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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 - p 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.