Gastro-oesophageal reflux disease redefined: Implications for primary care

Gastro-oesophageal reflux disease (GORD) is one of the commonest digestive disorders encountered by general practitioners. The condition affects around 10 to 20% of the population of western societies, and incidence and prevalence rates appear to be rising in the eastern world [1]. The disorder has significant implications for quality of life and the cost of medical treatment [2], and is also regarded as a risk factor for Barrett's oesophagus and oesophageal adenocarcinoma.

One of the difficulties of getting to grips with GORD has been the lack of a consistent definition of the condition. Different words are used in different countries to describe what are regarded as the cardinal symptoms of GORD—heartburn and regurgitation—and it appears that different GORD symptoms may be regarded as more or less troublesome in different cultures and countries [2–4]. In addition, there is evidence that general practitioners’ approach to the management of GORD is variable and often inconsistent with the current evidence base, particularly with regard to the use of investigations and different treatment modalities.

For these reasons, a group of primary- and secondary-care clinicians with a particular interest in GORD became involved in a project which eventually generated the “Montreal definition” of GORD, the summary paper of which has recently been published in the American Journal of Gastroenterology [5]. The conclusions of the Montreal working group were based on a series of carefully conducted systematic reviews in which the strength of evidence was assessed using the GRADE system [6]. These informed a Delphi process [7], which was used to identify globally acceptable definitions of GORD and its associated symptoms that would be useful in clinical practice, in research, and in pharmaceutical regulation. A number of important messages for primary care have emerged, which are summarized in the box.

Box 1. Montreal definition of gastro-oesophageal reflux disease: key messages for primary care

• GORD creates a high symptom burden, and the definition of GORD, of which heartburn and regurgitation are cardinal symptoms, involves assessing the troublesomeness of these symptoms to patients.

• The diagnosis of GORD can almost always be made on the basis of symptoms alone; conversely, the concept of non-erosive reflux disease (NERD) must be well understood.

• Chest pain, closely mimicking ischemic heart pain, and significant sleep disturbances are frequently manifestations of GORD.

• The spectrum of reflux disease runs from symptomatic GORD through the complications of haemorrhage and stricture into Barrett's oesophagus and on to adenocarcinoma.

• There is a poor relationship between symptoms and endoscopic appearances in GORD.

• As suppression of acid is very effective in alleviating heartburn, this provides indirect evidence for the association between acid reflux and heartburn.

• Dysphagia is a common feature of GORD but is only troublesome (i.e., progressive) in a minority of patients.

• The new definition of Barrett's oesophagus means that the concept of endospically suspected endothelial metaplasia needs to be understood.

• Cough and other respiratory symptoms, including asthma, can be made worse, and possibly initiated by GORD, although this is unlikely to be the mechanism in the absence of typical reflux symptoms—heartburn and regurgitation.

The first of these is that the diagnosis of GORD can generally be made on the basis of clinical symptoms, and treatment can be started without the need for endoscopy. Conversely, it is important for clinicians to recognize the existence of “non-erosive reflux disease”, in which patients have typical symptoms but no abnormal findings at endoscopy. The relationship between endoscopy and clinical symptoms is poor, and clinicians are advised to assess response to therapy in terms of symptom response, rather than conducting serial endoscopies.

GORD is a common cause of non-cardiac chest pain, and “GORD chest pain syndrome” is now recognized as an integral feature of the condition, in which pain which is often indistinguishable from ischaemic heart pain is caused by acid reflux and/or oesophageal motor abnormalities.

The Montreal definition also emphasizes the links between oesophageal damage and subsequent metaplastic and malignant change in the oesophageal mucosa, whilst recognizing that the incidences of Barrett's oesophagus and adenocarcinoma in the GORD population are relatively low, although they appear to be rising [8].

The expert group also focused on some controversial associations with GORD, including cough and asthma, chronic laryngitis, and ear pain. One important conclusion was that, in patients with unexplained cough or respiratory symptoms responding poorly to therapy, GORD should be considered as a potential exacerbating factor, although it is unlikely to play a part in the absence of heartburn or regurgitation.

Finally, the group examined the significance of the “alarm symptoms” in GORD, particularly dysphagia [9]. Dysphagia can be a feature of oesophagitis, rather than stricture (benign or malignant), and up to 15% of patients with oesophagitis complain of various degrees of dysphagia, which does not require investigation unless it is persistent and progresses after the oesophagitis has been treated.

The Montreal process has added considerably to the evidence base for the effective management of gastro-oesophageal reflux disease. The results of the systematic reviews provide a valuable overview of the current research literature and, although the Delphi process may not be regarded as possessing the rigour of a formal meta-analysis, its three iterations allowed the participants (representing 18 different countries) to synthesize an internationally acceptable set of recommendations. The cardinal messages for primary-care practice from this Montreal process are that the patient's history, and not endoscopy, is the key to the clinical management of GORD, and that GPs should be alert to atypical manifestations of reflux disease.