Exploring the spectrum of GERD: myths and realities

Concepts of the spectrum of gastroesophageal reflux disease (GERD) continue to evolve as researchers and clinicians challenge conceptual frameworks and explore new paradigms aided by innovative technologies and novel developments in symptom assessment. In this review, the deliberations of a meeting of experts in gastroenterology (Athens, 2006) are presented as a critical evaluation of the current understanding of GERD and its symptoms, and an exploration of future directions. Consensus statements from Genval, Marrakesh and Montreal present working definitions of GERD; these will, inevitably, continue to be refined as our understanding of the spectrum of GERD-associated symptoms evolves and our appreciation of differences among non-erosive reflux disease (NERD), erosive GERD and Barrett’s esophagus, as well as the overlap between GERD and functional gastrointestinal disorders (FGIDs), grows. Currently, we lack an independent basis by which to determine whether particular symptoms are a manifestation of GERD per se or should be attributed to associated FGIDs. Furthermore our understanding of the etiology of atypical manifestations and extraesophageal symptoms is poor. It is possible that, in the future, acid-related NERD will become identifiable in terms of a microscopic inflammatory or ultrastructural change in the esophageal epithelium, thereby allowing a diagnosis of microscopic erosive reflux disease. It is likely that the natural history of GERD will be confirmed as largely benign and biomarkers will identify the minority who may be destined for a more sinister outcome. Finally, developments in symptom assessment will continue to improve our understanding of GERD and, ultimately, better predict treatment outcomes for patients.