Non-erosive GERD, Barrett's esophagus

Malcolm Robinson MD: There's a lot of controversy as to exactly how much symptomatology in nonerosive reflux disease is acid-mediated. Clearly, a good bit of the symptom complex is related to acid, because acid inhibition does relieve many of these patients very successfully. On the other hand, there are certainly patients with nonerosive reflux disease who do not respond or respond less than perfectly to acid suppression. In some of these patients, it is presumed that they may have motor disturbances for which motility drugs might be helpful.

Alan Cutler MD: Some patients have an acid-sensitive esophagus. That is, that acid refluxes up and causes them great symptoms. When you look on a 24-hour pH probe, the amount of acid hitting the esophagus is not large enough to define it as pathological. The patients, however, are acutely aware of each of these small episodes of reflux disease; that is, acid-sensitive esophagus.

Malcolm Robinson MD: The typical patient with nonerosive reflux disease should probably be treated initially with acid suppression. In my experience, this works out very well for the great majority of patients, most of whom become quite asymptomatic and often in a very short time.

Alan Cutler MD: The primary therapeutic option for nonerosive GERD are proton pump inhibitors; they are the basis for therapy. After that, we may move on to promotility agents. We may move on to antidepressants in an effort to reduce the patient's sensory input from the esophagus.

Malcolm Robinson MD: Barrett's esophagus is a very complicated issue [Editor's note: see also Gastro-Pro's learning modules on Barrett's]. There is no doubt that Barrett's esophagus is related to reflux disease. It is clearly related epidemiologically to long-standing reflux disease, and probably is more likely in severe reflux disease. However, symptoms do not necessarily predict reflux severity, and therefore symptoms do not reliably predict Barrett's. On the contrary, Barrett's esophagus is most likely to be present in patients who actually have had no symptoms at all, and the majority of people who in fact are found to have Barrett's esophagus in epidemiologic studies based on autopsies are patients who never had any gastroesophageal reflux complaints at all

Alan Cutler MD: Barrett's is more common in Caucasian males over age 40. We don't know exactly where Barrett's comes from and we're not sure how it develops. And at this point, we do not have an ability to get rid of it or prevent its progression.

We hope that very strong acid reduction will reduce the progression to malignancy, but this has not been proven yet.

If you have Barrett's esophagus, the risk of malignancy is about a half a percent per year. We survey Barrett's patients; we do endoscopy at regular intervals to look for any early changes towards cancer, so that we can intervene more aggressively.

In general, patients with Barrett's esophagus are placed on a proton pump inhibitor once a day. We have yet to show that this prevents the progression to malignancy or achieves any reduction in the size of the Barrett's, but it remains the standard of care.

Malcolm Robinson MD