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Revisiting Montreal: New Insights into Symptoms and Their Causes, and Implications for the Future of GERD

Lookup NU author(s): Emeritus Professor Amritpal Hungin



This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).


© 2018, American College of Gastroenterology. The Montreal definition of gastroesophageal reflux disease (GERD) provided a rationale for acid suppression medication without investigation, thus enhancing the management of the substantial symptom burden in these patients. Increased proton-pump inhibitor use has also highlighted their limitations, with one third of “typical” symptoms known to be refractory. Most refractory symptoms are ascribed to reflux hypersensitivity (RH) and functional heartburn (FH). RH may be caused by impaired esophageal mucosal barrier function and sensitization of peripheral esophageal receptors. Central sensitization may also contribute to the perception of non-pathologic reflux in RH, and the perception of physiological stimuli in FH. Importantly, mechanisms underlying GERD, RH, and FH are (in theory) not mutually exclusive, further complicating patient management. Methods used to distinguish GERD from RH and FH are impractical for use in epidemiological studies and pragmatic care and may have limited diagnostic accuracy. This is impeding accurate prevalence estimates and risk factor determination and the identification of new therapies. Direct assessment of mucosal barrier function by measuring impedance is a promising candidate for improved diagnosis. Ultimately though the concept of GERD as a composite, symptom-based entity needs re-evaluation, so that new understandings of upper GI symptoms can direct more precise management.

Publication metadata

Author(s): Hungin APS, Molloy-Bland M, Scarpignato C

Publication type: Article

Publication status: Published

Journal: American Journal of Gastroenterology

Year: 2019

Volume: 114

Issue: 3

Pages: 414-421

Print publication date: 01/03/2019

Online publication date: 15/10/2018

Acceptance date: 13/08/2018

Date deposited: 30/10/2018

ISSN (print): 0002-9270

ISSN (electronic): 1572-0241

Publisher: Nature Publishing Group


DOI: 10.1038/s41395-018-0287-1


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