Diagnosing non-oesophageal reflux disease in Australia

The 17th World Congress for Oesophageal Diseases, held virtually from 27–30 September 2021, brought clinicians and researchers together to examine difficult oesophageal problems. Its scientific sessions and research abstracts showed why a confident reflux label depends on evidence, not symptoms alone.

Non-erosive reflux disease, often shortened to NERD, describes reflux symptoms without erosive oesophagitis on endoscopy. The label is easily confused with functional heartburn, reflux hypersensitivity, dyspepsia and upper gastrointestinal ulcer disease, making careful history and testing essential.

Australian primary care adds practical complications: long distances, mixed public and private pathways, and patients who often describe “heartburn” simply as “indigestion” or “acid reflux.” The congress’s virtual format was therefore relevant locally, even though diagnosis still depends on services available in each community.

Symptoms that do not settle the diagnosis

Heartburn and acid regurgitation are typical reflux symptoms, but neither is unique to reflux. Chest discomfort may arise from musculoskeletal, cardiac, pulmonary or oesophageal causes, while difficulty swallowing can indicate obstruction rather than reflux.

Cough, hoarseness, throat clearing and recurrent laryngitis can accompany reflux, yet these complaints also occur with asthma, post-nasal drip, infections and voice disorders. “Reflux” should describe a supported pattern, not become a convenient explanation for every upper-body symptom.

In Australian consultations, asking what “the burning” means, when it occurs and what the patient has eaten can reveal the difference between meal-related dyspepsia and true reflux. Timing, triggers and associated symptoms often carry more diagnostic weight than the word heartburn itself.

What endoscopy can and cannot show

A normal gastroscopy does not prove that reflux is absent. It shows that visible mucosal breaks are not present at that time, which is why NERD remains a functional diagnosis requiring compatible symptoms and objective reflux evidence.

Los Angeles grading is useful, but observers can disagree about tiny erosions, and inter-observer variation is greatest at the mild end. Biopsy may be needed when another oesophageal disorder is suspected, including eosinophilic oesophagitis, but it cannot replace reflux monitoring.

Proton pump inhibitors (PPIs) can heal erosions before gastroscopy, masking the previous appearance without resolving the underlying diagnosis. Medication history is therefore crucial, particularly when a private endoscopy has been arranged after months of treatment.

Monitoring reflux beyond acid

Ambulatory oesophageal pH testing measures acid exposure over 24 hours or longer, using either a wireless capsule or a catheter. pH-impedance monitoring uses impedance changes to detect weakly acidic or non-acid reflux that pH alone may miss.

Both methods rely partly on diaries, so patients must record meals, lying down, symptoms and unusual activity. In Australia, that may include early-morning coffee, a long driving shift, a barbecue or late dinner during a mining or transport roster.

A reflux-symptom association can support the diagnosis when the timing is convincing, but a coincidental association is possible. Multiple symptoms and repeated events must be interpreted together; one symptomatic reflux episode does not establish reflux disease.

Interpreting results in clinical context

Acid exposure time (AET) is not a pass-or-fail measure. Lyon Consensus thresholds help classify conclusive or inconclusive evidence, yet borderline readings require symptoms, endoscopy and medication use to be considered before a patient is labelled either positive or negative.

For unproven reflux or symptoms in established gastro-oesophageal reflux disease, supervised withdrawal of PPIs may be needed before off-therapy monitoring. This can be inappropriate for severe symptoms and should not be attempted without clinical direction. On-therapy testing is more useful for selected patients whose symptoms persist despite treatment.

Results must also be weighed against complications and alternatives. Dysphagia, odynophagia, gastrointestinal bleeding, persistent vomiting, iron deficiency or weight loss warrant specific investigation rather than a simple reflux diagnosis.

Paediatric clues and longer horizons

Children may present with crying, feeding refusal, back-arching, poor weight gain or respiratory symptoms rather than verbal heartburn. Physiological reflux is common in infancy, so indiscriminate PPI prescribing can expose infants to harms without establishing the cause.

The ISDE 2021 site’s coverage of long-term gastrointestinal outcomes after oesophageal atresia illustrates the value of following swallowing and reflux problems across childhood and adulthood. Structural repairs and repeated interventions can leave a symptom pattern that needs specialist interpretation, not a generic reflux label.

Paediatric history should therefore include feeds, growth, respiratory admissions and previous procedures. The same discipline applies in adults: prior surgery, pregnancy, obesity, hiatus hernia and medication effects may alter the meaning of a monitoring result.

An Australian pathway to a careful diagnosis

Australian care commonly begins with a general practitioner who manages reflux, gives a prescription or “script,” and refers privately or through Medicare to a gastroenterologist. Public hospital outpatient lists can be long, while private appointments may involve gaps charged to patients.

Specialist services are concentrated in major cities such as Melbourne, Sydney and Brisbane, leaving rural and remote clinicians to use telehealth and shared care. Pathology, gastroscopy and pH-impedance monitoring still need local access, and results may need transfer between regional and metropolitan centres.

Community pharmacists often hear about reflux first and can identify medication triggers, unsuitable antacids and adherence problems. Aboriginal and Torres Strait Islander patients also need equitable access, respectful communication and culturally safe assessment, particularly where distance and distrust of institutions affect willingness to undergo testing.

A sound diagnosis combines a clear symptom pattern, a properly timed endoscopy and, when needed, reflux monitoring interpreted by someone who understands medication, comorbidities and local lifestyle. It also keeps functional heartburn, reflux hypersensitivity and other oesophageal disorders in view.

The point to remember is that a normal endoscopy does not end the investigation, and an abnormal reflux number does not finish the reasoning. NERD is a carefully supported clinical conclusion, not a label for indigestion that happens to improve with an acid suppressant.