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LEARNING OBJECTIVES

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LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Explain the underlying causes of gastroesophageal reflux disease (GERD).

  2. Understand the difference between symptom-based esophageal GERD syndromes and extraesophageal GERD syndromes.

  3. Determine which diagnostic tests should be recommended based on the clinical presentation.

  4. Identify the desired therapeutic outcomes for patients with GERD.

  5. Recommend appropriate nonpharmacologic and pharmacologic interventions for patients with GERD.

  6. Formulate a monitoring plan to assess the effectiveness and safety of pharmacotherapy for GERD.

  7. Educate patients on appropriate lifestyle modifications and drug therapy issues including compliance, adverse effects, and drug interactions.

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INTRODUCTION

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Gastroesophageal reflux disease (GERD) is defined as troublesome symptoms and/or complications caused by refluxing of stomach contents into the esophagus.1,2 To be considered GERD-related, these troublesome symptoms should adversely affect patient well-being.1 KEY CONCEPT Esophageal GERD syndromes can be divided into two distinct categories: (a) symptom-based esophageal syndromes and (b) tissue injury-based esophageal syndromes.1 Symptom-based esophageal syndrome is associated with troublesome reflux symptoms with or without normal endoscopic findings. Conditions associated with esophageal tissue injury include erosive esophagitis, strictures, Barrett esophagus, and esophageal adenocarcinoma. Erosive esophagitis occurs when the esophagus is repeatedly exposed to refluxed material for prolonged periods. The inflammation that occurs progresses to erosions of the squamous epithelium.

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Barrett esophagus is a complication of GERD characterized by replacement of the normal squamous epithelial lining of the esophagus with specialized columnar-type epithelium. Barrett esophagus is more common in male patients with a long history of reflux (greater than 5–10 years), age older than 50 years, and obesity. The presence of Barrett esophagus may be a risk factor for developing adenocarcinoma of the esophagus.

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Extraesophageal reflux syndrome involves “atypical” symptoms outside the esophagus, primarily chronic cough, laryngitis, and asthma.2 Reflux chest pain syndrome may also occur and may be indistinguishable from cardiac chest pain. When extraesophageal manifestations are present, other causes must be excluded before considering a diagnosis of GERD. In addition, atypical symptoms should only be considered GERD-related if a concurrent esophageal GERD syndrome is present.

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EPIDEMIOLOGY AND ETIOLOGY

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GERD is prevalent in patients of all ages; approximately 18% to 28% of adults in the United States are affected.3 Although mortality is rare, symptoms can significantly decrease quality of life. There does not appear to be a gender difference in incidence except for its association with pregnancy. Barrett esophagus and esophageal adenocarcinoma occur more frequently in males.4

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PATHOPHYSIOLOGY

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The retrograde movement of acid or other noxious substances from the stomach into the esophagus is a major factor in the development of GERD.5 Commonly, gastroesophageal reflux is associated with defective lower esophageal sphincter (LES) pressure or function. Problems with other normal mucosal defense mechanisms such as anatomic factors, esophageal clearance, mucosal resistance, gastric emptying, epidermal growth factor, and ...

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