GERD phenotypes predicting abnormal reflux burden from clinical evaluation and oesophageal testing
| Pathological GERD | ||||
| High likelihood | Intermediate likelihood | Low likelihood | Modifiers | |
| Clinical phenotypes | ||||
| Symptoms | Heartburn, acid regurgitation | Chest pain | Cough, laryngeal symptoms | Hypersensitivity and hypervigilance |
| Endoscopy | High-grade oesophagitis, Barrett’s mucosa, peptic stricture | Low-grade oesophagitis, normal exam on PPI therapy | Hiatus hernia, ongoing PPI therapy | |
| ROME IV | NERD (abnormal pH-metry)* | Symptom response to PPI therapy | Reflux hypersensitivity functional heartburn, functional chest pain | Hypersensitivity and hypervigilance |
| Lyon Consensus* | Conclusive evidence of GERD | Borderline or inconclusive evidence | Physiological reflux parameters | Novel metrics Motor classification |
| Mechanistic phenotypes | ||||
| Pattern of reflux | Increased acid exposure ±increased numbers of reflux episodes* | Borderline acid exposure±borderline numbers of reflux episodes* | Normal reflux metrics | pH of refluxate, baseline impedance, hypochlorhydria, achlorhydria |
| Mechanism of reflux | TLESR Hypotensive EGJ Abnormal EGJ morphology | Supragastric belch Rumination | Normal EGJ morphology and function | Obesity, increased abdominal girth |
| Clearance of refluxate | Absent contractility Hiatus hernia | Minor motor disorder±contraction reserve | Normal peristalsis | Xerostomia, baseline impedance, PSPW index, motor classification |
| Cognition, perception of sensation | Appropriate symptom perception, symptom reflux association | Increased perception | Visceral hypersensitivity, hypervigilance | Anxiety, depression Panic disorder |
*As described by the Lyon Consensus, figure 3.
EGD, oesophagogastroduodenoscopy; EGJ, oesophagogastric junction; NERD, non-erosive reflux disease; PSPW, postreflux swallow-induced peristaltic wave; TLESR, transient lower oesophageal sphincter relaxation.