A Critical Assessment of the Current Status of Non-Erosive Reflux Disease

Abstract

Non-erosive reflux disease (NERD) has assumed increasing prominence in studies of gastroesophageal reflux disease (GERD), but it remains a challenge to define NERD precisely and to define its place in the investigation and treatment of GERD. Most simply, NERD may be defined as GERD in an individual who has no evidence of erosions at endoscopy. Unfortunately, the characteristic symptoms of GERD – heartburn and regurgitation – are insufficient to identify all GERD patients and, hence, the diagnosis of NERD is hampered by the lack of clear criteria for the symptomatic diagnosis of GERD. The diagnosis of NERD is hampered further by limited interobserver agreement on the endoscopic diagnosis of erosive esophagitis and by the fact that endoscopy is often performed soon after patients have discontinued therapy. Improvements in endoscopic technology will increase the likelihood of identifying small erosions or other reflux-related lesions; however, this will increase the proportion of patients considered to have erosive esophagitis without defining precisely what constitutes NERD. It is important to recognize that NERD is but one manifestation of GERD and that it, like other manifestations of GERD, is associated with a marked diminution in patients’ quality of life. However, this recognition apart, there seems to be little practical benefit or understanding to be gained in clinical practice or clinical research from considering NERD as a distinct entity or from studying NERD patients in isolation. Advances in understanding the pathogenesis of GERD and its symptoms may be better served by categorizing GERD with respect to the spectrum of its histologic, functional, endoscopic and symptomatic manifestations rather than by studying NERD, a manifestation that is characterized solely by the absence of esophageal erosions.

Nonerosive gastroesophageal reflux disease and mild degree of esophagitis: Comparison of symptoms endoscopic, manometric and pH-metric patterns

“…Furthermore, the incidence is probably underestimated, because many patients have extraesophageal symptoms such as asthma, cough, hoarseness and chest pain [1,2]. …”

Treatment of non-erosive reflux disease with a proton pump inhibitor in Chinese patients: a randomized controlled trial

“…Limitations of the present study include the exclusion of RE on endoscopy, which has been recognized to be imprecise, as the accuracy of the diagnosis is dependent on the technique and observer's skill, among other factors [2]. Thus, there is a small possibility that some patients may have been misclassified as having NERD rather than RE, a condition which is more responsive to proton pump inhibition [30].…”

“…Although NERD as an entity is not well defined or well understood, 30-70% of patients with typical reflux symptoms have no endoscopic evidence of reflux-related macroscopic esophageal injury, and are thus classified as having NERD [2]. NERD is more common than reflux esophagitis (RE) [2], and is associated with symptoms that are comparable in severity and effect on the patient's quality of life (QOL) to those associated with RE. The absence of erosions does not mean these patients have milder reflux disease [2,3].…”

“…NERD is more common than reflux esophagitis (RE) [2], and is associated with symptoms that are comparable in severity and effect on the patient's quality of life (QOL) to those associated with RE. The absence of erosions does not mean these patients have milder reflux disease [2,3].…”

Symptom-histopathology relation in upper GI endoscopy

“…Although this approach is questionable, if the patient's symptoms are related to gastric acid and if they have GERD, this may be a tool to assess the efficacy of proton pump inhibitor treatment (PPI) (12 (14). None of the patients presenting with GER symtoms had reflux oesophagitis in our study.…”