Many extraesophageal (or supraesophageal) manifestations of GERD are now acknowledged as parts of the disease spectrum ; we disagree with considering these manifestations as only possible complications of the NERD category, as proposed by Fass and Ofman. If, in fact, it holds true that the majority of such patients do not show esophageal mucosal damage at endoscopy, a definite proportion, between 20% and 30% of such patients do indeed have erosive or ulcerative esophagitis . We too dispute that NERD and "atypical'' GERD patients should be regarded as having less severe disease; this is however not based on the absence or presence of mucosal damage, but on the pathogenesis of symptom perception in those patients. NERD patients are in fact possibly at least three groups of different patients (true refluxers, patients with esophageal hyperalgesia and patients with psychological disturbances) , and the traditional treatment with antisecretory agents can possibly be more useful in the first group than in the others. Grouping these patients and the "atypical'' ones into a single disease entity will only result in greater heterogeneity and less management skill. On the other hand, the diagnostic criterion based on the absence of mucosal damage presently allows only an imperfect, operational diagnosis, which will be rapidly surpassed by new methods of investigating the pathophysiology of GERD (i.e., impedance measurements), similar to what happened some years ago for nonA-nonB hepatitis, which was subsequently positively defined according to virus etiology (hepatitis C virus, delta, E, etc.), when new sierology methods became available.
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