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Functional esophageal disorders / General approach to functional esophageal disorders
General approach to functional esophageal disorders
Treatment remains largely empirical, although the efficacy of several interventions (psychopharmacological agents and psychological or behavioral approaches) has been established for several functional esophageal disorders(2).
Treatment for functional esophageal disorders remains largely empirical(1,2). ]
As gastroesophageal reflux disease presentation overlaps most of these disorders and because symptoms are, at least partially, caused by acid reflux events in many patients, antireflux therapy also plays an important role both in diagnosis and management(2). Management approaches that modulate central symptom perception or amplification often are required once local provoking factors (e.g., noxious esophageal stimuli) have been eliminated(1).
Future research should address further understanding of the fundamental mechanisms responsible for symptoms, as well as development of novel management strategies with the consideration of treatment outcome in a sense broader than the mere reduction in esophageal symptoms, and definition of the most cost-effective diagnostic and treatment approaches(1). Likewise, the value of inclusive rather than restrictive diagnostic criteria that encompass other gastrointestinal and non-gastrointestinal symptoms should be examined to improve the accuracy of symptom-based criteria and reduce the dependence on objective testing(2).
Therefore, GERD is the first diagnosis when reflux esophagitis or excessive esophageal exposure to acid is present, or when symptoms are closely related to acid reflux events or responsive to antireflux therapy(1). ]
The purpose of this modification is to give preference to GERD diagnosis over a functional disorder in the initial evaluation, enabling thus to reduce the risk of overlooking GERD treatments in management(1). "Consequently, the acid-sensitive esophagus is now excluded from the group of functional esophageal disorders and considered within the realm of GERD, even if physiologic data indicate that hypersensitivity of the esophagus in this setting may involve stimuli other than acid(1)" .
"Presumably, symptoms that persist despite interventions for GERD or that are out of proportion for GERD findings would be reconsidered as indicating a potential functional diagnosis(1)".
The role of weakly acidic reflux events (i.e. pH between 4 and 7) remains unclear, and technological advances are expected to further define the small proportion of cases with functional heartburn that truly meeting all stated criteria(1,4). The development of intraluminal impedance monitoring has highlighted the fact that pH monitoring does not detect all gastroesophageal reflux events, inclusive when little or no acid is present in the reflux, even if special pH tracing analysis criteria are used(5).
1. Galmiche J.P., Clouse R.E., Bálint A. Functional esophageal disorders. Gastroenterology 2006; 130 (5): 1459-1465.
2. Clouse R.E., Richter J.E., Heading R.C. Functional esophageal disorders. Gut 1999; 45 Suppl 2: II31-II36.
3. Functional esophageal disorders. In: Drossman DA, Corazziari E, Delvaux M, Spiller R, Talley NJ, Thompson WG, Whitehead WE, eds. Rome III. The functional gastrointestinal disorders. 3rd ed. McLean, VA: Degnon Associates (in press).
4. Sifrim D. Acid, weakly acidic and non-acid gastroesophageal reflux: differences, prevalence and clinical relevance. Eur J Gastroenterol Hepatol 2004; 16: 823-830.
5. Sifrim D., Castell D., Dent J. Gastro-oesophageal reflux monitoring: review and consensus report on detection and definitions of acid, non-acid, and gas reflux. Gut 2004; 53 (7):1024-1031.
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