In recent years, gastroesophageal reflux disease as a benign esophageal disease has attracted more and more attention from doctors and patients. In April 2006, academician Wang Zhonghao called for a new understanding of GERD in the medical community, and a large number of patients, especially those with respiratory symptoms such as asthma and cough, have been effectively treated. Stretta lower esophageal microfrequency therapy is also used as a quick, painless and effective treatment for the GERD community. With the increase in the number of patients treated and follow-up work, we have observed that vagus nerve dysfunction may be the main mechanism of symptoms in the onset and progression of the disease in some patients, which is tentatively assumed to be Vagusnervedisfunction syndrome (VDS), a syndrome that is different in pathogenesis from The pathogenesis of this syndrome is fundamentally different from that of the gastroesophageal reflux disease, which is considered by the current medical community to be caused by various symptoms in and outside the gastrointestinal tract. The anatomical basis of the tenth pair of cerebral nerves – the vagus nerve is a mixed nerve, the longest traveled and most widely distributed cerebral nerve in the body, containing four fiber components: parasympathetic fibers, general visceral sensory fibers, general somatic sensory fibers, and specific visceral motor fibers. The vagus nerve sends out many branches in the cranial, thoracic and abdominal regions, among which the more important ones are: 1. The superior laryngeal nerve, the outer branch innervates the cricothyroid muscle. The inner branch is distributed to the laryngeal mucosa above the glottis and to the epiglottis, tongue root, etc. 2. The cervical cardiac branch, with two branches, upper and lower, descends into the thoracic cavity and forms the cardiac plexus together with the sympathetic nerve. 3. The recurrent laryngeal nerve, whose motor fibers innervate all laryngeal muscles except the cricothyroid muscle, and sensory fibers are distributed to the laryngeal mucosa below the glottis. The laryngeal nerve is a branch of the heart, bronchus and esophagus, which join the heart, lung and esophageal plexuses, respectively.4. The bronchial and esophageal branches, in addition to innervating smooth muscles and glands, also conduct sensation in the organs and pleura.5. The anterior gastric and hepatic branches, near the cardia, originate from the anterior vagus trunk. The anterior branch of the stomach follows the lesser curvature of the stomach to the right and sends 4-6 small branches along the way to the anterior wall of the stomach, with its terminal branches distributed in the anterior wall of the pylorus in the shape of “crow’s claw”. The hepatic branch has one to three branches, which participate in the hepatic plexus and are distributed in the liver and gallbladder with the branches of the intrinsic hepatic artery.6. The posterior gastric branch, which originates from the posterior vagus trunk near the cardia, travels deep along the gastric lesser curvature and branches along the way to the posterior gastric wall. The terminal branch, like the anterior branch of the stomach, branches in the shape of “crow’s claw” and is distributed in the posterior wall of the pyloric sinus and the pyloric duct. 7. The ventral branch, originating from the posterior trunk of the vagus nerve, travels to the right and forms the ventral plexus together with the sympathetic nerve, along with the ventral trunk, superior mesenteric artery and renal artery, etc. It is distributed in the bile, spleen, small intestine, cecum, colon, transverse colon, liver, pancreas and kidney, etc. Most of the abdominal organs. From tinnitus and salivation to panic and shortness of breath, from GERD with esophageal mucosal damage caused by acid reflux to NERD without esophageal mucosal damage caused by bile reflux, from irritability and crying in children to anxiety and depression in adults, all are related to the effector organs of vagus nerve branches (larynx, epiglottis, external auditory canal, heart, lung, esophagus, stomach, gallbladder, etc.). stomach, gallbladder, etc.). Does GERD cause symptoms such as tinnitus, sneezing, runny nose, snoring, hoarseness and wheezing, or are all symptoms, including GERD, the result of vagus nerve dysfunction or dysregulation? Moreover, epidemiological studies have shown that although GERD is an important factor in the occurrence of extra-digestive symptoms, there is now insufficient evidence that acid reflux occurs prior to various concomitant symptoms [1]. III. Insights from clinical data Insight 1: Why is GERD difficult to cure? Although it is a benign disease, GERD is a chronic recurrent disease. Our long-term follow-up revealed that, especially in patients with respiratory disorders, after oral acid-suppressing drugs or even fundoplication, although acid reflux symptoms such as acid reflux and heartburn improved significantly or even disappeared, the respiratory symptoms did not improve significantly or did not improve in the long term. Allergic asthma and primary asthma were excluded from this group of patients, and the antispasmodic and antiasthmatic drugs had little effect, and most of them needed to use hormones or wait for the symptoms to disappear on their own. Our explanation is that although acid-suppressing drugs and fundic folding reduce the exposure of the lower esophagus to acid, vagal dysfunction persists or occurs intermittently, resulting in pathological changes in the effector organs of the “sensitive branch” of the vagus nerve. Insight 2: Why are the symptoms of acid reflux and wheezing mild during the day but obvious at night? Many patients with respiratory wheezing symptoms describe their symptoms with two characteristics of nocturnal asthma attacks: first, there is a time pattern, basically between midnight. Second, the symptoms are severe and potentially life-threatening, and there have even been cases of emergency tracheotomy after laryngospasm syncope. Our explanation is that because of the existence of autonomic nerves in the process of regulating the body’s activities to adapt to the body’s biorhythmic cycle, and because of the joint action of parasympathetic and sympathetic nerves. The vagus nerve, as the main parasympathetic nerve, becomes dysfunctional at night when the body is at rest, and loses its normal tone regulation of the target organs, or its antagonistic sympathetic nervous system does not play a timely antagonistic role, resulting in pathological changes in the “sensitive branch” of the effector organ. The current view is that NERD is a type of GERD with symptoms such as heartburn, acid reflux, and chest pain due to bile reflux into the stomach, without the manifestation of esophageal mucosal breakdown [2]. In patients with typical NERD symptoms, about 20% of 24h esophageal PH monitoring does not suggest pathological acid reflux, but their symptom index is positive [3]. Non-acidic GERD is defined as reflux of gastric contents into the esophagus, resulting in only minor changes in esophageal PH or the presence of bile reflux. It has been reported in the literature [4] that the pathophysiological mechanisms of non-acidic GERD and acidic GERD are not very different, mainly due to the presence of transientloweresophagealsphincterrelaxations (TLESRs), but only the nature of the refluxed material is different. This literature specifically states that non-acidic reflux can also cause both intraesophageal and extraesophageal symptoms, and although the mechanism is not known, the relationship between non-acidic reflux and symptom perception and PH is now known [5]. The problem would become very simple if explained by monism, since both the lower esophageal sphincter and the stomach, duodenum and gallbladder are effector organs of the vagus nerve, and impaired regulation of the vagus nerve makes it possible for each effector organ to develop pathological changes (enhanced digestive function?). . Inspiration 4: Why is there a high incidence of GERD in pediatric patients? Studies have shown that chronic pharyngotracheal disease is associated with pathologic GERD in at least 59% of pediatric patients [1,6]. Apart from smoking, alcohol consumption, overeating, medications, H. pylori infection, and irregularities in starting and living due to night life, we believe that the most plausible explanation is due to the imperfect development of the organism’s nervous system during infancy, which leads to the development of pathological reflux. IV. Clinical evidence Zhou xx, a female, was admitted with 45 years of reflux, 35 years of chest pain and 8 years of intermittent tightness in the pharynx. This patient also had significant cardiac arrhythmia and premature ventricular arrhythmias. According to the current view, this is a typical case of GERD with extraesophageal symptoms. After the diagnosis of GERD was confirmed in our hospital, microfrequency treatment was given to the lower esophagus, and after the treatment, the regurgitation, chest pain and tightness of the pharynx improved significantly, and the arrhythmia and ventricular premature arrhythmias also improved significantly. It is well known that the autonomic regulation of the heart under normal conditions is balanced by the joint interaction of sympathetic and vagal nerves, and the heart will exhibit various arrhythmias if any external factor disturbs this balance. In this patient, our explanation is that the radiofrequency heat acting on the lower esophagus stimulated the esophageal branch of the vagus nerve, which reflexively regulated the cardiac branch of the vagus nerve and the superior laryngeal nerve innervating the heart, bringing the originally “unbalanced” regulation of the heart and laryngeal muscles into balance. Patient Zhang xx, male, was admitted to the hospital mainly because of recurrent wheezing episodes for 4 years. After detailed medical history, the patient complained of occasional acid reflux and heartburn, and often had poor appetite. The patient was treated with micro radiofrequency in the lower esophagus and long-term oral antispasmodic, antiasthmatic and acid-suppressing drugs, but the recurrent wheezing still existed. We also monitored the patient’s 24-hour esophageal PH and ambulatory ECG, and understood the patient’s autonomic nervous system function by heart rate variability (HRV). The results showed a significant increase in both vagal tone and sympathetic tone, and more importantly, we found a slowing of the heart rate in conjunction with acid reflux, as measured by the 24-hour esophageal PH and ECG changes. This phenomenon seems to be more indicative of the fact that all initiating factors originate from the vagus nerve. The sympathetic and parasympathetic nerves act on the same organ both antagonistically and in unison with each other. Normally, when the organism is in a quiet or sleepy state, parasympathetic activity is enhanced and sympathetic nerves are inhibited, resulting in slowed heartbeat, decreased blood pressure, bronchoconstriction (asthma?) , pupil narrowing, increased digestive activity (acid reflux, refeeding, bile reflux?) etc. Either an increase in parasympathetic activity or a decrease in sympathetic activity will disrupt this balance and result in pathological changes. Autonomic influences on GERD have also been reported in previous studies, such as: visceral hypersensitivity, enteric nervous system, vagal-vagal reflex, and brain-gut axis [7]. However, all of them are mentioned in passing as part of the neurological system that is discussed last in the pathogenesis. Regarding the diagnosis and treatment of such patients, HRV is a new tool for non-invasive assessment of autonomic activity and is a commonly used quantitative indicator for independent evaluation of autonomic activity. With the exception of primary asthma, gastric ulcer, esophagitis, and allergic asthma, and with the simultaneous monitoring of the patient’s 24-hour esophageal PH and ambulatory ECG, the HRV assessment can screen for abnormal autonomic function, which, when compared to the esophageal PH, will help in the diagnosis of vagal dysfunction syndrome (VDS). Sympathetic and parasympathetic activity is regulated in the higher centers of the brain, particularly in the limbic lobe and hypothalamus. The following vagal treatment modalities have been reported in the literature: oral administration of anticholinergic drugs, somatic physical therapy stimulation, vagus nerve stimulation or implantable vagus nerve stimulation generators. However, the results are limited and there are concomitant adverse effects: hoarseness 37%, sore throat 11%, cough 7%, shortness of breath 6%, sensory abnormalities 6%, and muscle pain 6%. More recently, it has been suggested that there is also an autonomic nervous system more advanced than the sympathetic and parasympathetic nerves, a social nervous system unique to mammals [8]. In conclusion, some patients with GERD may have recurrent episodes due to vagal nerve dysfunction, but there is a lack of effective means to regulate the vagus nerve, and the main treatment modality may need to return to the body’s own regulation.