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Bowel Symptoms in Nonerosive Gastroesophageal Reflux Disease: Nature, Prevalence, and Relation to Acid Reflux

Zimmerman, Joseph MD; Hershcovici, Tiberiu MD

Journal of Clinical Gastroenterology: March 2008 - Volume 42 - Issue 3 - pp 261-265
doi: 10.1097/MCG.0b013e31802fc591
ALIMENTARY TRACT: Clinical Research

Background: Nonerosive gastroesophageal reflux disease (NERD) patients frequently show features of the irritable bowel syndrome (IBS).

Aims: To investigate the prevalence and intensity of bowel symptoms and their relationship to esophageal acid exposure in NERD patients.

Methods: Bowel and reflux symptoms and IBS status were assessed in NERD patients (normal upper endoscopy; esophageal pH <4 for ≥5% of the time on 24-h pH monitoring; n=326), in relation to nonpatient controls. Bowel symptoms were scored on the 3 scales: diarrhea, constipation, and pain/gas symptoms.

Results: NERD and age were independently associated with bowel symptoms. NERD patients scored significantly higher than controls on all bowel scales. In a multivariate analysis, the scores on the pain/gas scale were independently associated with NERD. In NERD patients, reflux symptoms independently predicted the bowel symptoms while acid exposure did not. Forty-nine percent of the NERD patients and 18% of the controls met the criteria for IBS [IBS(+)NERD]. IBS(+)NERD patients scored significantly higher than those not meeting IBS criteria [IBS(−)] on all bowel scales. Yet IBS(−) patients scored significantly higher than controls on the scales of constipation and pain/gas. IBS(+)NERD patients scored higher than IBS(−) also on the GERD symptoms scale.

Conclusions: (1) NERD patients scored significantly higher than controls on all the bowel scales; (2) Bowel symptoms were associated with reflux symptom scores, but not with acid exposure. (3) The presence of IBS features in a large proportion of NERD patients reflects a high prevalence of visceral hypersensitivity that may aggravate acid reflux symptoms.

Gastroenterology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel

The authors declare no conflict of interest.

The authors confirm that there is no financial arrangements.

Reprints: Tiberiu Hershcovici, MD, Gastroenterology Unit, Hadassah University Hospital, Jerusalem, Israel 91120 (e-mail:

Received for publication August 10, 2006; accepted November 22, 2006

© 2008 Lippincott Williams & Wilkins, Inc.