Letter to Editor “Exploring the association between esophageal mucosal inflammation, impaired motility and GERD”: Author’s reply

Abstract

Dear Editor, We are grateful to Drs Ribolsi and Savarino for their interest in our study of THE MECHANISMS ASSOCIATED WITH REFLUX EPISODES IN AMBULANT SUBJECTS WITH GASTROESOPHAGEAL REFLUX DISEASE.1 We agree that impaired esophageal motility is of key importance for clearance of refluxate from the esophagus following gastroesophageal reflux and, therefore, for mucosal damage due to gastroesophageal reflux disease (GERD). We also agree that the interesting issue of whether impaired esophageal motility is a primary or secondary phenomenon associated with chronic refluxinduced inflammation remains unresolved. Factors such as the esophagogastric junction (EGJ) morphology, the presence of a hiatus hernia, and the ineffective motility (IEM) increase the confidence in the presence of pathological GERD, when evidence is otherwise borderline or inconclusive.2 A higher esophageal reflux burden is reported within IEM, with higher acid exposure when more than 70% sequences are ineffective.3 In the Chicago 4.0 classification based on emerging data, the definition of IEM became more stringent and might better identify the association between higher esophageal reflux burden and IEM in the context of GERD.4 In our study of 27 patients with different severities of GERD, the esophageal acid clearance time was much longer times in those with severe esophagitis or BE and this was the clearest difference between the two GERD groups. HRM recommended by Drs Ribolsi and Savarino will only reveal a diagnosis of IEM based on primary peristalsis, when the phenomenon of esophageal refluxate clearance is more complex than this. It includes the ability of the esophageal smooth muscle to generate effective peristalsis to transport neutralizing saliva to the distal esophagus through primary peristalsis (postreflux swallowinduced peristaltic wave) or through secondary peristalsis.5 Sensation of the refluxate to induce primary or secondary peristalsis and variations in the neutralizing capacity of swallowed saliva are also likely to play an important role. Other new provocative tests such as multiple rapid swallows (MRS) that define the esophageal body contraction reserve, assessing the ability of the esophageal smooth muscle to augment contraction when challenged, may help to better understand the differences within IEM.6 New effective and safe prokinetic drugs would certainly be welcome for the management of GERD and other upper GI disorders. However, it is important to remember that refluxate clearance is a more complex process than simply an impairment of primary peristalsis and this is certainly an area of GERD pathophysiology that merits further study given the link with the severity of mucosal injury.