Symptoms and endoscopic findings--can they predict abnormal nocturnal acid gastro-oesophageal reflux?

Nocturnal gastro-oesophageal reflux is known to be particularly damaging to the oesophageal mucosa, being associated with stricture formation and columnarisation. At present, this can only be detected by prolonged intra-oesophageal pH monitoring. A total of 50 patients with endoscopic oesophagitis were evaluated by ambulatory pH monitoring to detect the presence of nocturnal reflux. Whether certain symptoms in the presence of a hiatal hernia would identify those patients with reflux at night was investigated. Thirty-three patients had nocturnal reflux, two-thirds of whom had a hiatal hernia. Heartburn at night was of limited value (specificity = 65%) in detecting acid reflux whereas regurgitation and cough showed greater specificity (88% and 100% respectively) but lacked sensitivity (45% and 12% respectively). The combination of nocturnal symptoms and a hiatal hernia in patients with endoscopic oesophagitis correctly identified 58% of patients with nocturnal reflux and was highly specific (100%). This study has confirmed that symptoms and endoscopic findings can detect a significant proportion of 'at risk' patients, but the remainder will require pH monitoring to assess their pattern of acid exposure.