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Clinical Study on Pathophysiology of Endoscopy-Negative GERD

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Konagaya, Toshihiro M.D.; Hayakawa, Toshihiko M.D.; Kaneko, Hiroshi M.D.; Funaki, Yasushi M.D.; Kasahara, Akihito M.D.; Kakumu, Shinichi M.D.

American Journal of Gastroenterology: September 2005 - Volume 100 - Issue - p S27
Supplement Abstracts Submitted for the 70th Annual Scientific Meeting of the American College of Gastroenterology: ESOPHAGUS
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Gastroenterology, Aichi Medical University, Nagakute, Aichi, Japan.

Purpose: The underlying mechanisms for symptoms in patients with endoscopy-negative GERD (EN-GERD) remain unclear. Proton pump inhibitors (PPI) are not always effective for relief from reflux symptoms. It was reported that prokinetics drug improved heartburn in patients of functional dyspepsia (FD). To analyze pathophysiology of EN-GERD in the view of gastric acid secretion and emptying, and long-term outcome.

Methods: Fifty-two GERD patients with chief complaint of ‘heartburn’ (38 males: mean age; 56.1 yr) gave informed consent to entry this study. GERD related symptoms intake (by QUEST; cut off: 6 points), upper gastrointestinal endoscopy, 24-h gastroesophageal pH monitoring, and gastric emptying test were performed. pH monitoring was performed under hospitalization. Gastric emptying time was determined by the paracetamol method. In 47 out of 52 subjects, prescription, symptoms and endoscopic findings were followed up for at least 1 yr (average; 1,347 d).

Results: Grades of endoscopic esophagitis were classified according to the Los Angeles classification into none (Grade O; 12 cases), mild (Grade A & B; 20), and severe (Grade C & D; 20). No correlation with esophagitis grades were determined in gender, age, QUEST score, and H. pylori status. In accordance with esophagitis grades, prevalence of hiatus hernia of the esophagus and grade of gastric mucosal atrophy were significantly higher. Lower gastro-esophageal reflux and higher gastric pH > 3 holding time ratio were observed in EN-GERD. Lower pepsinogen I/II ratio were observed in patients with none esophagitis, but gastrin concentration showed no difference among the groups. Delayed gastric emptying was observed in patients with EN-GERD as compared with either those with esophagitis or healthy volunteers (P < 0.05). Among 37 esophagitis, PPI (18 cases), H2 blocker (15), and prokinetics (1) were prescribed with no recurrence and symptom-free. In 10 EN-GERD, prokinetics alone was effective in 4 cases and PPI was needed in 2. One patients in EN-GERD developed esophagitis (Grade A).

Conclusions: The clinical characteristics of EN-GERD involve less acid reflux to the esophagus and low gastric acidity accompanied by mucosal atrophy together with delayed gastric emptying. Taking the advantage of prokinetics in EN-GERD into consideration, EN-GERD should be categorized into (dysmotility-like) FD rather than endoscopy-positive esophagitis.

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