In a multiracial country like Malaysia, where we can compare the changes between different Asian races, Rosaida and Goh, in an earlier study identified Indian race as a risk factor for GERD and erosive reflux esophagitis.22 In a time trend study by the same group, Goh et al. recorded a significantly higher rise in esophagitis over a 10-year interval amongst Indians (2.4%–8.1%) compared to Chinese (1.7%–6.4%) and Malays (1.5%–3.7%).68

In another study, Rajendra et al. showed a distinct predisposition to develop Barrett’s esophagus in Indian patients and further showed a predominance of HLA B7 subtype amongst Indians with Barrett’s esophagus.52 While environmental influence would remain fairly consistent across all races, these differences identify Indians as a genetically susceptible SAHA HDAC datasheet race to the influence of Akt inhibitor environmental

factors in the development of GERD. Interestingly a study from the UK lends support to this notion by identifying South Asian race (Indian) versus White Caucasians as a risk factor for GERD.120 While heartburn is the cardinal symptom of GERD and is well recognized in the West, the situation is distinctly different in our part of the world. For example, there is no word in the Chinese vernacular language to describe this symptom. Spechler et al.121 in a survey of outpatients attending clinics in the Boston area, USA, discovered that the majority of patients of East Asian origin did not understand the symptom of heartburn. In the Asian setting many patients complain of chest discomfort which has been loosely classified as non-cardiac chest pains.121–124“Wind” is also a predominant complaint of many patients with reflux disease.125 In many Southeast Asian countries, Malay patients use vernacular terms which

do not translate exactly to the original terms of heartburn and acid regurgitation.126 Endoscopy is a widely used tool for diagnosis PDK4 of upper gastrointestinal complaints and will continue to be so. More Asian centers are now utilizing pH measurements as an adjunct to clinical and endoscopic diagnosis. The advent of the “catheterless” Bravo capsule has allowed more tertiary centers throughout the region to utilize pH measurements. Bilitec and impedance measurements are also more readily available nowadays in many Asian centers. The past 20 years has seen the emergence of reflux disease as an important disease in Asia. Although, it generally remains a mild disease in Asian patients, we know from the Western experience that serious complications can arise, chiefly Barrett’ esophagus and associated adenocarcinoma of the cardio-esophageal junction. Continued efforts must be made to ensure an accurate description of the disease burden and to track the evolution of the disease over time and across the whole region. In particular, translated and validated questionnaires should be utilized for surveys of GERD symptoms in the population.