Clinical characteristics and natural history of symptomatic but not excess gastroesophageal reflux

Abstract

Esophageal pH monitoring in patients with gastroesophageal reflux symptoms identifies some who have normal esophageal acid exposure but nevertheless a convincing correlation between symptoms and those reflux events that do occur. These patients may exhibit enhanced sensory perception of physiological reflux. Little is known about the natural history of reflux symptoms in this group, which in our experience comprises up to 6% of those referred for diagnostic pH monitoring. We have therefore followed up by postal questionnaire 70 patients whose initial pH study had demonstrated normal acid exposure but a symptom index ≥50% and 58 patients found to have excess reflux, for a median of 4.4 and 6.5 years, respectively. The presenting character and frequency of symptoms and endoscopic and manometric findings were similar in the two groups. At review overall symptom frequency had improved (P<0.01) for both groups similarly. However, 87% of those with normal acid exposure and 79% of those with excess reflux remained symptomatic, 53% and 47%, respectively, recording their symptoms to be the same or worse than at original presentation, despite over 60% in each group continuing to take regular medication. Only six patients in each group were asymptomatic and receiving no therapy at the time of review. The results demonstrate that patients with symptomatic but not excess gastroesophageal reflux constitute a significant clinical problem. Both the persistence of their symptoms and their requirement for therapy are similar to that observed in “genuine” refluxers.