Nonerosive reflux disease and functional heartburn are clearly separate entities.

To The Editor: We read with interest the paper by Blaga et al on the clinical and functional profiles of patients with functional heartburn (FH) (1). The Authors must be congratulated because this is one of the first studies in which the population of FH is clearly separated from the other subgroups of NERD on the basis of an objective method (i.e. impedance-pH). We have already stressed that this is the only way to favour a better understanding of the epidemiologic, pathogenetic and clinical features of this group of patients without any kind of reflux underlying their symptoms (2). Moreover, the Authors found that the impedance-pH parameters of their FH patients were within the normal range and we have also shown that the number of total, acid and weakly acidic reflux episodes is quite identical between controls and FH and significantly lower than that of NERD subsets with both increased acid and hypersensitive oesophagus (3). In addition, we have found that FH patients do not present a higher rate of dilation of intercellular spaces as compared to controls and this histological alteration is largely recognized as an important morphological marker of NERD (4). The above findings confirm that FH cannot be anymore considered in the realm of GORD. Finally, Blaga et al included in their study patients who did not respond to PPI therapy, but 10 declared that their symptoms improved using PPIs. According to Rome III definition (5), these patients should be part of NERD, even though impedance-pH did not show any kind of reflux in them and the result of impedance-pH is highly reproducible in identifying FH (3). The good response to PPIs is due to a likely placebo effect, as we have also observed (2). Anyway, the empiric criterion of non-response to PPIs adopted by the Rome III Committee for diagnosing FH is of limited value and must be replaced by a functional test able to measure the reflux events, if any.