The Spectrum of Reflux Phenotypes

Abstract

The focus on a symptom-based definition for gastroesophageal reflux disease (GERD) in adults and children has contributed to widespread use of acid suppression medications in patients with so-called typical reflux symptoms to treat the possibility of acid-mediated disease. Diagnostic testing with upper endoscopy, esophageal biopsies, ambulatory reflux monitoring, and/or esophageal manometry is often pursued when patients do not respond optimally to these medications. By using information from this diagnostic testing, GERD has shifted from a single diagnosis to a phenotypic spectrum, and each phenotype has unique pathophysiologic mechanisms driving symptom perception. Understanding these mechanisms is important to tailor individualized treatment plans and guide therapeutic interventions. The aim of this article is to discuss the different reflux phenotypes, the utility of esophageal reflux testing, the mechanisms underlying symptoms, and the management strategies for each phenotype.

Keywords: Multichannel intraluminal impedance; functional heartburn; nonerosive reflux disease; proton pump inhibitor; reflux hypersensitivity.

Figure.

Proposed algorithm for the approach to bothersome symptoms in older children. EGD, esophagogastroduodenoscopy; EoE, eosinophilic esophagitis; GERD, gastroesophageal reflux disease; H2RA, histamine 2 receptor antagonist; NERD, nonerosive reflux disease; pH-MII, multichannel intraluminal impedance with pH; PPI, proton pump inhibitor.