Patients with gastroesophageal reflux disease usually present with heartburn and acid regurgitation into the esophagus [1]. A minority of patients present with supraesophageal symptoms such as dental erosions, laryngitis, asthma, cough, or non-cardiac chest pain [1].

Gastroesophageal reflux disease-related complications include erosive esophagitis, Barrett esophagus, and esophageal adenocarcinoma [2].

The typical symptoms of gastroesophageal reflux disease include [1] [2] [5]:

• Heartburn
• Regurgitation
• Dysphagia

Atypical (supraesophageal) symptoms include the following [2] [4]:

• Coughing and/or wheezing
• Throat clearing
• Apnea
• Aspiration pneumonia
• Bronchitis
• Hoarseness, sore throat
• Otitis media
• Non-cardiac chest pain
• Enamel erosion or other dental problems

Several techniques are used to diagnose gastroesophageal reflux disease, beginning with a comprehensive patient history. The history should include symptoms, duration, frequency, precipitating and alleviating factors [6].

Laboratory tests are usually not useful or necessary to establish a diagnosis of gastroesophageal reflux disease [1]. The only way to definitively diagnose the disorder is through the presence of elevated pH levels and abnormal pressure using esophageal manometry and pH monitoring [1] [6].

A trial with proton-pump inhibitors (PPI) is now the recommended diagnostic technique in individuals with symptoms [6]. Patients who improve with this therapy are likely to have the disease [6]. In patients unresponsive to this trail therapy another diagnosis should be sought [6].

The following studies are recommended in patients suspected to have gastroesophageal reflux disease [12] [13]:

• Upper endoscopy
• Esophageal manometry
• Twenty-four hour pH monitoring

Manometry measures intraesophageal pressures [6]. It is the primary method for identifying the causative mechanisms of gastroesophageal reflux disease [12].

Imaging studies [12]:

• Upper gastrointestinal contrast-enhanced studies
• Chest radiographic to assess pulmonary status and presence of hiatal hernia

Computed tomography scanning, magnetic resonance imaging, or ultrasonography are not usually needed [12]. When serious supraesophageal complications are suspected more invasive diagnostic studies may be needed. These include esophagogastroduodenoscopy, laryngoscopy, and esophageal biopsy [6].

Gastroesophageal reflux disease is treated by a progressive approach moving from lifestyle modification to control of gastric secretion by medication, and finally surgical treatment [1] [2]. Aggressive therapy with proton pump inhibitors, acid suppressive medications, is the recommended initial treatment[1].

The goals of treatment are to control symptoms, heal esophagitis, and prevent recurrent esophageal irritation and other complications. For optimum treatment of gastroesophageal reflux disease it is important to identify the underlying etiology responsible so that the most effective therapy can be initiated.

Lifestyle changes

Lifestyle changes have been proven to be effective in the treatment of gastroesophageal reflux disease [3]. Life modifications include the following [2] [8]:

• Weight loss, if overweight [7] [8]
• Avoidance of alcohol, coffee, chocolate, citrus juice, and tomatobased foods
• Small, frequent meals
• Wait 3 hours after a meal before lying down
• Refrain from eating within 3 hours of bedtime
• Elevate the head of the bed 8 inches [6]
• Avoid bending or stooping

Pharmacotherapy

The following medications are used in the management of gastroesophageal reflux disease [1] [10]:

• H2 receptor antagonists: Ranitidine, cimetidine, famotidine, nizatidine
• Proton pump inhibitors: Omeprazole, lansoprazole, rabeprazole, esomeprazole, pantoprazole
• Prokinetic agents: Aluminum hydroxide
• Antacids: Aluminum hydroxide, magnesium hydroxide

Protein pump inhibitors have become the primary intervention for the treatment of gastroesophageal reflux disease. It has proven to be cost-effective and generally safe [1]. A trial course of proton pump inhibitors may be used to help diagnosis the disorder [10]. Recent research has shown that long-term use of proton pump inhibitors may interfere with calcium absorption, but may also reduce bone reabsorption [10]. Standard-dosage of anti-reflux medications does not seem to reduce the incidence of cancer or Barrett’s esophagus [7].

Surgical intervention

Nissen fundoplication is an alternative therapy in patients who do not respond to medication. It involves wrapping the lower esophagus with muscles to increase the tone of the lower esophageal sphincter. However, as with any surgery this procedure may have significant complications [1]. Surgical repair of hiatal hernia is also an effective treatment for chronic gastroesophageal reflux disease [1].

Most patients with gastroesophageal reflux disease do well on medication therapy. Relapse after discontinuation of medication is common and indicates a need for long-term therapy [1] [7].

Surgical interventions, such as laparoscopic Nissen fundoplication may be necessary for patients with gastroesophageal reflux disease not responsive to medication or experiencing serious complications. It has been reported to be effective in approximately 92% of patients [1] [11].

Gastroesophageal reflux is usually benign in infants and very young children and responds to non-pharmacologic or conservative treatment [1].

Complications of chronic gastroesophageal reflux disease include erosive esophagitis, Barrett esophagus, and esophageal adenocarcinoma [2] [7].

The etiology of gastroesophageal reflux disease is the excessive movement of gastric secretions, containing gastric acids and bile, from the duodenum and stomach into the esophagus [1] [4]. It is thought to be due to the relaxation of the lower esophageal sphincter or an imbalance in pressure surrounding this sphincter [3] [5].

Normal relaxation of the lower esophageal sphincter occurs with swallowing. Increased transient relaxation of this sphincter can be trigger by [3] [5]:

• Foods, such as coffee, alcohol, chocolate, fatty meals, 
• Medications: beta-agonists, nitrates, calcium channel blockers, and anticholinergics
• Hormones: progesterone, estrogen
• Nicotine 

In most adults the amount of gastric material refluxed into the esophagus is limited by normal defense mechanisms. These barriers minimize irritation to the esophageal mucosa and reduce symptoms [1]. Normal lower esophageal sphincter function and normal esophageal motility are the basis of these defensives [2].

While gastric reflux occurs in about 70% of adults in the general population, only 20% have symptoms of gastroesophageal reflux disease and erosion of the esophageal mucosa. Some recent studies hypothesize the influence of inherited mucosal resistance to be a factor [3].

Gastroesophageal reflux disease may cause other supra-esophageal symptoms such as laryngitis, asthma, cough, chest pain, and dental erosions [6] [7].

Gastroesophageal reflux disease is most common in Western societies, probably due to dietary habits and the rate of obesity. The incidence in the United States is as high as 25 to 40% [3] [5]. Prevalence of gastroesophageal reflux disease worldwide ranges from 10 to 20% [8]. A large proportion of individual with gastroesophageal reflux disease are able to control symptoms with over-the-counter medications so the incidence is probably higher [10].

Obese individuals are almost three times more likely to suffer from gastroesophageal reflux disease with a prevalence of about 37% [8] [9].

The incidence is not influenced by race or gender. It occurs with equal frequency in men and women. However, severe symptoms such as Barrett esophagus are higher in men than women, perhaps 2 to 10 times as often [4] [8]. Gastroesophageal reflux disease occurs in all age groups but its prevalence increases in people over the age of 40 [8].

Gastroesophageal reflux disease results from the increased exposure of the esophagus to stomach contents causing mucosal damage and esophageal erosion [5]. The frequency of acid reflux is key to the development of gastroesophageal reflux disease. Reflux occurs most often during the normal lower esophageal sphincter relaxations that follow swallowing [11] [12] [13].
The etiology of gastroesophageal reflux disease is multifactorial with the primary factors [2] [5] [13]:

• Increased intraabdominal pressure
• Impaired gastric emptying
• Decreased lower esophageal sphincter pressure
• Increased frequency of transient sphincter relaxation
• Gastric distention
• Impaired esophageal or gastric clearance

The lower esophageal sphincter, located in the abdomen, is assisted by the diaphragmatic crura, tendon-like attachments, to prevent reflux [11]. When the lower esophageal sphincter migrates into the chest due to the presence of a hiatal hernia this function is lost [12] [13].

Decreased esophageal clearance is a result of poor esophageal motility [12] [13]. Esophageal acid clearance time is the amount of time it takes the esophagus to return to a neutral pH level after acidic reflux [13]. Acid clearance time and esophageal motor function combine to affect the amount of mucosa irritation [13].

Delayed gastric emptying may also be a factor, as it increases the volume and pressure in the stomach until the balance of pressure against the lower esophageal sphincter is disturbed leading to reflux [3] [11].

Esophageal mucosal resistance is a protective mechanism that varies from individual to individual. Some have suggested that this factor has a hereditary basis [3] [11].

Studies have shown that gastroesophageal reflux disease is much more prevalent in obese individuals and that a high body mass index (BMI) is a risk factor for the development of this disorder. The exact reason for this is not fully known. It is thought that hiatal hernia occurs more frequently and intraabdominal pressure increases with obesity [2] [9].

Complications of gastroesophageal reflux disease are usually associated with supraesophageal or upper airway exposure to gastric acid from microaspiration and triggering of the vasovagal reflex [4].

These complications include [2]:

• Chronic cough 
• Asthma 
• Laryngitis 
• Pneumonia
• Esophagitis
• Barrett esophagus
• Esophageal adenocarcinoma

The most effective method of preventing gastroesophageal reflux disease and its complications is through the appropriate lifestyle changes [6]. Weight reduction to normal is probably the single most effective single intervention for prevention [8].

Taking antacids immediately after an episode of heartburn may help decrease esophageal exposure time and prevent esophageal damage and complications of gastroesophageal reflux disease [6].
Rinsing with neutral pH mouthwashes, applying fluoride gels and avoiding brushing teeth immediately after reflux episodes may help to prevent dental erosion [6].

Gastroesophageal reflux disease results from the reflux of gastric contents into the esophagus causing symptoms of heartburn, regurgitation, and dysphagia [1] [2]. It is associated with esophagitis, laryngitis, and dental erosion. Other symptoms may accompany this disease including non-cardiac chest pain, asthma, pneumonia, hoarseness, and aspiration [2].

Reflux of small amounts of stomach contents into the esophagus is a normal physiologic occurrence experienced by most people intermittently. Gastroesophageal reflux disease (GERD) occurs when this process is abnormal and excessive amounts of gastric acid or mucosal exposure time are extended [1] [2].

Gastroesophageal reflux disease is estimated to occur in 25-40% of healthy American adults [3]. At least, 7-10% of these people experiences symptoms on a daily basis [2].

Complications of gastroesophageal reflux disease include chronic painful esophagitis, appetite disturbances, dental erosion, asthma, and potentially esophageal cancer [3] [4].

What is gastroesophageal reflux disease?

Gastroesophageal reflux disease refers to symptoms resulting from an abnormal backflow of stomach contents into the esophagus. This fluid contains gastric acids and bile. Both of these substances cause irritation, inflammation, and erosion of the mucosa of the esophagus.

What are the symptoms?

The typical symptoms of gastroesophageal reflux disease include:

• Heartburn
• Regurgitation
• Dysphagia

Other less frequent symptoms of this disorder are:

• Coughing or wheezing
• Throat clearing
• Aspiration pneumonia
• Bronchitis
• Hoarseness, sore throat
• Ear pain
• Non-cardiac chest pain
• Enamel erosion or other dental problems

What causes gastroesophageal reflux disease?

The cause of gastroesophageal reflux disease is the abnormal backflow of gastric acid into the esophagus. The reasons for this are multiple and are different for each patient. Factors that influence reflux include:

• Lifestyle: Diet, alcohol, caffeine, obesity
• Structural abnormalities: Hiatal hernia
• Mechanical abnormalities: Poor lower esophageal sphincter function, decreased esophageal motility

Who gets gastroesophageal reflux disease?

Approximately 10 to 20% of the adults in the United States suffer from gastroesophageal reflux disease. It occurs at all ages, equally in men and women and in all races and ethnic groups. Obese individuals are at higher risk of this disorder as it occurs three times more often in those who are overweight. Gastroesophageal reflux disease occurs most frequently in Western societies probably due to diet and the prevalence of obesity.

How is gastroesophageal reflux disease diagnosed?

Gastroesophageal reflux disease is generally suspected on the basis of patient history and symptoms. Two procedures are useful in diagnosing the disorder: monitoring of the pH, acid concentration, in the esophagus and manometry, that measures the functioning of the lower esophageal sphincter.
Today diagnosis is often made by a non-invasive means with a trial of anti-reflux medication. A relief of symptoms with medication confirms the diagnosis.

How is gastroesophageal reflux disease treated?

Gastroesophageal reflux disease may be treated in three ways:

• Lifestyle changes: Avoiding  high acid foods, citrus, fatty foods, chocolate, alcohol, caffeine, and nicotine
• Medications: Antacids, anti-reflux medications, and acid suppressors
• Surgery to repair esophageal sphincter abnormalities and hiatal hernia

What are the complications?

There are many possible complications of gastroesophageal reflux disease. They include:

• Chronic cough
• Asthma
• Laryngitis, hoarse voice
• Erosion of tooth enamel
• Pneumonia
• A severe form of esophagitis called Barrett esophagus
• Esophageal cancers

How can gastroesophageal reflux disease be prevented?

Prevention of gastroesophageal reflux disease depends upon the underlying cause of the disorder. The most effective method of preventing gastroesophageal reflux disease and its complications is through the appropriate lifestyle changes. Weight reduction to normal is probably the single most effective intervention for prevention. Taking antacids immediately after an episode of heartburn may help decrease esophageal damage. Rinsing with neutral pH mouthwashes, applying fluoride gels and avoiding brushing teeth immediately after reflux episodes may help to prevent dental erosion.

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