competence and interfering with esophageal clearance [17,18] . Hiatal hernia is apparently a dominant predictor of erosive esophagitis [19] but it has been little studied in patients with NERD who are less likely to have hiatal hernias than patients with esophagitis [14,5,20] .…”

Section: General Considerations: Study Populationmentioning

confidence: 99%

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Non-erosive and uncomplicated erosive reflux diseases: Difference in physiopathological and symptom pattern

Bresàdola¹

2011

WJGP

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AIM: To investigate differences in the physiopathological findings (manometry and pH monitoring) and symptoms between cases of non-erosive reflux disease (NERD) and erosive reflux disease (ERD) found positive at 24 h pH monitoring. METHODS:For a total of 670 patients who underwent 24 h pH monitoring, esophageal manometry and upper endoscopy were retrospectively evaluated, assessing the reflux symptoms, manometric characteristics of the lower esophageal sphincter (LES) and esophageal body and the presence or absence of esophagitis and hiatal hernia. Typical and atypical symptoms were also evaluated. For inclusion in the study, patients had to have NERD or ERD and be found positive on pH monitoring (NERD+). Patients with Gastroesophageal reflux disease (GERD) complicated by stenosis, ulcers or Barrett's esophagus were ruled out.RESULTS: 214 patients were involved in the study, i.e. 107 cases of NERD+ and 107 of ERD. There were no significant gender-or age-related differences between the two groups. The ERD group had more cases of hiatal hernia (P = 0.02) and more acid reflux, both in terms of number of reflux episodes (P = 0.01) and as a percentage of the total time with a pH < 4 (P = 0.00), when upright (P = 0.007) and supine (P = 0.00). The NERD+ cases had more reflux episodes while upright (P = 0.02) and the ERD cases while supine (P = 0.01). The LES pressure was higher in cases of NERD+ (P = 0.03) while the amplitude and duration of their esophageal peristaltic waves tended to be better than in the ERD group (P >0.05). The NERD+ patients presented more often with atypical symptoms (P = 0.01). CONCLUSION:The NERD+ patients' fewer reflux episodes and the fact that they occurred mainly while in the upright position (unlike the cases of ERD) may be two factors that do not favor the onset of esophagitis. The frequently atypical symptoms seen in patients with NERD+ need to be accurately evaluated for therapeutic purposes because patients with GERD and atypical symptoms generally respond only partially to medical and surgical treatments.

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Medical Management of Barrett's Esophagus

Kuipers¹

2006

Barrett's Esophagus and Esophageal Adenocarcinoma

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Different patterns of oesophageal acid exposure distinguish complicated reflux disease from either erosive reflux oesophagitis or non‐erosive reflux disease

Cited by 76 publications

References 46 publications

Hiatal Hernia, Lower Esophageal Sphincter Incompetence, and Effectiveness of Nissen Fundoplication in the Spectrum of Gastroesophageal Reflux Disease

Hiatal Hernia, Lower Esophageal Sphincter Incompetence, and Effectiveness of Nissen Fundoplication in the Spectrum of Gastroesophageal Reflux Disease

Non-erosive and uncomplicated erosive reflux diseases: Difference in physiopathological and symptom pattern

Medical Management of Barrett's Esophagus

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