Symptoms and Disease Severity in Gastro-Oesophageal Reflux Disease

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Abstract
The definition of criteria relevant to disease severity assessments should be considered in parallel with the long-term aims of treatment in gastro-oesophageal reflux disease (GORD). There is no doubt that the resolution of symptoms is the major management aim. Heartburn and regurgitation are specific for GORD when they are the predominant symptoms, but prove to be insensitive when the diagnosis of GORD is based on the measurement of oesophageal acid exposure. A relationship between the frequency of heartburn and the degree of acid exposure has been reported in GORD patients both with and without oesophagitis. GORD may also, however, cause a wide spectrum of atypical symptoms (e.g. non-cardiac chest pain or respiratory symptoms). To the extent that a causal relationship between these symptoms and reflux episodes has been established, evaluation of symptom severity should also encompass these atypical presentations. The role of symptoms in the prediction of relapse of oesophagitis is controversial, but in several studies the presence of residual symptoms of GORD at the time of healing has indicated a greater probability of relapse. Endoscopy is a useful technique for the evaluation of disease severity. Indeed, even typical symptoms may not predict the presence and severity of oesophagitis in an individual patient. Despite the fact that the interpretation of therapeutic trials is often impeded by differences in the grading systems used, healing rates of oesophageal lesions are inversely proportional to the initial severity of oesophagitis when drugs such as H2-receptor antagonists are used. Differences are less evident with highly effective drugs such as omeprazole. Although complete healing of oesophageal mucosal lesions is an ideal treatment end-point, there is no definite evidence that mild, patchy erosions either worsen with time or lead to complications. Therefore, in routine practice, endoscopic monitoring should be limited to patients with severe oesophagitis or Barrett's oesophagus. In most patients, GORD is a chronic relapsing disease and the factors that may affect the natural history of the disease are not as clearly understood as those in peptic ulcer. Although some studies indicate a higher risk of unfavourable outcome in patients with severe supine reflux, there is no definite evidence that the pre-treatment pH profile, as measured by 24-hour pH-monitoring, can actually be used to predict the evolution of GORD in an individual. Similarly, age, sex, weight, smoking and alcohol consumption do not seem to be important prognostic factors for the long-term outcome.