Dig Dis Sci (2011) 56:2871–2878
DOI 10.1007/s10620-011-1708-9
ORIGINAL ARTICLE
Algorithmic Approach to Patients Presenting with Heartburn
and Epigastric Pain Refractory to Empiric Proton Pump Inhibitor
Therapy
Andrew K. Roorda • Samuel N. Marcus •
George Triadafilopoulos
Received: 1 April 2009 / Accepted: 4 April 2011 / Published online: 22 April 2011
Ó Springer Science+Business Media, LLC 2011
Abstract
Background Reflux-like dyspepsia (RLD), where pre-
dominant epigastric pain is associated with heartburn and/
or regurgitation, is a common clinical syndrome in both
primary and specialty care. Because symptom frequency
and severity vary, overlap among gastroesophageal reflux
disease (GERD), non-erosive reflux disease (NERD), and
RLD, is quite common. The chronic and recurrent nature of
RLD and its variable response to proton pump inhibitor
(PPI) therapy remain problematic.
Aims To examine the prevalence of GERD, NERD, and
RLD in a community setting using an algorithmic approach
and to assess the potential, reproducibility, and validity of a
multi-factorial scoring system in discriminating patients
with RLD from those with GERD or NERD.
Methods Using a novel algorithmic approach, we evalu-
ated an outpatient, community-based cohort referred to a
gastroenterologist because of epigastric pain and heartburn
that were only partially relieved by PPI. After an initial
symptom evaluation (for epigastric pain, heartburn, regur-
gitation, dysphagia), an endoscopy and distal esophageal
A. K. Roorda
Section of Digestive Diseases, West Virginia University School
of Medicine, Morgantown, WV, USA
G. Triadafilopoulos (&)
Division of Gastroenterology and Hepatology, Stanford
University School of Medicine, Alway Building, Room M 211,
300 Pasteur Drive, MC: 5187, Stanford, CA 94305-5187, USA
e-mail: vagt@stanford.edu
S. N. Marcus
El Camino GI Medical Associates, Mountain View, CA, USA
biopsies were performed, followed by esophageal motility
and 24-h ambulatory pH monitoring to assess esophageal
function and pathological acid exposure. A scoring system
based on presence of symptoms and severity of findings
was devised. Data was collected in two stages: subjects in
the first stage were designated as the derivation cohort;
subjects in the second stage were labeled the validation
cohort.
Results The total cohort comprised 159 patients (59
males, 100 females; mean age 52). On endoscopy, 30
patients (19%) had complicated esophagitis (CE) and 11
(7%) had Barrett’s esophagus (BE) and were classified
collectively as patients with GERD. One-hundred and
eighteen (74%) patients had normal esophagus. Of these,
94 (59%) had one or more of the following: hiatal hernia,
positive biopsy, abnormal pH, and/or abnormal motility
studies and were classified as patients with NERD. The
remaining 24 patients (15%) had normal functional studies
and were classified as patients with RLD. Utilizing the
scoring system a total score was calculated for each patient
and effectively distinguished patients with GERD (mean
score 9), NERD (mean score 6), and RLD (mean score 3).
Receiver operating characteristic (ROC) curves confirmed
the optimization of the model, particularly in RLD
(P = 0.0001, 95% CI: 0.91–0.98).
Conclusion In a community cohort of patients presenting
with heartburn and epigastric pain partly refractory to
empiric PPI therapy, the prevalence of CE was 19%, BE
7%, NERD 59%, and RLD 15%. An algorithmic approach
coupled with a novel scoring system, effectively distin-
guishes GERD from NERD and RLD and facilitates further
management decisions. This novel and simple scoring
system is both reproducible and validated as a diagnostic
aid in evaluating patients presenting with both epigastric
pain and heartburn.
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Keywords Dyspepsia
Gastroesophageal reflux disease

Endoscopy
Esophageal motility
Esophageal pH
monitoring
Introduction
Dyspepsia is a common gastrointestinal syndrome with a
multi-factorial etiology and pathophysiology. Depending on
how it is defined, dyspepsia has a yearly incidence of
13–40%, but most affected people do not seek medical care
[1]. Dyspepsia accounts for significant health care costs and
absenteeism [2]. The international Rome III committee
defined dyspepsia as one or more of the following symp-
toms: postprandial fullness, early satiety, and epigastric pain
or burning [2]. There is controversy about whether heartburn
should be included in the definition of dyspepsia, because
patients often find it difficult to describe a predominant
symptom (i.e. epigastric pain or heartburn), and even when
they do, it may change over time [3]. The Rome III criteria do
not include heartburn in the definition, but the 1988 working
party defined dyspepsia as both epigastric pain and heartburn
[4]. The term ‘‘reflux-like dyspepsia’’ has been coined to
denote this combination of symptoms, in contrast with
‘‘ulcer-like dyspepsia or ‘‘dysmotility-like’’ dyspepsia,
where epigastric pain and nausea, respectively, may pre-
dominate [5]. In reality, there is substantial overlap of these
symptoms in clinical practice. In a Canadian primary care
study, the mean number of symptoms reported for patients
with dyspepsia was six, and these often included typical
heartburn [6]. It is therefore difficult to establish the accu-
racy of predominant reflux symptoms for diagnosing gas-
troesophageal reflux disease (GERD) in the uninvestigated
patient in primary care. In a recent systematic literature
review of the accuracy of primary care physicians, gast-
roenterologists, or computer models in diagnosing organic
dyspepsia, neither clinical impression nor computer models
that incorporated patient demographics, risk factors, history
items, and symptoms adequately distinguished between
organic and functional disease in patients referred for
endoscopic evaluation of dyspepsia [7].
In order to overcome these clinical difficulties, the main
objective of this study was to evaluate the potential,
reproducibility, and validity of a multi-factorial scoring
system in discriminating patients with epigastric pain and
associated heartburn to those with true GERD versus those
with dyspepsia. Because long-term management, natural
history, and prognosis of these two clinical entities differ,
this novel, arbitrary system takes into consideration several
variables—clinical, endoscopic, functional, and histo-
logic—in order to provide the highest level of confidence
in making an accurate diagnosis and, in turn, to assist in
long-term management of these patients.
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Dig Dis Sci (2011) 56:2871–2878
Patients and Methods
Patients and Algorithm
The study was approved by the Institutional Research
Board of El Camino Hospital, Mountain View, CA, USA,
and conducted at the Esophageal Function Laboratory of
the Mountain View Endoscopy Center and El Camino
Hospital, both in Mountain View. Only patients referred
because of recurring epigastric pain and heartburn that
were only partially relieved by empiric PPI therapy
implemented by their primary care provider were included
in this study. Each patient was assessed using the following
diagnostic algorithm: after initial symptom evaluation
(for epigastric pain, heartburn, regurgitation, dysphagia),
endoscopy (including assessment for hiatal hernia) and
distal esophageal biopsies were performed, followed by
esophageal motility and 24-h ambulatory pH monitoring to
assess esophageal function and pathologic acid exposure
(Fig. 1). A simple scoring system based on presence of
symptoms and severity of findings was devised (Table 1).
Symptom Assessment and Scoring
Both symptoms of epigastric pain and heartburn were
necessary for inclusion in the study and each symptom
received 1 point. Additionally, two esophageal symptoms,
acid regurgitation and dysphagia, if present, received 1
point each (Table 1).
Endoscopy and Biopsies
Patients were classified endoscopically as having either
normal esophagus (stage 0–1, 0 points), erosive esophagitis
or esophageal ulcer (stage 2, 1 point), esophageal stricture
(stage 4, 2 points), or Barrett’s esophagus (3 points) using
the Savary–Miller classification [8]. Barrett’s esophagus
(BE) was defined as any length of endoscopically visible
and histologically proven intestinal metaplasia, extending
proximally from the esophago–gastric junction [9, 10].
Patients without hiatal hernia received 0 points; those with
sliding hiatal hernia \2 cm received 1 point; 2 points were
given for [2 cm hiatal hernia. If any gastric or duodenal
pathology was found upon endoscopy, patients were
excluded from the study, because their dyspepsia was
attributed to the pathology found. Distal esophageal biop-
sies were taken using a standard-size biopsy forceps at
5 cm above the EGJ. The criteria of Ismail-Beigi et al. [11]
and Bowery et al. [12] were used to assess histological
changes of reflux. Patients with histologically normal distal
esophagus received 0 points; those with neutrophilic
inflammation 1 point; those with intestinal metaplasia
received 2 points.
Dig Dis Sci (2011) 56:2871–2878 2873

Fig. 1 Diagnostic algorithm to

differentiate between GERD,
NERD, and RLD

Table 1 The scoring system

Variable 0 points 1 point 2 points 3 points
used in this study
Epigastric pain Absent Present
Heartburn Absent Present
Acid regurgitation Absent Present
Dysphagia Absent Present
Endoscopy Normal Esophagitis/ulcer Stricture Barrett’s esophagus
Hiatal hernia Absent B2 cm [2 cm
Esophageal biopsy Negative Inflammation Barrett’s esophagus
DeMeester score B15 16–25 26–50 C51
LESP (mm Hg) [10 B10

Esophageal Motility Studies of esophageal body contractility below 20 mmHg, or

Esophageal manometry was performed using a low-com-
pliance pneumo-hydraulic capillary infusion system con-
nected to a fully automated esophageal motility analysis
system (Medtronic, Minneapolis, MN, USA). All patients
were studied supine after at least an 8-h fast. The mano-
metric studies were interpreted independently, without
knowledge of the patients’ symptom severity, endoscopic,
or ambulatory esophageal pH-monitoring data. The station
pull-through technique was used to assess LES competence
and esophageal body peristalsis. Compromised esophageal
peristalsis was defined as reduction of the mean amplitude
[75% failed or absent peristalsis [13]. For purposes of the
scoring system, 0 points were assigned to patients with
LESP of more than 10 mm Hg, and 1 point for LESP less
than or equal than 10 mm Hg.
Ambulatory 24-h pH Monitoring
Twenty-four-hour pH monitoring was performed using
either a dual sensor pH catheter connected to a portable
digital data recorder that stored pH data for up to 24 h or a
Bravo pH monitoring system for up to 48 h (Medtronic).
The positioning of the catheter was established on the basis

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of the pH differential between the distal (intra-gastric) and
proximal (intra-esophageal) sensors and previous LES
identification by esophageal motility. The positioning of
the Bravo capsule was determined on the basis of the
previous LES identification by esophageal motility and the
location of the esophago–gastric junction by endoscopy.
Patients then returned home with instructions to keep a
diary for recording symptoms, meal intake times, and body
position. They were also instructed to separately record the
time they remained supine at night, irrespective of sleep.
Patients were encouraged to carry out normal daily activ-
ities without dietary restrictions. No antacid or anti-secre-
tory drugs were given or allowed during the study. Data
were analyzed using EsopHogram software (Medtronic).
The percentage of time with pH \4.0 in the distal esoph-
agus was analyzed separately for total, upright, and supine
periods and the DeMeester score was calculated and used
for scoring [14]. Because the Bravo system monitors pH
for 48 h, we only used the data from the worse of the two
24-h periods of pH recording to assign a pH score to
patients who underwent pH monitoring with this technique.
Scoring
Depending on the findings upon clinical, endoscopic, histo-
logic, and functional evaluation, three groups were identified:
1. reflux-like dyspepsia (RLD) group, where a normal
endoscopy was associated with normal esophageal
biopsy, no hiatal hernia and normal pH and motility
studies (score range 2–4);
2. non-erosive reflux disease (NERD), where normal
endoscopy was associated with more esophageal
symptoms, abnormal pH studies, and possibly with
hiatal hernia, low LESP and inflammation on esoph-
ageal biopsy (score range 3–11); and
3. GERD, where erosive esophagitis or BE were found
together with more esophageal symptoms, hiatal
hernia, abnormal pH studies and LES hypotension
(score range 4–15).
According to this system, a minimum score for patients
included in this study would be 2 (2 points for epigastric
pain and heartburn, no dysphagia or regurgitation, negative
endoscopy and biopsy, no hiatal hernia, and normal LES
pressure and pH study) and such patients would be clas-
sified as having RLD. At the other extreme, a patient with
severe, complicated GERD and BE would have a score of
15 (4 points for all four symptoms, 3 points for endoscopic
BE, 2 points for histologic intestinal metaplasia, 2 points
for hiatal hernia, 1 point for LESP hypotension, and 3
points for pathologic pH profile).
On the basis of these data, patients were assigned to one
of three groups: The 41 patients with evidence of
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Dig Dis Sci (2011) 56:2871–2878
complicated esophagitis or BE were assigned to the GERD
group. Ninety-four of the remaining 118 patients with
normal endoscopy had an abnormality in hiatal hernia,
esophageal biopsy, pH study, and/or motility study and
were assigned the NERD group. The remaining 24 patients
with normal endoscopy had no evidence of hiatal hernia,
negative biopsy, and normal pH and motility studies and
were assigned to the RLD group.
Data Collection/Validation
Data were collected in two stages. One-hundred and ten
patients comprised the first stage and were defined as the
derivation cohort. The second stage consisted of 63
patients who were defined as the validation cohort. After
data obtained from the validation cohort were compared
against data collected in the derivation cohort, reproduc-
ibility and validity were assessed.
Statistical Analysis
The level of significance was set at P \ 0.05. Data are
presented in figures as bar graphs or in tables, as appro-
priate. Receiver operating characteristic (ROC) curves that
graphically plot the sensitivity versus (1 - specificity) of
the model were also performed in order to confirm the
value of the proposed model.
Results
Over a period of 24 months (January 2005–December
2006), 159 patients (59 males, 100 females) presenting
with heartburn and epigastric pain partly refractory to PPI
treatment entered the study. Their mean age was 52 (range
13–87). Table 2 depicts baseline demographics and clinical
characteristics of our study patients. Upon symptom
questioning, all patients reported heartburn and epigastric
pain, as this was a prerequisite for entry into the study.
Additionally, 84% reported regurgitation and 39% had
dysphagia. The mean total symptom scores in the three
study groups were indistinguishable from each other
(Table 2).
Upon endoscopy, 41 patients had evidence of GERD, 30
(19%) had esophagitis, ulcers or strictures (classified col-
lectively as CE), and 11 (7%) had endoscopically dis-
cernable BE. The other 118 (74%) patients had normal
esophagus. Thirty-nine patients (24.5%) had a hiatal her-
nia, 25 (15.7%) small (\2 cm) and 14 (8.8%) large
([2 cm).
Upon review of distal esophageal biopsies, 49 (30.8%)
patients had evidence of inflammation, 11 (6.9%) patients
had intestinal metaplasia, and 99 (62.3%) patients had a
Dig Dis Sci (2011) 56:2871–2878 2875

Table 2 Patients’
RLD NERD GERD TOTAL
characteristics
N (%) 15 59 26 100
Patient mean age (years, range) 50 (23–87) 51 (13–82) 54 (22–78) 52 (21–87)
Males:females 11:13 29:65 19:22 59:100
Symptoms (%)
Epigastric pain 15 59 26 100
Heartburn 15 59 26 100
Acid regurgitation 13 50 21 84
Dysphagia 7 23 9 39
Endoscopy (%)
Normal 15 59 0 174
Esophagitis/ulcer 0 0 18 18
Esophageal stricture 0 0 1 1
Barrett’s esophagus 0 0 7 7
Hiatal hernia (%)
Absent 15.1 44.7 15.7 75.5
\2 cm 0 10.7 5.0 15.7
[2 cm 0 3.8 5.0 8.8
Esophageal biopsy (%)
Negative 15.1 41.5 5.7 62.3
Inflammation 0 17.6 13.2 30.8
Barrett’s esophagus 0 0 7 6.9
LESP (%)
C10 mm Hg 15.1 28.3 8.8 52.2
\10 mm Hg 0 30.8 16.9 47.8
DeMeester score (%)
B15 15.1 12.6 0 27.7
[15–25 0 11.9 3.1 15.0
[25–50 0 21.4 8.2 29.6
C51 0 13.2 14.5 27.7

normal biopsy. At motility testing, 83 (52.2%) patients had
LESP greater than 10 mmHg, and the other 76 (47.8%) had
a LESP less than or equal to 10 mmHg. On pH testing, 44
(27.7%) patients had a DeMeester score less than or equal
to 15 (normal), 24 patients (15%) scored between 16 and
25, 47 (29.6%) patients had a score between 26 and 50, and
44 (27.7%) of patients had a score greater than or equal
to 51.
Data from each of the three groups were then compared.
Not surprisingly, significantly fewer (24%) patients had a
hiatal hernia in the NERD group compared with 41.5% of
patients in the GERD group. Significantly fewer (30%) of
the NERD group had a positive distal esophageal biopsy
(either inflammation or BE) compared with 78% of the
GERD group. Similarly, 52% of the NERD group had
abnormal motility studies, compared with 66% in the
GERD group. Without exception, RLD patients had no
hiatal hernia, negative esophageal biopsy, normal motility,
and normal pH scores.
Mean total scores for each of the three groups were:
GERD (mean score 9.5), NERD (mean score 5.94), and
RLD (mean score 3.34) (Fig. 2). Given such score distri-
bution, a score higher than 4 excludes RLD; a score higher
than 10 excludes NERD (Fig. 3). In the overall study
cohort, the prevalence of RLD was 15%, NERD 59%,
GERD 26%.
For our derivation cohort, 110 patients (35 men, 75
women) were evaluated. Endoscopy showed erosive or
complicated GERD in 33 patients (30%) and was normal in
77 patients (70%). Of this latter group, 62 (56%) had
abnormal pH and motility studies and were classified as
patients with NERD. The remaining 15 (14%) had normal
functional studies and were classified as patients with RLD.
The validation cohort comprised 63 patients (29 males, 34
females). In this group, endoscopy showed erosive or
complicated GERD in 22 patients (35%) and was normal in
41 (65%). Of this latter group, 32 (51%) had abnormal pH
and motility studies and were classified as patients with

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comparative total disease severity scores for both deriva-

tion and validation cohorts appear in Figs. 4 and 2,
respectively.
Figure 5a–c depicts the receiver operating characteristic
(ROC) curves that graphically plot the sensitivity versus
(1-specificity) of the scoring system, confirming its value,
particularly in RLD. In the case of GERD, the model
showed a sensitivity of 95.1% and a specificity of 72.9%
(P = 0.0001, 95% CI: 0.86–0.95). In NERD, the model
showed a sensitivity of 93.6% and a specificity of 40%
(P = 0.05, 95% CI: 0.5–0.66). In the case of RLD, the
model showed a sensitivity of 100% and a specificity of
85.2% (P = 0.0001, 95% CI: 0.91–0.98).

Fig. 2 Total mean patient scores for each cohort, incorporating all
clinical, endoscopic, histologic, and functional variables used in this
study (as shown in Table 1). Scores are higher with erosive and
complicated esophagitis, intermediate with non-erosive disease, and
low in reflux-like dyspepsia
Fig. 3 Score distribution among the study patients. No patient with
RLD had a score higher than 4; no patient with NERD had a score
higher than 10, thus effectively distinguishing among the three
entities
NERD. The remaining nine (14%) had normal functional
studies and were classified as patients with RLD. The mean
symptom and total disease severity scores for each
group within each cohort are listed in Table 3; graphic
representations of comparative symptom scores and
Discussion
Our study suggests that, in a community cohort of patients
presenting with heartburn and epigastric pain partly
refractory to empiric PPI therapy, the prevalence of CE is
19%, BE 7%, NERD 59%, and RLD 15%. Further, an
algorithmic approach, coupled with a new, simple, reliable,
and reproducible scoring system, effectively distinguishes
GERD from NERD and RLD and facilitates further man-
agement decisions.
On the basis of the pattern of their symptoms, patients
with dyspepsia are commonly classified into one of three
subgroups: ulcer-like, dysmotility-like, and reflux-like. In a
study of 1,040 adult patients with dyspepsia, analysis based
on the dominant symptom demonstrated that 463 (45%)
patients had ulcer-like, 393 (38%) had reflux-like, and 184
(18%) had dysmotility-like dyspepsia [6]. This classifica-
tion system is based on the assumption that dyspeptic
symptom patterns remain stable over time and as such they
would guide management. However, recent studies have
demonstrated significant problems in this classification.
In one study, most dyspeptic symptoms changed continu-
ously over time and without the effect of diagnostic
procedures or therapy [15]. In another three-year follow-
up study, changes from one dyspepsia subtype to
another were common, ulcer-like and reflux-like often
changed into dysmotility-like dyspepsia [16]. Few patients

Table 3 The mean symptom and total disease severity scores for each group within each cohort
Derivation cohort Validation cohort
N (%) Mean symptom Mean total N (%) Mean symptom Mean total
score (range) score (range) score (range) score (range)

RLD 15 (14) 3.27 (2–4) 3.27 (2–4) 9 (14) 3.44 (3–4) 3.44 (3–4)
NERD 62 (56) 3.33 (2–4) 6.23 (3–10) 32 (51) 3.00 (2–4) 5.34 (3–9)
GERD 33 (30) 3.24 (2–4) 8.70 (5–15) 22 (35) 3.06 (2–4) 9.50 (5–15)
Total 110 (100) 3.30 (2–4) 6.49 (2–15) 63 (100) 3.09 (2–4) 6.52 (3–15)

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Dig Dis Sci (2011) 56:2871–2878 2877

Fig. 4 Comparative symptom scores for derivation and validation

cohorts

with dysmotility-like dyspepsia changed subtype over time.

Further, subgroups of functional dyspepsia play only a
minor role in prediction of the long-term outcome [17].
Nevertheless, patients with reflux-like dyspepsia have a
high response to omeprazole treatment [18]. However, a
four-week, double-blind, randomized, placebo-controlled
study of lansoprazole in Chinese patients with functional
dyspepsia failed to show that lansoprazole was superior to
placebo and all symptom sub-groups (ulcer-like, dysmo-
tility-like, and reflux-like) had similar symptom relief after
treatment [19].
The evaluation and therapy of patients with burning,
sub-xyphoid, epigastric discomfort or pain (RLD) remains
challenging both because of its underlying etiology but also
frequently because of its inadequate response to empiric
PPI therapy and its recurrent nature when such therapy is
discontinued. In our community-based study of such
patients, most (59%) exhibited objective evidence of non-
erosive reflux disease, followed by erosive esophagitis
(19%) and Barrett’s esophagus (7%). Only 15% of such
patients exhibited no objective evidence of GERD predis-
position, representing the reflux-like dyspepsia group. In
this subgroup, anti-reflux therapy would not be expected to
be effective and other strategies, for example the use of
tricyclic anti-depressants could be pursued.
The central premise of our study is that one cannot
easily differentiate between GERD, NERD, and reflux-like
dyspepsia on clinical grounds and further testing is nec-
essary. The need to distinguish between these three entities
is great, because the response to treatment is different for Fig. 5 Receiver operating characteristic (ROC) curves for GERD (a),
NERD (b), and RLD (c)
each of them. Attempts to distinguish between functional
and organic dyspepsia based on symptoms alone have
proved unsuccessful [20]. Moayyedi et al. investigated functional disease in patients referred for endoscopic
whether clinical history could distinguish between organic evaluation of dyspepsia [7].
and functional dyspepsia. They concluded that neither A key strength of our study is its prospective validation
clinical impression nor computer models that incorporated in a community-based cohort of patients referred to a
patient demographics, risk factors, history items, and gastroenterologist after having partly failed empiric PPI
symptoms adequately distinguished between organic and therapy instituted by the primary care physician. As such,

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its results are applicable to large Western population
cohorts that are referred to gastroenterology practices from
primary care. Using such a simple validated system, cli-
nicians may easily and objectively establish the underlying
etiology of the patients’ symptoms, establish prognosis and
plan therapy. One could argue that the value of our score in
daily practice is limited, because the score is constructed
on the basis of an extensive algorithmic approach that
involves, beyond symptoms, the performance of endoscopy
and biopsy, and esophageal motility and pH monitoring
tests. However, using such a validated score, clinicians
could easily exclude the possibility of RLD if a score
exceeded 4, that is, if a patient simply reported all four
symptoms, in addition to exhibiting a hiatal hernia upon an
otherwise normal endoscopy. Such a hypothetical patient
would not require any further testing and would be com-
fortably characterized and treated as suffering from NERD.
Although our numbers are relatively small for the vali-
dation cohort, the idea of an algorithmic approach coupled
with a scoring system to aid in distinguishing patients with
functional dyspepsia from patients with GERD and NERD
is novel and warrants further investigation, given that there
remains considerable difficulty in distinguishing these
three entities. In both the derivation and validation cohorts,
one could not differentiate between the three groups on the
basis of symptoms alone. However, when utilizing the
multi-factorial scoring system, one can effectively dis-
criminate among the groups.
In conclusion, in a community cohort of patients pre-
senting with heartburn and epigastric pain partly refractory
to empiric PPI therapy, the prevalence of CE was 19%, BE
7%, NERD 59%, and RLD 15%. An algorithmic approach
coupled with a novel scoring system effectively distin-
guishes GERD from NERD and RLD and facilitates further
management decisions. Furthermore, this novel multi-
factorial scoring system is simple, reliable, and reproduc-
ible as a diagnostic aid in evaluating patients presenting
with both epigastric pain and heartburn.
Conflict of interests Dr Triadafilopoulos has received honoraria for
lectures from Astra-Zeneca LLP and Takeda. Drs Marcus and Roorda
have no conflicts to declare. This study was not sponsored.
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