Evaluation and significance of reflux from the duodenum and stomach

SUMMARY Duodeno‐gastric and gastro‐oesophageal reflux are of potential significance in the pathogenesis of dyspepsia and heartburn. However, convincing evidence that duodeno‐gastric reflux, in itself, causes symptoms is not yet available, and none of the techniques designed to measure duodeno‐gastric reflux has gained broad clinical acceptance. Monitoring of oesophageal pH has become the gold standard, however, for demonstrating gastro‐oesophageal reflux disease, and the technique has become fairly standardized. The importance of measuring gastro‐oesophageal reflux is not so much to differentiate normal (physiological) reflux from abnormal (pathological) reflux, but rather to assess the effect of treatment and to quantify the relationship between gastro‐oesophageal reflux and symptoms. To achieve the latter, a number of indices have been described and tested, with which the temporal association between reflux and symptoms can be expressed quantitatively. It has become clear that troublesome symptoms may be induced by reflux in the absence of oesophagitis and even pathological oesophageal acid exposure. Primary indications for oesophageal pH monitoring are: reflux symptoms in the absence of oesophagitis, atypical symptoms (with or without oesophagitis), non‐cardiac chest pain, and an unsatisfactory response to the treatment of gastro‐oesophageal reflux disease.