Natural course of gastroesophageal reflux disease: 17-22 year follow-up of 60 patients.

Objective: To elucidate the long-term course of conservatively managed gastroesophageal reflux disease without H2-antagonists or omeprazole. Methods: Design: Clinical trial, uncontrolled. Setting: Gastroenterological outpatient department of a teaching hospital. Patients: Sixty of 87 patients consecutively referred for severe gastroesophageal reflux symptoms and with objectively proven pathological reflux. Measurements: Esophagoscopy, esophagography, cinecardiography of cardiac region, standard reflux test, and confirmatory Bernstein-Baker test. Follow-up included a standardized interview, esophagoscopy with biopsy, and 24-h pH monitoring. Results: At follow-up 17-22 yr after referral, symptoms were less than at the time of referral in 36 of the 50 nonoperated patients (six now symptom-free), were unchanged in five, and were worse in nine patients. Medication for reflux symptoms was no longer used by 34 of the nonoperated patients. The prevalence of erosive esophagitis fell from 40% at referral to 27% at follow-up endoscopy; 42% of the studied patients had pathological 24-h pH, and the endoscopies revealed six new cases of Barrett's metaplasia. Of the 41 nonoperated patients examined with both endoscopy and 24-h pH, 27 (66%) had erosive esophagitis and/or pathological pH values. Of the 10 operated patients, all had fewer symptoms at follow-up than they had had at referral (nine were symptom-free). The prevalence of erosive esophagitis fell from 60% at referral to 10% at follow-up. One of the 10 patients had pathological 24-h pH at follow-up. Neither the presence of esophagitis or hiatal hernia nor the severity of symptoms at the time of referral predicted the course of the disease of the conservatively treated patients. Conclusions: The severity of the symptoms declines in the long term, but pathological reflux persists in most of the conservatively treated patients. Thus, the reflux itself is not self-limiting, and therapy should be designed with this in mind.