The clinical course of reflux esophagitis depends to a great extent on whether the patient has erosive or nonerosive GERD on initial presentation. Furthermore, patients tend not to cross over from one group to another unless they are treated medically or surgically: in follow-up ranging from 6 months to more than 5 years, only 15% of patients with nonerosive disease evolved over time to having esophagitis or complications of GERD.
Nonerosive Acid Reflux Disease
Although early studies from tertiary referral centers suggested that nearly half of patients with GERD had esophagitis, studies carried out in community practices reveal that up to 70% of the patients with GERD had a normal endoscopic examination. Furthermore, another community-based study of antacid users found that 53% of patients with GERD had nonerosive disease, and two thirds of the remaining had only minimal erosive changes at endoscopy. Endoscopy-negative patients with GERD are more likely to be female, younger, thin, and without hiatal hernia. Despite their mild mucosal damage, these patients demonstrate a chronic pattern of symptoms with periods of exacerbation and remission.
Nonerosive GERD is suspected by the presence of typical reflux symptoms with a normal endoscopic examination and is confirmed by the patient’s response to antisecretory therapy. When performed, 24-hour esophageal pH monitoring identifies three distinct subset of patients with nonerosive disease. First, there are the patients with abnormal acid exposure time who are usually responsive to antisecretory therapy. Second are the patients with normal reflux parameters but a good relationship between acid reflux episodes and symptoms. This group represents 30% to 50% of patients with nonerosive GERD and has “functional heartburn.” These patients probably have heightened esophageal sensitivity to acid and are less likely to respond to antireflux therapy. The third group is characterized by normal acid exposure times and poor symptom correlation. Despite sometimes having classical reflux symptoms, other diseases such as achalasia, gastroparesis, bile reflux, or functional dyspepsia are the cause of their symptoms. Overall, patients with nonerosive GERD do not respond to antireflux treatments as well as do patients with erosive GERD, probably because these three subsets are not carefully defined before treatment.
Erosive Acid Reflux Disease
The clinical course of patients with erosive esophagitis is more predictable and is associated with complications of GERD. Controlled studies have shown that in the absence of ongoing maintenance therapy, up to 85% of patients with erosive GERD will have a relapse within 6 months, and the relapse rate is highest in those with the more severe grades of esophagitis. This observation, however, should not prevent at least one attempt to withdraw medication, because 20% of patients remain in remission for up to 1 year, especially those with milder esophagitis grades. Although the natural history of untreated erosive GERD is well studied, two European studies suggest that these patients are more prone to reflux complications. In a Finnish study, 20 patients with erosive GERD treated with lifestyle changes, antacids, and prokinetic drugs were followed up for a median of 19 years. Fourteen patients continued to have erosions, and 6 new cases of Barrett esophagus were detected. Likewise, a large retrospective European study with 6.5 years of follow-up found a high rate of complications (21%) including 13 esophageal ulcers, 15 with strictures, and 45 patients with Barrett epithelium. However, these data must be contrasted with other studies in which no patients with erosive esophagitis developed Barrett esophagus in a 2-year trial in the
Labels: Acid Reflux Disease