The main symptom of gastroesophageal reflux disease (GERD) is heartburn . The retrosternal burning sensation that ascends towards the throat can have various causes, such as hypersensitivity to reflux and functional heartburn; Both factors are mainly associated with an unsatisfactory response to the administration of proton pump inhibitors (PPIs), which are considered the standard treatment.
Currently, the diagnostic criteria for the different phenotypes of heartburn are based on various studies, such as upper digestive tract endoscopy, high-resolution manometry (MAR), and 24-hour multichannel esophageal impedance-pHmetry (pH -ICM). However, many professionals still have limited knowledge about these diagnostic criteria.
In the last 10 years, the Rome III criteria have been used as a guide for the diagnosis of heartburn. Currently and due to the publication of the Rome IV criteria, the proportion of patients who have true GERD and functional esophageal disorders seems to vary according to the update of this tool.
In this study, the authors analyzed the proportion of the different heartburn phenotypes and compared both Rome criteria for its diagnosis.
| Materials and methods |
Between 2013 and 2016, patients with heartburn not previously studied, referred to the hospital where the authors of this work carry out their activities, were included.
In all cases, endoscopy of the upper digestive tract was performed before esophageal tests, a biopsy of the distal portion of the esophagus to rule out eosinophilic esophagitis, together with MAR, using a 4.2 mm external diameter catheter with 36 sensors, located one centimeter from each other.
For the pH-ICM test, a catheter was placed through the nose, whose pH electrode was located 5 cm above the lower esophageal sphincter, together with the impedance channels placed at different heights with respect to the sphincter.
Symptoms were assessed using the validated Chinese language version of the GERD Questionnaire before and after PPI administration, which was considered effective in the absence of symptoms during the last week of treatment.
Based on the Rome IV criteria, patients were classified into five different phenotypes: reflux esophagitis, non-erosive reflux disease, functional heartburn, reflux hypersensitivity, and unclassified cases (those with negative results on endoscopy and pH-ICM test, but with improvement after PPI administration). In turn, according to the Rome III criteria, the participants were divided into three categories: reflux esophagitis, non-erosive reflux disease and functional heartburn.
After the functional tests, PPIs were used for 8 weeks, administered in standard or double doses and indicated once or twice a day: esomeprazole, rabeprazole, omeprazole, lansoprazole, pantoprazole and ilaprazole.
The data obtained were compared by ANOVA analysis of variance or by the Kruskal-Wallis test. Bonferroni correction was applied for multiple comparisons and differences were considered significant with a p value of less than 0.05.
| Results |
Initially, 331 patients were selected. 233 were included with an average age of 43.35 ± 13.21 years; 122 were men.
In 174 patients, no disorders were found in the endoscopies performed, while in 59 subjects (25.32%) reflux esophagitis was observed, mainly grade A and B, according to the Los Angeles classification. In the MAR, ineffective esophageal motility was detected in 80 participants (34.33%), in 151 (64.81%) no alterations in motility were found and 2 (0.86%) participants did not have fragmented contractions.
Of the 59 patients with reflux esophagitis, 37.29% presented pathological reflux in the pH-ICM, while in the group without findings in the endoscopy (n = 174) 28 (16.09%) had pathological reflux and, according to the criteria of Rome IV, were classified in the category of non-erosive reflux disease.
In relation to the diagnosis of the phenotypes and after the clinical evaluation, based on the Rome III criteria, 59 patients received the diagnosis of reflux esophagitis, 96, non-erosive reflux disease, and 78, functional acidity. (25%, 41% and 34%, respectively).
However, using the Rome IV criteria, in 68 of the 96 participants, the diagnosis of non-erosive disease was reclassified to reflux hypersensitivity or a categorization could not be established. Thus, according to these criteria, the proportion of non-erosive reflux disease decreased to 12%.
No patient with functional heartburn responded to treatment with PPIs, while the response rate to these drugs in participants with a diagnosis of reflux esophagitis, non-erosive esophageal disease or reflux hypersensitivity was 61.36%, 65% and 36.67%, respectively. .
When the comparison was made between the different phenotypes, the authors observed that patients with GERD, according to the Rome III and IV criteria, were mostly men and had a higher body mass index (p < 0.05).
In addition, a lower number of hiatal hernias and higher values in the parameter related to the contractility of the gastroesophageal junction were observed in subjects who presented functional heartburn or reflux hypersensitivity, compared to patients with reflux esophagitis and non-esophageal disease. erosive according to the Rome IV criteria (all values were statistically significant).
No significant differences were detected in MAR parameters between patients with reflux esophagitis and those with non-erosive disease, nor between participants with functional heartburn or hyperreactivity to reflux.
| Discussion and conclusion |
Reflux hypersensitivity and functional heartburn were associated with fewer hiatal hernias and greater contractility of the esophagogastric junction.
The authors consider that this was the first work that evaluated the usefulness of the Rome IV criteria in outpatients and also that compared both criteria for the diagnosis of heartburn in clinical practice. They highlight that the incorporation of the Rome IV criteria made it possible to classify patients with heartburn into more detailed and strict categories.
The results obtained suggested that heartburn has different causes, since only true GERD was diagnosed in less than 40% of the study participants, while the application of the updated criteria made it possible to modify the diagnoses made according to the Rome III criteria in 71% of cases (from non-erosive reflux disease to reflux hypersensitivity or unclassifiable).
Likewise, hypersensitivity to reflux and functional acidity were associated with fewer hiatal hernias and greater contractility of the esophagogastric junction compared to patients with non-erosive disease according to the Rome IV criteria, a fact that does not agree with the pathophysiology of the latter. disease.
The researchers consider it important to highlight that participants without findings in the endoscopy or in the pH-ICM test, but with an adequate pharmacological response, who used to be classified within non-erosive esophageal diseases according to the Rome III criteria, were not they adapt to the updated criteria; According to experts, the reasons why these patients respond to pharmacological therapy still remain to be clarified.
The study had several limitations, such as its retrospective design, so there may be biases in relation to the evaluation of symptoms and therapeutic efficacy, the use of different PPIs and that some referred patients were already undergoing treatment, so they were not they were able to perform esophageal tests; Finally, the results should be interpreted with caution, since the analysis could be influenced by different factors.
Based on the results obtained, the authors conclude that the Rome IV criteria are more stringent for defining different phenotypes associated with heartburn and that they are superior to the Rome III criteria for distinguishing non-erosive reflux disease from functional heartburn. and hypersensitivity due to reflux.
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