New classifications of gastroesophageal reflux disease: an improvement for patient management?

ABSTRACT

Introduction: Gastroesophageal reflux disease (GERD) is a very common and often debilitating disease. In the broad spectrum of GERD phenotypes, three main groups may be traditionally distinguished: 1) patients only affected by esophageal and/or extra-esophageal symptoms; 2) patients with erosive esophagitis and 3) patients with further complications.

Areas covered: This review provides an overview on the current classifications of GERD patients, and their impact on their management.

Expert opinion: In 2017, the GERD Consensus Working Group focused the attention on patients unresponsive to PPIs. In this scenario, a diagnosis of GERD might be confirmed by evident signs of erosive esophagitis and the finding of pH or multichannel intraluminal impedance-pH tests, such as more than 6%. The ‘Lyon Consensus’ panel of experts confirmed that positive indices of reflux-symptom association, without other altered parameters, represent reflux hypersensitivity. GERD requires a customized management; it is crucial to assess frequency and severity of symptoms and their response to an optimal course of therapy as well as to explore the endoscopic alterations and consider other diagnoses responsible for persistent symptoms.

KEYWORDS:

• GERD
• NERD
• multichannel intraluminal impedance-pH
• lyon consensus
• PPIs

Article highlights

• Gastroesophageal reflux disease (GERD) is a very common and often debilitating disease. It has been reported that one-fourth of the general population suffers from relapsing and troublesome reflux symptoms and, more rarely, complications.

• In 2006, the Montreal classification had the merit of stigmatizing, for the first time, the whole disease spectrum, proposing an extremely schematic separation of patients into ‘esophageal’ and ‘extra-esophageal’ syndrome.

• Impedance-pH monitoring test assesses two main variables: the acid exposure of the distal esophagus and the temporal association between symptoms and reflux episodes; these measures allow to distinguish the so-called true NERD patients, characterized by a pathological acid exposure – with or without a positive association with symptoms – from patients with reflux hypersensitivity, showing an enhanced sensitivity to a physiological amount of reflux.

• The ‘Lyon Consensus’ panel of experts confirmed that positive indices of reflux-symptom association, without other altered parameters, represent reflux hypersensitivity.

• PPIs efficiently modify the composition of the refluxate reducing the acid component, although they cannot stop the reflux of gastric content towards the throat; moreover, they result ineffective whether acid is not the main trigger of patient’s symptoms.

• In the subgroup of NERD patients, a reduced response rate to PPIs has been demonstrated; in such cases, direct reflux tests revealing an incomplete acid suppression while on PPIs may support the decision to increase the dosage, administered before breakfast and dinner, or to switch from one molecule to another.

• Laparoscopic fundoplication is an effective treatment, although hampered by the variable duration of the mechanical effects.

Declaration of interest

No sources of funding to declare. The Authors of the present manuscript have no financial/other relationships (such as consultancies, employment, expert testimony, honoraria, speakers bureaus, retainers, stock options or ownership) to declare.

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript.

Reviewer disclosures

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Funding

This paper was not funded.