Can one predict NERD on the basis of clinical evaluation? While the NERD patient is, on average, younger and more likely to be female that the individual with complicated GERD, these demographic features are not sufficiently discriminating to be of diagnostic value. In terms of typical GERD symptoms, neither severity nor duration can discriminate between NERD and GERD, or predict complications or manometric or pH study results. Some atypical or extraesophageal symptoms, in contrast, tend to be associated with NERD and may in of themselves predicate a different therapeutic strategy. It has been suggested, for example, that both laryngitis and asthma related to GERD require more intensive and more prolonged acid-suppressive therapy in order to optimise symptomatic response. It is also abundantly clear that this area continues to suffer from a striking paucity of data derived from randomised controlled clinical trials.

Many approaches may be taken to the evaluation of the individual presenting, for the first time, with symptoms indicative or suggestive of GERD. Decisions regarding the extent of assessment are based on individual patient factors and on some generic issues. With regard to the former, patient age and nature of symptomatology are fundamental; few would dispute the appropriateness of endoscopy in a 63-year old patient with heartburn and dysphagia referred to the lower esophagus. More controversial are the generic issues and one, in particular, Barrett's esophagus. One's assessment of the role of Barrett's in the pathogenesis of esophageal adenocarcinoma and one's attitude to the efficacy and appropriateness of screening and surveillance policies for this manifestation of GERD will determine enthusiasm for such approaches to GERD as "once in a life-time endoscopy for every GERD patient" or "endoscopy for all over 50". In the absence of conclusive data, approaches are largely empiric and extend from one of recommending endoscopy in all GERD patients to a position which, unimpressed by the efficacy of either screening or surveillance, would not factor Barrett's into the equation when making decisions on evaluation. Endoscopy may have other roles in assessment. These include the obvious value of defining GERD, on the basis of endoscopic findings, in a patient with atypical or non-responsive symptoms and also the less well-defined role of endoscopic fea tures in predicting long-term prognosis and therapeutic response. If, as some evidence suggests, GERD phenotypes remain stable, over time, this has fundamental implications from a management perspective. In choosing a therapeutic strategy for a NERD patient, for example, one can do so confident that progression to esophagitis or Barrett's esophagus is so unlikely that the effect of a particular treatment modality on natural history is not an issue. Several studies from Lagergren and colleagues, in Sweden, have raised a note of caution in this regard. Their suggestion that the risk for adenocarcinoma of the esophagus, in the patient with GERD, relates to heartburn frequency, severity and duration and not to such mucosal pathologies as Barrett's epithelium [61], certainly requires confirmation but cannot be ignored.

Reasons, Remedies And Treatments For Heartburns

Reasons, Remedies And Treatments For Heartburns

Find Out The Causes, Signs, Symptoms And All Possible Treatments For Heartburns!

Get My Free Ebook

Post a comment