GastroesophagealGastroesophagealReflux DiseaseReflux Disease

(GERD)(GERD)

GastroesophagealGastroesophagealReflux DiseaseReflux Disease

(GERD)(GERD)ByBy

Tarek ShetaTarek ShetaLecturer of Internal MedicineLecturer of Internal Medicine

Faculty of medicine, MansouraFaculty of medicine, Mansourauniversityuniversity

GERD: MontrealGERD: MontrealDefinitionDefinition

GERD is defined as abnormalGERD is defined as abnormalreflux of the gastric contentsreflux of the gastric contentsinto the esophagus causinginto the esophagus causingtroublesome symptoms and/ortroublesome symptoms and/orcomplicationscomplications >> 22 heartburnheartburn

episodes/weekepisodes/week Adversely affects theAdversely affects the

individual’s well beingindividual’s well being

GERD is defined as abnormalGERD is defined as abnormalreflux of the gastric contentsreflux of the gastric contentsinto the esophagus causinginto the esophagus causingtroublesome symptoms and/ortroublesome symptoms and/orcomplicationscomplications >> 22 heartburnheartburn

episodes/weekepisodes/week Adversely affects theAdversely affects the

individual’s well beingindividual’s well being

From Vakil N et al. Am J GastroenterolFrom Vakil N et al. Am J Gastroenterol 20062006;;101101::19001900--2020..

Montreal Classification of GERDMontreal Classification of GERD

From Vakil N et al. Am J GastroenterolFrom Vakil N et al. Am J Gastroenterol 20062006;;101101::19001900--2020..

PREVALENCE

ApproximatelyApproximately 2020% of adults have frequent "classic"% of adults have frequent "classic"symptoms of gastroesophageal reflux (GER):symptoms of gastroesophageal reflux (GER):

HeartburnHeartburn -- Regurgitation.Regurgitation.

More in the Western world.More in the Western world.

The main pathogenicThe main pathogenicmechanism of GERD ismechanism of GERD isconsidered to be theconsidered to be thetransient lowertransient loweresophageal sphincteresophageal sphincterrelaxation (TLESR).relaxation (TLESR).

AETIOLOGYAETIOLOGYGERD is a multifactorial disease inGERD is a multifactorial disease in

which bothwhich both anatomical and functionalanatomical and functionalfactors play a pathogenic role.factors play a pathogenic role.

The main pathogenicThe main pathogenicmechanism of GERD ismechanism of GERD isconsidered to be theconsidered to be thetransient lowertransient loweresophageal sphincteresophageal sphincterrelaxation (TLESR).relaxation (TLESR).

The Physiologic MechanismsThe Physiologic MechanismsProtecting Against GERDProtecting Against GERD

DIAGNOSISDIAGNOSIS The diagnosis of GERD is based on theThe diagnosis of GERD is based on the

combination of: clinical symptoms,combination of: clinical symptoms,endoscopic findings, pH monitoring, andendoscopic findings, pH monitoring, andhistologic changes.histologic changes.

However, GERD is a heterogeneousHowever, GERD is a heterogeneousdisease, and the findings in these tests dodisease, and the findings in these tests donot always correspond. For example, somenot always correspond. For example, somepatients report typical symptoms but lackpatients report typical symptoms but lackother positive tests, whereas otherother positive tests, whereas otherpatients are asymptomatic yet exhibitpatients are asymptomatic yet exhibittypical endoscopic and histologic featurestypical endoscopic and histologic featuresof GERD.of GERD.

DIAGNOSISDIAGNOSIS The diagnosis of GERD is based on theThe diagnosis of GERD is based on the

combination of: clinical symptoms,combination of: clinical symptoms,endoscopic findings, pH monitoring, andendoscopic findings, pH monitoring, andhistologic changes.histologic changes.

However, GERD is a heterogeneousHowever, GERD is a heterogeneousdisease, and the findings in these tests dodisease, and the findings in these tests donot always correspond. For example, somenot always correspond. For example, somepatients report typical symptoms but lackpatients report typical symptoms but lackother positive tests, whereas otherother positive tests, whereas otherpatients are asymptomatic yet exhibitpatients are asymptomatic yet exhibittypical endoscopic and histologic featurestypical endoscopic and histologic featuresof GERD.of GERD.

The sensitivity of refluxThe sensitivity of refluxsymptoms for diagnosingsymptoms for diagnosingGERD is onlyGERD is only 5555%, if%, ifendoscopy is consideredendoscopy is consideredas the gold standard.as the gold standard.

The sensitivity of refluxThe sensitivity of refluxsymptoms for diagnosingsymptoms for diagnosingGERD is onlyGERD is only 5555%, if%, ifendoscopy is consideredendoscopy is consideredas the gold standard.as the gold standard.

In view of this low sensitivity, aIn view of this low sensitivity, amultidisciplinary approach formultidisciplinary approach fordiagnosis is highly requireddiagnosis is highly required (Gersonet(Gersonetet al,et al, 20112011).).

DIAGNOSTIC TESTSDIAGNOSTIC TESTSFOR GERDFOR GERD

DIAGNOSTIC TESTSDIAGNOSTIC TESTSFOR GERDFOR GERD

Role of Endoscopy in ManagementRole of Endoscopy in Managementof GERD: ASGE Guidelinesof GERD: ASGE Guidelines

GERD despite therapyGERD despite therapy DysphagiaDysphagia OdynophagiaOdynophagia GI bleeding/anemiaGI bleeding/anemia Mass, stricture or ulcer on imagingMass, stricture or ulcer on imaging

studystudy Recurrent symptoms after antirefluxRecurrent symptoms after antireflux

surgerysurgery

GERD despite therapyGERD despite therapy DysphagiaDysphagia OdynophagiaOdynophagia GI bleeding/anemiaGI bleeding/anemia Mass, stricture or ulcer on imagingMass, stricture or ulcer on imaging

studystudy Recurrent symptoms after antirefluxRecurrent symptoms after antireflux

surgerysurgeryFrom Gastrointest EndoscFrom Gastrointest Endosc 20072007;;6666::219219--2424..

Role of Endoscopy in ManagementRole of Endoscopy in Managementof GERD: ASGE Guidelinesof GERD: ASGE Guidelines

Screening for Barrett’s inScreening for Barrett’s inselected patientsselected patients

Persistent vomitingPersistent vomiting Suspected extraesophagealSuspected extraesophageal

GERDGERD

Screening for Barrett’s inScreening for Barrett’s inselected patientsselected patients

Persistent vomitingPersistent vomiting Suspected extraesophagealSuspected extraesophageal

GERDGERD

From Gastrointest EndoscFrom Gastrointest Endosc 20072007;;6666::219219--2424..

LA Classification of EsophagitisLA Classification of Esophagitis

From Nayar DS et al. Gastrointest EndoscFrom Nayar DS et al. Gastrointest Endosc 20042004;;6060::253253--77..

The Los Angeles Classification SystemThe Los Angeles Classification Systemfor the endoscopic assessment offor the endoscopic assessment of

reflux oesophagitisreflux oesophagitisGRADE A:GRADE A:

One or more mucosal breaks noOne or more mucosal breaks nolonger thanlonger than 55 mm, non of whichmm, non of whichextends between the tops of theextends between the tops of themucosal foldsmucosal folds

GRADE A:GRADE A:One or more mucosal breaks noOne or more mucosal breaks nolonger thanlonger than 55 mm, non of whichmm, non of whichextends between the tops of theextends between the tops of themucosal foldsmucosal folds

TheThe Los Angeles Classification SystemLos Angeles Classification System

GRADE B:GRADE B:One or moreOne or moremucosal breaksmucosal breaksmore thanmore than 55 mmmmlong, none oflong, none ofwhich extendswhich extendsbetween thebetween thetops of twotops of twomucosal foldsmucosal folds

GRADE B:GRADE B:One or moreOne or moremucosal breaksmucosal breaksmore thanmore than 55 mmmmlong, none oflong, none ofwhich extendswhich extendsbetween thebetween thetops of twotops of twomucosal foldsmucosal folds

TheThe Los Angeles Classification SystemLos Angeles Classification System

GRADE C:GRADE C:Mucosal breaksMucosal breaksthat extendthat extendbetween the topsbetween the topsof two or moreof two or moremucosal folds, butmucosal folds, butwhich involve lesswhich involve lessthanthan 7575% of the% of theoesophagealoesophagealcircumferencecircumference

GRADE C:GRADE C:Mucosal breaksMucosal breaksthat extendthat extendbetween the topsbetween the topsof two or moreof two or moremucosal folds, butmucosal folds, butwhich involve lesswhich involve lessthanthan 7575% of the% of theoesophagealoesophagealcircumferencecircumference

The Los Angeles Classification SystemThe Los Angeles Classification System

GRADE D:GRADE D:Mucosal breaksMucosal breakswhich involvewhich involveat leastat least 7575%%of theof theoesophagealoesophagealcircumferencecircumference

GRADE D:GRADE D:Mucosal breaksMucosal breakswhich involvewhich involveat leastat least 7575%%of theof theoesophagealoesophagealcircumferencecircumference

AGA Esophageal GERD PracticeAGA Esophageal GERD PracticeGuidelines: ManometryGuidelines: Manometry

Indications:Indications: GERD despite therapyGERD despite therapy Negative endoscopyNegative endoscopy

Goals:Goals: LES locationLES location Peristaltic function preoperativelyPeristaltic function preoperatively Detection of motility abnormalitiesDetection of motility abnormalities

Indications:Indications: GERD despite therapyGERD despite therapy Negative endoscopyNegative endoscopy

Goals:Goals: LES locationLES location Peristaltic function preoperativelyPeristaltic function preoperatively Detection of motility abnormalitiesDetection of motility abnormalities

From Kahrilas PJ et al. GastroenterologyFrom Kahrilas PJ et al. Gastroenterology 20082008;;135135::13831383--9191..

AGA Esophageal GERD PracticeAGA Esophageal GERD PracticeGuidelines: pH metryGuidelines: pH metry

Indications:Indications: Failure to respond to PPIFailure to respond to PPI Negative endoscopy.Negative endoscopy. Atypical symptoms: respiratory, ENTAtypical symptoms: respiratory, ENT

,atypical chest pain,atypical chest pain Preoperative confirmation of GERDPreoperative confirmation of GERD

Indications:Indications: Failure to respond to PPIFailure to respond to PPI Negative endoscopy.Negative endoscopy. Atypical symptoms: respiratory, ENTAtypical symptoms: respiratory, ENT

,atypical chest pain,atypical chest pain Preoperative confirmation of GERDPreoperative confirmation of GERD

From Kahrilas PJ et al. GastroenterologyFrom Kahrilas PJ et al. Gastroenterology 20082008;;135135::13831383--9191..

2424--Hour Esophageal pHHour Esophageal pHMonitoringMonitoring

Most accurate test for measuringMost accurate test for measuringpattern, frequency, and durationpattern, frequency, and durationof reflux episodesof reflux episodes

Documents correlation betweenDocuments correlation betweenreflux episodes and symptomsreflux episodes and symptoms

Dent et al. Gut.Dent et al. Gut. 19991999;;4444(suppl(suppl 22):S):S11--SS1616..

Normal inNormal in 2525%%of esophagitis!of esophagitis!

AGA GERD Practice Guidelines:AGA GERD Practice Guidelines:Diagnostic Testing SequenceDiagnostic Testing Sequence

1.1. EndoscopyEndoscopy

2.2. ManometryManometry

3.3. pH testingpH testing

1.1. EndoscopyEndoscopy

2.2. ManometryManometry

3.3. pH testingpH testing

From Kahrilas PJ et al. GastroenterologyFrom Kahrilas PJ et al. Gastroenterology 20082008;;135135::13831383--9191..

Treatment Options for GERD

Pharmacologic Therapy of GERDPharmacologic Therapy of GERDNot RecommendedNot Recommended

Nocturnal HNocturnal H22 blockerblockerNot supported by clinicalNot supported by clinical

endpointsendpointsRapid tachyphylaxisRapid tachyphylaxis

MetoclopramideMetoclopramidemonotherapy or adjunctivemonotherapy or adjunctive

therapytherapy

Nocturnal HNocturnal H22 blockerblockerNot supported by clinicalNot supported by clinical

endpointsendpointsRapid tachyphylaxisRapid tachyphylaxis

MetoclopramideMetoclopramidemonotherapy or adjunctivemonotherapy or adjunctive

therapytherapyFrom Kahrilas PJ. GastroenterologyFrom Kahrilas PJ. Gastroenterology 20082008;;135135::13831383--9191..

Surgical TreatmentSurgical Treatment

IndicationsIndications StrictureStricture Barrett’s metaplasiaBarrett’s metaplasia Medication failureMedication failure

Purpose of surgeryPurpose of surgery : restoration the: restoration theLESLES

IndicationsIndications StrictureStricture Barrett’s metaplasiaBarrett’s metaplasia Medication failureMedication failure

Purpose of surgeryPurpose of surgery : restoration the: restoration theLESLES

Endoscopic TreatmentsEndoscopic Treatments

In development with ongoing studiesIn development with ongoing studies

Most try to improve LES function in someMost try to improve LES function in somemannermanner

Not quite ready for prime time inNot quite ready for prime time incommunity practicecommunity practice

In development with ongoing studiesIn development with ongoing studies

Most try to improve LES function in someMost try to improve LES function in somemannermanner

Not quite ready for prime time inNot quite ready for prime time incommunity practicecommunity practice

Stretta procedureStretta procedure

Stretta procedureStretta procedure

Decrease in symptomDecrease in symptomscorescore

Decreased PPIDecreased PPI No effect on LESPNo effect on LESP No effect on acidNo effect on acid

exposureexposure

Some serious thermalSome serious thermalinjury complicationsinjury complications

Decrease in symptomDecrease in symptomscorescore

Decreased PPIDecreased PPI No effect on LESPNo effect on LESP No effect on acidNo effect on acid

exposureexposure

Some serious thermalSome serious thermalinjury complicationsinjury complications

Enteryx injectionEnteryx injection

Appearance Enteryx after polymerization as a spongyAppearance Enteryx after polymerization as a spongyblack material.black material.

Enteryx injectionEnteryx injection

Decreased in heartburn symptomsDecreased in heartburn symptoms DecreasedDecreased 2424 hour acid exposurehour acid exposure Decreased need for PPIDecreased need for PPI

No improvement in severity of esophagitisNo improvement in severity of esophagitisat EGDat EGD

Long term safety issues not knownLong term safety issues not known

Decreased in heartburn symptomsDecreased in heartburn symptoms DecreasedDecreased 2424 hour acid exposurehour acid exposure Decreased need for PPIDecreased need for PPI

No improvement in severity of esophagitisNo improvement in severity of esophagitisat EGDat EGD

Long term safety issues not knownLong term safety issues not known

Endoscopic suturingEndoscopic suturing

Endoscopic suturingEndoscopic suturing

Decreased heartburn symptomsDecreased heartburn symptoms PPI eliminated inPPI eliminated in 7474% of patients at% of patients at 66

monthsmonths Decreased esophageal acid exposure;Decreased esophageal acid exposure;

however, onlyhowever, only 3030% completely normalized% completely normalized

Long term followLong term follow--up neededup needed

Decreased heartburn symptomsDecreased heartburn symptoms PPI eliminated inPPI eliminated in 7474% of patients at% of patients at 66

monthsmonths Decreased esophageal acid exposure;Decreased esophageal acid exposure;

however, onlyhowever, only 3030% completely normalized% completely normalized

Long term followLong term follow--up neededup needed

FullFull--Thickness PlicationThickness PlicationTechniqueTechnique

FullFull--Thickness Plication TechniqueThickness Plication TechniqueFullFull--Thickness Plication TechniqueThickness Plication Technique

Plicator and gastroscoperetroflexed to GEJ

Arms opened, tissueretractor advanced to serosa

Gastric wall retracted1 2 3Plicator and gastroscoperetroflexed to GEJ

Arms opened, tissueretractor advanced to serosa

Arms closed, single pre-tiedimplant deployed

Resulting full-thicknessplication

1 2 3

44 55

Esophageal Changes inEsophageal Changes inGastroesophagealGastroesophageal

Reflux DiseaseReflux Disease

ThesisThesisbyby

Tarek Fouad ShetaTarek Fouad ShetaAssistant Lecturer of Internal MedicineAssistant Lecturer of Internal Medicine

Faculty of medicine, Mansoura universityFaculty of medicine, Mansoura university

This study was conducted onThis study was conducted on 6868 patients referredpatients referredto Specialized Medical Hospital outpatient clinicto Specialized Medical Hospital outpatient cliniccomplaining of classic GERD symptoms.complaining of classic GERD symptoms.

Management of patientsManagement of patients The researcher completed a detailedThe researcher completed a detailed

symptom assessment for each patientsymptom assessment for each patientusing a validated questionnaire.using a validated questionnaire.

The typical reflux symptoms ofThe typical reflux symptoms ofheartburn and acid regurgitation wereheartburn and acid regurgitation wererecorded as:recorded as:-- Frequent (symptoms on at leastFrequent (symptoms on at least 22 daysdaysper week) orper week) or

-- Infrequent (symptoms on fewer thanInfrequent (symptoms on fewer than 22days per week).days per week).

The researcher completed a detailedThe researcher completed a detailedsymptom assessment for each patientsymptom assessment for each patientusing a validated questionnaire.using a validated questionnaire.

The typical reflux symptoms ofThe typical reflux symptoms ofheartburn and acid regurgitation wereheartburn and acid regurgitation wererecorded as:recorded as:-- Frequent (symptoms on at leastFrequent (symptoms on at least 22 daysdaysper week) orper week) or

-- Infrequent (symptoms on fewer thanInfrequent (symptoms on fewer than 22days per week).days per week).

Data were also collected on:Data were also collected on:-- Age.Age.-- Sex.Sex.-- Weight, height and body mass index.Weight, height and body mass index.-- Smoking.Smoking.-- Coffee consumption.Coffee consumption.-- The use of drugs: namely aspirin,The use of drugs: namely aspirin,NSAIDs and corticosteroids.NSAIDs and corticosteroids.

After that, all patients and controls wereAfter that, all patients and controls weresubjected to the following:subjected to the following:

Data were also collected on:Data were also collected on:-- Age.Age.-- Sex.Sex.-- Weight, height and body mass index.Weight, height and body mass index.-- Smoking.Smoking.-- Coffee consumption.Coffee consumption.-- The use of drugs: namely aspirin,The use of drugs: namely aspirin,NSAIDs and corticosteroids.NSAIDs and corticosteroids.

After that, all patients and controls wereAfter that, all patients and controls weresubjected to the following:subjected to the following:

((11) Upper GI endoscopy) Upper GI endoscopy The following endoscopic findings wereThe following endoscopic findings were

recorded for all patients:recorded for all patients:-- Presence or absence of gross endoscopicPresence or absence of gross endoscopic

signs of GERD.signs of GERD.-- The degree of GERDThe degree of GERD

according to theaccording to theLos Angeles Classification.Los Angeles Classification.

-- Other esophageal findings (e.g. ulcer,Other esophageal findings (e.g. ulcer,stricture…etc).stricture…etc).

-- Presence or absence of hiatal hernia.Presence or absence of hiatal hernia.

((11) Upper GI endoscopy) Upper GI endoscopy The following endoscopic findings wereThe following endoscopic findings were

recorded for all patients:recorded for all patients:-- Presence or absence of gross endoscopicPresence or absence of gross endoscopic

signs of GERD.signs of GERD.-- The degree of GERDThe degree of GERD

according to theaccording to theLos Angeles Classification.Los Angeles Classification.

-- Other esophageal findings (e.g. ulcer,Other esophageal findings (e.g. ulcer,stricture…etc).stricture…etc).

-- Presence or absence of hiatal hernia.Presence or absence of hiatal hernia.

((22) Esophageal Manometry) Esophageal Manometry--Esophageal ManometryEsophageal Manometry

was performed to locatewas performed to locatethe LES using waterthe LES using waterperfused eight lumenperfused eight lumenpressure catheter.pressure catheter.

--The catheter was passedThe catheter was passedthrough the nose andthrough the nose andadvanced into theadvanced into thestomach.stomach.

--Esophageal ManometryEsophageal Manometrywas performed to locatewas performed to locatethe LES using waterthe LES using waterperfused eight lumenperfused eight lumenpressure catheter.pressure catheter.

--The catheter was passedThe catheter was passedthrough the nose andthrough the nose andadvanced into theadvanced into thestomach.stomach.

((33) Ambulatory twenty) Ambulatory twenty--four hourfour hourpH monitoringpH monitoring

AmbulatoryAmbulatory 2424 hour pHhour pHmonitoring was performedmonitoring was performedusing a disposable pHusing a disposable pHelectrode passed and securedelectrode passed and securedto the nose with an electrodeto the nose with an electrodeplacedplaced 55cm above the LEScm above the LES(located by manometric(located by manometricexamination) and theexamination) and theelectrode was connected to aelectrode was connected to aportable recording device.portable recording device.

AmbulatoryAmbulatory 2424 hour pHhour pHmonitoring was performedmonitoring was performedusing a disposable pHusing a disposable pHelectrode passed and securedelectrode passed and securedto the nose with an electrodeto the nose with an electrodeplacedplaced 55cm above the LEScm above the LES(located by manometric(located by manometricexamination) and theexamination) and theelectrode was connected to aelectrode was connected to aportable recording device.portable recording device.

Interpretation of results:Interpretation of results:

-- Esophageal acid exposure was scoredEsophageal acid exposure was scoredaccording to DeMeester and Johnsonaccording to DeMeester and Johnsonscoring systemscoring system ((DeMeester & Johnson,DeMeester & Johnson, 19851985))..

-- This score is a composite of physiologicalThis score is a composite of physiologicalparameters including frequency andparameters including frequency andduration of acid exposure and positionduration of acid exposure and positionduring reflux events, with a score ofduring reflux events, with a score of 1414..77as the upper limit of normal.as the upper limit of normal.

Interpretation of results:Interpretation of results:

-- Esophageal acid exposure was scoredEsophageal acid exposure was scoredaccording to DeMeester and Johnsonaccording to DeMeester and Johnsonscoring systemscoring system ((DeMeester & Johnson,DeMeester & Johnson, 19851985))..

-- This score is a composite of physiologicalThis score is a composite of physiologicalparameters including frequency andparameters including frequency andduration of acid exposure and positionduration of acid exposure and positionduring reflux events, with a score ofduring reflux events, with a score of 1414..77as the upper limit of normal.as the upper limit of normal.

((33) Esophageal histopathology) Esophageal histopathologyThe histopathological report included :The histopathological report included :

-- Basal cell hyperplasia (BH).Basal cell hyperplasia (BH).-- Papillary elongation (PE).Papillary elongation (PE).--Dilatation of intercellular spacesDilatation of intercellular spaces

(DIS).(DIS).

-- Each one of those parametersEach one of those parameterswere scored aswere scored as 00 (absent),(absent), 11(mild), and(mild), and 22 (marked).(marked).

-- Basal cell hyperplasia (BH).Basal cell hyperplasia (BH).-- Papillary elongation (PE).Papillary elongation (PE).--Dilatation of intercellular spacesDilatation of intercellular spaces

(DIS).(DIS).

-- Each one of those parametersEach one of those parameterswere scored aswere scored as 00 (absent),(absent), 11(mild), and(mild), and 22 (marked).(marked).

In addition, the followingIn addition, the followingparameters were recorded :parameters were recorded :--The presence of intraepithelialThe presence of intraepithelial

eosinophils (IE) (scoreeosinophils (IE) (score 00 =absent,=absent,11 ==11 eosinophil,eosinophil, 22 =>=>11 eosinophileosinophilper HPF.per HPF.

--The presence of intraepithelialThe presence of intraepithelialneutrophils (neutrophils (00 =absent,=absent, 22=present).=present).

--Necrosis /or erosions (Necrosis /or erosions (00 =absent,=absent,22 =present).=present).

In addition, the followingIn addition, the followingparameters were recorded :parameters were recorded :--The presence of intraepithelialThe presence of intraepithelial

eosinophils (IE) (scoreeosinophils (IE) (score 00 =absent,=absent,11 ==11 eosinophil,eosinophil, 22 =>=>11 eosinophileosinophilper HPF.per HPF.

--The presence of intraepithelialThe presence of intraepithelialneutrophils (neutrophils (00 =absent,=absent, 22=present).=present).

--Necrosis /or erosions (Necrosis /or erosions (00 =absent,=absent,22 =present).=present).

Basal cell hyperplasia

Intraepithelial neutrophils in association with lymphocytes

Areas of necrosis in an esophageal tissue sample

Dilated intercellular spaces

-- Calculation of this score wasCalculation of this score wasobtained by summing up all theobtained by summing up all thescores for:scores for:

BH + PE + ISD + IE + INBH + PE + ISD + IE + IN (range(range 00 –– 22))________________________________________________________________________________________________________________________________________________________________________________

the number of lesionsthe number of lesions

Global severity scoreGlobal severity score-- The overall severity of all the lesionsThe overall severity of all the lesions

was described by means of a global scorewas described by means of a global score(GSS).(GSS).

-- Calculation of this score wasCalculation of this score wasobtained by summing up all theobtained by summing up all thescores for:scores for:

BH + PE + ISD + IE + INBH + PE + ISD + IE + IN (range(range 00 –– 22))________________________________________________________________________________________________________________________________________________________________________________

the number of lesionsthe number of lesions

Control groupControl group-- Fifteen subjects (Fifteen subjects (99 males andmales and 66females) not complaining of any GERDfemales) not complaining of any GERDsymptoms were used as controls.symptoms were used as controls.

-- They underwent upper GI endoscopyThey underwent upper GI endoscopywith esophageal biopsy andwith esophageal biopsy and 2424--hhesophageal pH monitoring with normalesophageal pH monitoring with normalresults of all investigations.results of all investigations.

Control groupControl group-- Fifteen subjects (Fifteen subjects (99 males andmales and 66females) not complaining of any GERDfemales) not complaining of any GERDsymptoms were used as controls.symptoms were used as controls.

-- They underwent upper GI endoscopyThey underwent upper GI endoscopywith esophageal biopsy andwith esophageal biopsy and 2424--hhesophageal pH monitoring with normalesophageal pH monitoring with normalresults of all investigations.results of all investigations.

RESULTSRESULTSRESULTSRESULTS

ROC curve analysis of the global severity score resultsshowed that 0.3 was the cut-off value to distinguish

patients (either ERD or NERD) from controls.

The GSS was directly related to the frequency of refluxepisodes. Patients with higher global severity score

reported more frequent reflux episodes.

The GSS was directly correlated to the time elapsedbelow pH 4.0

The GSS was directly correlated to composite acidscore (DeMeester Score)

SUMMARY ANDSUMMARY ANDCONCLUSIONSCONCLUSIONS

SUMMARY ANDSUMMARY ANDCONCLUSIONSCONCLUSIONS

OOur study shows that theur study shows that thediagnostic role of histology indiagnostic role of histology inpatients with GERD should bepatients with GERD should bereconsidered.reconsidered.

The high rates of sensitivity andThe high rates of sensitivity andspecificity lead us to stronglyspecificity lead us to stronglysupport histology in the diagnosissupport histology in the diagnosisof GERD (especially the NERDof GERD (especially the NERDentity).entity).

OOur study shows that theur study shows that thediagnostic role of histology indiagnostic role of histology inpatients with GERD should bepatients with GERD should bereconsidered.reconsidered.

The high rates of sensitivity andThe high rates of sensitivity andspecificity lead us to stronglyspecificity lead us to stronglysupport histology in the diagnosissupport histology in the diagnosisof GERD (especially the NERDof GERD (especially the NERDentity).entity).

Histopathology can be the onlyHistopathology can be the onlydiagnostic tool in NERDdiagnostic tool in NERDpatients especially when thepatients especially when therecent diagnostic techniquesrecent diagnostic techniques(such as narrow band imaging(such as narrow band imagingand high resolutionand high resolutionmagnification endoscopy) aremagnification endoscopy) arenot available.not available.

Histopathology can be the onlyHistopathology can be the onlydiagnostic tool in NERDdiagnostic tool in NERDpatients especially when thepatients especially when therecent diagnostic techniquesrecent diagnostic techniques(such as narrow band imaging(such as narrow band imagingand high resolutionand high resolutionmagnification endoscopy) aremagnification endoscopy) arenot available.not available.

Histopathology might contributeHistopathology might contributeto the assessment of someto the assessment of somesubgroups of patients (e.g. thosesubgroups of patients (e.g. thosewith atypical GERD symptoms)with atypical GERD symptoms)and play a role in the comparativeand play a role in the comparativeevaluation of different therapiesevaluation of different therapiesfor NERD treatment.for NERD treatment.

Histopathology might contributeHistopathology might contributeto the assessment of someto the assessment of somesubgroups of patients (e.g. thosesubgroups of patients (e.g. thosewith atypical GERD symptoms)with atypical GERD symptoms)and play a role in the comparativeand play a role in the comparativeevaluation of different therapiesevaluation of different therapiesfor NERD treatment.for NERD treatment.

Histology can be omitted inHistology can be omitted inpatients with erosivepatients with erosiveesophagitis since it doesesophagitis since it doesnot add valuable data,not add valuable data,whereas it provideswhereas it providesobjective additional data inobjective additional data inpatients with NERD.patients with NERD.

Histology can be omitted inHistology can be omitted inpatients with erosivepatients with erosiveesophagitis since it doesesophagitis since it doesnot add valuable data,not add valuable data,whereas it provideswhereas it providesobjective additional data inobjective additional data inpatients with NERD.patients with NERD.

We recommend using the globalWe recommend using the globalseverity score for histopathologicalseverity score for histopathologicalscoring rather than using a singlescoring rather than using a singlepathological parameter.pathological parameter.

Using the cutUsing the cut--off value (off value (00..33) can) candistinguish patients from controls.distinguish patients from controls.This simple and cheap tool canThis simple and cheap tool cancontribute to relaunch the use ofcontribute to relaunch the use ofupper GI endoscopy in patients withupper GI endoscopy in patients withGERD.GERD.

We recommend using the globalWe recommend using the globalseverity score for histopathologicalseverity score for histopathologicalscoring rather than using a singlescoring rather than using a singlepathological parameter.pathological parameter.

Using the cutUsing the cut--off value (off value (00..33) can) candistinguish patients from controls.distinguish patients from controls.This simple and cheap tool canThis simple and cheap tool cancontribute to relaunch the use ofcontribute to relaunch the use ofupper GI endoscopy in patients withupper GI endoscopy in patients withGERD.GERD.