Distinct phenotypic presentations of gastroesophageal reflux disease: a new view of the natural history

Abstract

For decades the natural history of gastroesophageal reflux disease (GERD) has been approached as spectrum-continuum, emphasizing the potential progress over time of patients along the spectrum. This commonly adopted conceptual framework had a profound impact on the field, affecting our research priorities and current management of GERD patients. A recent new conceptual framework has been proposed, suggesting that in response to factors that promote gastroesophageal reflux, patients may develop 3 distinct phenotypic presentations: non-erosive reflux disease; erosive esophagitis, and Barrett's esophagus. Most studies thus far, albeit unsatisfactory in their design, have demonstrated a very limited movement in between the 3 phenotypic presentations of GERD, further suggesting that those once determined remain true to form. The new conceptual framework emphasizes the importance of understanding symptom generation in GERD and the need to focus on the etiology and management of each phenotypic presentation of GERD. Additionally, it supports the usage of on-demand or intermittent antireflux treatment in clinical practice and provides better understanding of one of the most important clinical dilemmas - proton pump inhibitor failure.