SYMPTOMS AND DISEASE SEVERITY IN GASTROESOPHAGEAL REFLUX DISEASE

The definition of criteria relevant to disease severity assessments sh ould 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 regu rgitation are specific for GORD when they are the predominant symptoms , but prove to be insensitive when the diagnosis of GORD is based on t he measurement of oesophageal acid exposure. A relationship between th e frequency of heartburn and the degree of acid exposure has been repo rted in GORD patients both with and without oesophagitis. GORD may als o, however, cause a wide spectrum of atypical symptoms (e.g. non-cardi ac chest pain or respiratory symptoms). To the extent that a causal re lationship between these symptoms and reflux episodes has been establi shed, evaluation of symptom severity should also encompass these atypi cal presentations. The role of symptoms in the prediction of relapse o f oesophagitis is controversial, but in several studies the presence o f residual symptoms of GORD at the time of healing has indicated a gre ater probability of relapse. Endoscopy is a useful technique for the e valuation of disease severity. Indeed, even typical symptoms may not p redict the presence and severity of oesophagitis in an individual pati ent. Despite the fact that the interpretation of therapeutic trials is often impeded by differences in the grading systems used, healing rat es of oesophageal lesions are inversely proportional to the initial se verity of oesophagitis when drugs such as Hz-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 mi ld, patchy erosions either worsen with time or lead to complications. Therefore, in routine practice, endoscopic monitoring should be limite d to patients with severe oesophagitis or Barrett's oesophagus. In mos t patients, GORD is a chronic relapsing disease and the factors that m ay affect the natural history of the disease are not as clearly unders tood as those in peptic ulcer. Although some studies indicate a higher risk of unfavourable outcome in patients with severe supine reflux, t here is no definite evidence that the pre-treatment pH profile, as mea sured by 24-hour pH-monitoring, can actually be used to predict the ev olution of GORD in an individual. Similarly, age, sex, weight, smoking and alcohol consumption do not seem to be important prognostic factor s for the long-term outcome.