Natural history of gastro‐oesophageal reflux disease: the neglected factor

Abstract

The natural history of gastro-oesophageal reflux disease (GORD) is still a matter for research. The follow-up of GORD patients under placebo and after suspension of the drugs that healed the disease, along with observations of large patient populations treated with, or without, antisecretory drugs for long periods of time, may give some information on the spontaneous evolution of the disease. To single out the outcome of each patient, predictive factors based on demographic, morphologic and pathophysiologic characteristics have been devised, but their reliability is debatable. The reason for their many discrepancies could lie in the fact that, to date, the large majority of investigators have focused their research on the characteristics of gastro-oesophageal reflux and underlying motor activity, and have overlooked the resistance of the oesophageal mucosa. As many studies have shown that the severity of GORD is not proportional to the amount of reflux, we strongly believe that knowledge of the capacity of the mucosa to resist injury and repair the damage is the key to understanding why patients with low reflux may have severe disease, while patients with high reflux may not. Research on the kind and degree of mucosal defects in patients with GORD should receive more attention and because it may help to clarify the laws that govern the GORD evolution.

Circumferential and axial distribution of esophageal mucosal damage in reflux disease

“…On average, more acid is refluxed into the esophagus in those presenting with mucosal breaks compared to those without, but great overlap exists 3 . Moreover, it is far from clear whether some GERD patients who initially present with no mucosal breaks, eventually develop these 4,5 …”

“…3 Moreover, it is far from clear whether some GERD patients who initially present with no mucosal breaks, eventually develop these. 4,5 There is a growing interest in histological changes at the region of the squamo-columnar junction (SCJ). 6 The most extensively studied and recognized parameters, believed to represent acid-peptic damage to the epithelium, are: thickening of the basal squamous cell layer (BCL) representing basal cell hyperplasia, increased length of the mucosal papillae (PL) 7 and dilatation of the intercellular spaces (DIS).…”

Outcome of nonerosive gastro-esophageal reflux diseasepatients with pathological acid exposure

“…The apparent lack of a relationship between extent of esophageal acid exposure time (and other pathophysiologic parameters of reflux and of esophageal motility) and development of esophagitis has been taken into consideration recently [22] , and it has been suggested that the majority of investigations conducted so far have overlooked the resistance of the esophageal mucosa. Although the effect of smoking on GERD symptoms and lesions is not clear-cut, it probably acts on different pathogenetic sites, including mucosal resistance.…”