• Mohammed Omer Mohammed Department of Medicine, College of Medicine, University of Sulaimani, Kurdistan Region, Iraq.
  • Hewa Ahmed Hama Department of Medicine, College of Medicine, University of Sulaimani, Kurdistan Region, Iraq.



Heartburn, GERD, NERD, Combined pH-impedance, KCGH



Heartburn is characterized by a discomfort or burning sensation behind the sternum that arises from the epigastrium and may radiate toward the neck. A subset of patients with heartburn are Non-erosive reflux disease (NERD) is characterized by reflux symptoms in the absence of esophageal mucosal breaks, with objective evidence of pathological levels of gastroesophageal reflux on pH or pH-impedance monitoring.


To evaluate patients with heartburn clinically, endoscopically and by combined pH-impedance study.


This is a cross-sectional descriptive study, a total of 60 cases of heartburn, referred to Kurdistan center for Gastroenterology and Hepatology in Sulaimani from February 2015 to December 2015 were enrolled. Cases interviewed and a questionnaire filled; body mass index measured. OGD and pH-impedance study were done for all participants.


Out of 60 cases of heartburn, erosive esophagitis (EE) found in 21.7% of cases and 78.7% had normal OGD. Regurgitation found in almost all cases of EE (100%) which was statistically significant (p=0.02). Patients with hiatus hernia HH are at greater risk for EE than non-erosive cases (p=0.01). By OGD and pH-study more than half of our cases (51.6%) were proved to have gastroesophageal reflux disease (GERD). There was significant different (p <0.001) between those with erosive and non-erosive esophagitis in relation to number of reflux episodes and intensity of acid exposure.


Only 21.3% of heartburn cases had EE. Having HH is a risk factor for EE. Almost half of cases with EE had abnormal pH-study; this means ODG has low sensitivity in the diagnosis of GERD with greater specificity. Adding combined pH-impedance test to OGD in the evaluation of heartburn increase the diagnostic utility of GERD.


- Peter J. Kahrilas, Ikuo Hirano. Diseases of the Esophagus in: Dan L. Longo,Dennis L. Kasper, J.Larry Jameson, Anthony S. Fauci, Stephen L.Hauser, JosephLoscaizo (editors). Harrison’s principal of internal medicine. New York: McGraw Hill; 2015.p.1900.

- Christine Hachem and Nicholas J. Shaheen, Diagnosis and Management Of Functional Heartburn: Am J Gastroenterol 2016; 111:53–61; DOI:

- Wu JC, Chenng CMY, Wong VWS, Sung JJY. Distinct clinical characteristics between patients with non-erosive reflux disease and those with reflux esophagitis. ClinGastroenterolHepatol 2007; 5:690-5. DOI:

- EI-Serag HB, Sweet S, Winchester CC. Update on the epidemiology of gastro-: a esophageal reflux disease systemic review. Gut 2014; 63:871-880. DOI:

- Ronkainen J, Aro P, StorskrubbT. Gastro-esophageal reflux symptoms and related quality of life in the adult general population-the Kalixanda study. Aliment PharmacolTher 2006;23:1725-1733. DOI:

-Wahlqvist P, Reilly MC, Barkun A. Systemic review: the impact of gastro-esophageal reflux disease on work productivity. Aliment PharmacolTher 2006;24:259-272. DOI:

- Joel E. Richter and Frank K. Friedenberg.Gastroesophageal Reflux Disease. in: Mark Feldman, Lawrence S. Freidman, Lawrence J. Bratnes, editors. Sleisenger& Fordtrnas,gastroenterology and liver disease.10thed. Saunderes: Elsevier Inc; 2016.p.735.

- Shaheen NJ, Weinberg DS, Denberg TD. Upper endoscopy for GERD: Best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Int Med 2012; 157:808-16. DOI:

- Richter JE. Severe reflux esophagitis. GastrointestEndosc Clin North Am 1994; 4:677-98. DOI:

- Martinez SD , Malagon IB , Garewal HS. Non-erosive reflux disease (NERD) acid reflux and symptom patterns. Aliment Pharmacol Ther 2003 ; 17 : 537 – 45. DOI:

- Park EY , Choi MG , Baeg M .The value of early wireless esophageal pH monitoring in diagnosing functional heartburn in refractory gastroesophageal reflux disease. Dig Dis Sci, 2013; 58: 2933 – 9. DOI:

- Lundell LR, Dent J, Bennett JR, Endoscopic assessment of oesophagitis: Clinical and functional correlation and further validation of the Los Angeles classification. Gut 1999; 45:172-80. DOI:

-Joel E. Richter and Frank K. Friedenberg. Gastroesophageal Reflux Mark Feldman, LawrenceS. Freidman, Lawrence J.Bratnes, editors. Sleisenger& Fordtrnas, gastroenterology and liver disease.10thed. Saunderes: Elsevier Inc; 2016. P.743-44.

- Miller FA. Utilization of lying pH probe for evaluation of acid-peptic diathesis. Arch Surg. 1964;89: 199–203. DOI:

- Johnson LF, DeMeester TR. Twenty-four-hour pH monitoring of the distal esophagus: a quantitative measure of gastroesophageal reflux. Am J Gastroenterol. 1974;62: 325–332.

- Tutuian R, Vela MF, Shay SS, Castell DO). “Multichannel intraluminal impedance in esophageal function testing and gastroesophageal reflux monitoring”. J. Clin. Gastroenterol. 2003; 37 (3): 206–15. DOI:

- Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association technical review on the management of gastroesophageal reflux disease. Gastroenterology 2008; 135:1392-413. DOI:

- Bredenoord AJ, Weusten BL, Timmer R. Addition of esophageal impedance monitoring to pH monitoring increases the yield of symptom association analysis in patients off PPI therapy. Am J Gastroenterol 2006;101: 453–9. DOI:

- Hirano I, Richter JE. ACG practice guidelines: Esophageal reflux testing. Am J Gastroenterol 2007; 102:668-85.

- Kahrilas PJ, Sifrim D. High-resolution manometry and impedance-pH/manometry: valuable tools in clinical and investigational esophagology. Gastroenterology 2008;135: 756–769. DOI:

- Hirano I and Richter JE. Practice Parameters Committee of American College of Gastroenterology. ACG practice guidelines: esophageal reflux testing. Am J Gastroenterol 2007;102: 668–85. DOI:

- BMI Classification”. Global Database on Body Mass Index.World Health Organization. 2006. Retrieved July 27, 2012.

- WHO Expert Consultation.Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet2004; 363: 157–163. DOI:

- Biccas BN, Lemme EM, Abrahão LJ Jr, Aguero GC, Alvariz A, Schechter RB.Higher prevalence of obesity in erosive gastroesophageal reflux disease. ArqGastroenterol. 2009 Jan-Mar;46(1):15-9. DOI:

- Frootan M, Choobtashani S, Azargashb E, Amin PM, Hamide M, Zali MR, HalehA.Nonerosive reflux disease compared with erosive esophagitis with regards to acid reflux and symptom patterns.Turk J Gastroenterol. 2011 Oct; 22(5):464-71. DOI:

- Basim A. AskirF ,Amira. H. Shubbar ,Raghad J.AL-Akashi ,Rayadh A.Zaidan ,Aswad Al-Obeidy: Clinical and endoscopic evaluation of a sample of Iraqi patients with symptoms of gastroesophageal reflux disease. IJGE 2005; Vol 1 Issue 5.

- Lazebnik LB , Vasil’evIuV , Masharova AA , Manannikov IV ,Terape vticheskii Arkhiv. Prevalence of gastroesophageal reflux disease in Moscow: results of a population study. J Clin Gastroenterol _ September 2006; Volume 40, Suppl. 4, DOI:

- Rezailashkajani M, Roshandel D, Shafaee S, ZaliMR.High prevalence of reflux oesophagitis among upper endoscopies of Iranian patients. Eur J GastroenterolHepatol. 2007 Jun; 19(6):499-506. DOI:

- Morozova IuN, Pogromov AP, Mnatsakanian MG. 24-hour combined pH-impedance measurement in differential diagnosis of non erosive reflux disease and functional gastroesophageal disorders. Eksp Klin Gastroenterol. 2013; (12):39-43.

- Wong BC, Kinoshita Y. Systematic review on epidemiology of gastroesophageal reflux disease in Asia. Clin Gastroenterol Hepatol. 2006 Apr; 4(4):398-407. DOI:

-Michele Grande, Pierpaolo Sileri, Grazia Maria Attinà, Elisabetta De Luca, Paolo Ciano, Carolina Ilaria Ciangola and Federica Cadeddu.Nonerosive gastroesophageal reflux disease and mild degree of esophagitis: Comparison of symptoms endoscopic, Manometric and pH-metric patterns. World Journal of Surgical Oncology. 2012 10:84. DOI:

- Nasi A, Filho JP, Zilberstein B, Cecconello I, Gama-Rodrigues JJ, Pinotti HW: Gastroesophageal reflux disease: clinical, endoscopic, and intraluminal esophageal pH monitoring evaluation. Dis Esophagus. 2001, 14: 41-49. 10.1111/j.1442-2050.2001.00130. DOI:

- Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med 2006; 166:965-71. DOI:

-Savarino E, Zentilin P, Marabotto E, Bonfanti D, Inferrera S, Assandri ,et al.Overweight is a risk factor for both erosive and non-erosive reflux disease. Dig 2011 Dec; 43(12):940-5. DOI:

- Hajar N,Castell DO, Ghomrawi H, Impedance pH confirms the relationship between GERD and BMI. Dig Dis Sci 2012; 57:1875-9. DOI:

- Derakhshan MH, Robertson EV, Fletcher J. Mechanism of association between BMI and dysfunction of the gastro esophageal barrier in patients with normal endoscopy. Gut 2012; 61:337-43. DOI:

- Hsu CS, Wang PC, Chen JH. Increasing insulin resistance is associated with increased severity and prevalence of gastro-esophageal reflux disease. Aliment PharmacolTher 2011; 34:994-1004. DOI:

-Yi ZH, Feng L, Wen MY, Liu JR, Yang L. Association between acid reflux and esophageal dysmotility in patients with gastroesophageal reflux disease. Sichuan Da XueXueBao Yi Xue Ban. 2014 May; 45(3):480-3.

- Long JD, Orlando RC. Nonerosive reflux disease. Minerva Gastroenterol Dietol. 2007 Jun; 53(2):127-41.

- Cheng FK, Albert DM, Maydonovitch CL, Wong RK, Moawad FJ. Categorization of patients with reflux symptoms referred for pH and impedance testing while off therapy. ClinGastroenterol Hepatol.2015 May; 13(5):867-73. DOI:



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