Acid is believed to be the most injurious component of the refluxed liquid. Pepsin and bile also may injure the esophagus, but their role in the production of esophageal inflammation and damage is not as clear as the role of acid.
Several endoscopic, non-surgical techniques can be used to remove the cells. These techniques are attractive because they do not require surgery; however, there are associated with complications, and the long-term effectiveness of the treatments has not yet been determined. Surgical removal of the esophagus is always an option. Long-standing and/or severe GERD causes changes in the cells that line the esophagus in some patients.
Because our perception of nonacid reflux disease largely relies on studies performed during the preimpedance era, our current understanding is limited, especially because of the lack of epidemiological data and the undetermined impact of non-acid reflux disease. A recent multicentre trial (4) that used multichannel impedance combined with pH monitoring in patients with reflux-indicating symptoms despite being on a PPI twice daily, identified nonacid reflux in 37% and acidic reflux in 11%. Whereas the clinical approach to patients with persistent acid reflux seems evident, the approach to patients with nonacid reflux is less evolved. GERD is diagnosed clinically according to the typical symptoms that respond to treatment with a PPI or by 24 h esophageal pH monitoring, in which a pH below 4.0 is regarded to indicate acid reflux, and the length of time in which esophageal mucosa is in contact with acid is used to diagnose GERD.
Your GP will often be able to diagnose gastro-oesophageal reflux disease (GORD) based on your symptoms. But for people with GORD, stomach acid is able to pass back up into the oesophagus.
In both of these situations, the pH test can be very useful. If testing reveals substantial reflux of acid while medication is continued, then the treatment is ineffective and will need to be changed. If testing reveals good acid suppression with minimal reflux of acid, the diagnosis of GERD is likely to be wrong and other causes for the symptoms need to be sought. There are problems with using pH testing for diagnosing GERD.
Because pH is monitored simultaneously, the information obtained enables the differentiation of acid reflux from nonacid reflux using a pH cut-off of 4.0 (Figure 1). Interestingly, one of the first things that was learned using this technique is that a PPI reduces the number of acid reflux episodes; however, the absolute number of reflux episodes remains unchanged – the reflux episodes in patients taking a PPI are simply turned into nonacidic episodes (8). Multichannel impedance monitoring enables the quantification of acid and nonacid reflux episodes, and contact time and, additionally, allows us to to distinguish liquid, gaseous and mixed reflux.
If the damage goes deeply into the esophagus, an ulcer forms. An ulcer is simply a break in the lining of the esophagus that occurs in an area of inflammation. Ulcers and the additional inflammation they provoke may erode into the esophageal blood vessels and give rise to bleeding into the esophagus. Regurgitation is the appearance of refluxed liquid in the mouth. In most patients with GERD, usually only small quantities of liquid reach the esophagus, and the liquid remains in the lower esophagus.
What’s more, the true cause of their symptoms will not be pursued. There are a variety of procedures, tests, and evaluation of symptoms (for example, heartburn) to diagnose and evaluate patients with GERD.