The Clinical Course of Reflux Esophagitis

Reflux esophagitis - how does it progress? 

The clinical course of reflux esophagitis, or in other words the way the disease is likely to progress or not, depends to a great extent on whether the person has erosive or non-erosive gerd when the initial diagnosis is made. It is interesting that generally patients do not tend to cross over from one group to another unless they are treated medically or surgically. When studied in follow-up (length of time varied from 6 months to over 5 years) only 15% of those patients with non-erosive disease evolved over time to having esophagitis or complications of GERD.

Non-erosive reflux disease

Medical thinking about the progression of gerd has changed over the years. The first studies from large medical centres (tertiary referral centres) found that almost half of people with acid reflux disease had signs of esophagitis. More recent research studies, which have taken place in community practices, have found that about 70% of the patients with GERD had a normal esophagus when examined with an endoscope. In addition, another study carried out in the community, of antacid users found that about 50% of patients with GERD had non-erosive disease, and two-thirds of the remainder had only mild erosive changes when endoscoped. Patients with a normal endoscopy and symptoms of acid reflux disease are more likely to be female, young, thin, and not have a hiatus hernia. Despite their mild mucosal damage of the esophagus, these gerd sufferers had a long-term (chronic) pattern of symptoms with times of flare up and remission. Medical research studies suggest that the dilation (opening) of the spaces between the cells lining the esophagus is a histological (microscopic) marker of this disease, regardless of the amount of exposure of the esophagus to refluxed stomach acid.

The diagnosis of non-erosive GERD is made when a person has typical reflux symptoms (heartburn etc.), has a normal upper gastrointestinal endoscopy and has a good symptomatic response to anti-secretory therapy (i.e.treatment with a proton pump inhibitor - PPI).

When patients are tested with 24-hour esophageal pH monitoring doctors have found three distinct groups of patients with non-erosive gerd:

Patients who have abnormal acid exposure times and who respond to anti-secretory treatment with a PPI.

Patients with normal reflux parameters (results from esophageal pH monitoring which are within the normal range for the population) and a good relationship between acid reflux episodes and symptoms. This group amounts to about 30%–50% of patients with non-erosive gerd they have “functional heartburn” . These patients probably have heightened esophageal sensitivity to acid and are less likely to respond to anti-reflux therapy.

Patients with normal acid exposure times and poor symptom correlation. Despite sometimes having classical re?ux symptoms, other medical conditions such as achalasia, gastroparesis, bile reflux, or functional dyspepsia are the cause of their symptoms.

Generally those patients with non-erosive gerd do not respond to anti-reflux treatments as well as patients with erosive GERD. This is probably because these three groups of people are not carefully delineated before treatment.

Erosive reflux disease

The clinical course of patients who have erosive esophagitis is more predictable than those with non-erosive esophagitis and is associated with complications of gerd. Careful medically controlled studies have found that, without ongoing maintenance therapy with acid suppression drugs, up to 85% of patients with erosive GERD will have a relapse within 6 months. The relapse rate is highest in those patients who have the more severe degrees of esophagitis. Despite this, medical specialists in gastroenterology still usually recommend at least one attempt to withdraw medication. This is because it has been found that 20% of patients will be in remission for up to 1 year, especially those who have the milder esophagitis grades.

The natural history of untreated erosive GERD has been well studied, and two clinical studies in Europe have indicated that these patients are more prone to reflux complications. In a study in Finland, 20 patients with erosive GERD treated with lifestyle changes, antacids, and prokinetic drugs were followed up for a median of 19 years. In total, 14 patients continued to have erosions, and six new cases of Barrett esophagus were detected. In a similar large retrospective European study with 6.5 years of follow-up there was a high rate of complications (21%) including 13 patients with esophageal ulcers, 15 with strictures, and 45 with Barrett epithelium. These days it is unlikely that patients would not receive treatment with PPI's and it is unlikely that ethical approval would be given for this sort of trial now. However, these data must be contrasted with other studies, for example a 2-year trial in the United States in which no patients with erosive esophagitis developed Barrett esophagus, and a study over a 12-year period of 3800 French patients in whom the development of stricture was reported in only 0.26%.

If you have persistent or recurrent heartburn then it is important to receive optimal medical treatment and to consult your doctor regularly. Acid reflux disease is readily and effectively treated with medication and a GERD diet. With proper treatment, complications are less likely to develop.