The Many Manifestations of Gastroesophageal Reflux Disease: Presentation, Evaluation, and Treatment

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Gastroesophageal reflux disease (GERD) is a common problem that is expensive to diagnose and treat. The disease is increasing in prevalence in the Western world, with important risk factors being obesity and the eradication of Helicobacter pylori. Heartburn and acid regurgitation are classic symptoms of GERD, but their sensitivity is poor. Ambulatory esophageal pH testing is the most sensitive test for GERD, whereas endoscopy is the most specific test. Medical treatment with proton pump inhibitors (PPIs) has revolutionized the treatment of GERD and its complications, but long-term side effects do exist. Laparoscopic anti-reflux surgery and PPIs have similar efficacy in the few available long-term trials. This article reviews the presentation, evaluation, and treatment of GERD.

Section snippets

Definition

Unfortunately there is no gold standard test for GERD. Because the reflux of acid, particularly after meals, is a physiologic process, the simple presence of gastroesophageal reflux (GER) or occasional symptoms of heartburn or acid regurgitation cannot be defined as a disease. Recently a group of 44 experts from 18 countries used a modified Delphi process to develop a globally acceptable definition and classification of GERD that can be applied in clinical practice and in research (Fig. 1) [2].

Prevalence and Incidence

The prevalence and incidence of GERD was recently estimated in two systematic reviews that defined GERD as at least weekly heartburn and/or acid regurgitation and met criteria concerning sample size, response rate, and recall period [3], [4]. The prevalence in the Western world generally ranges between 15% and 25%, whereas in Asia the prevalence is reported to be less than 5% (Fig. 2). Time trends confirm a significant increase in the prevalence of reflux symptoms averaging 5% annually in North

Clinical Presentations

Heartburn and acid regurgitation are the classic symptoms of GERD. Heartburn describes a burning feeling, rising from the stomach or lower chest and radiating toward the neck, throat, and occasionally, the back [18]. It occurs postprandially, particularly after large meals or after eating spicy foods, citrus products, fats, chocolates, or drinking alcohol. The supine position or bending over may exacerbate heartburn. Nighttime heartburn may cause sleeping difficulties and impair next-day

Diagnostic Tests

A large number of tests are available for evaluating patients who have suspected GERD. Many times these tests are unnecessary, because the presence of frequent heartburn and acid regurgitation are sufficiently accurate to identify the disease and begin medical treatment. This is not always the case, however, and clinicians must decide which tests to choose so as to make the diagnosis in a reliable, timely, and cost-effective manner, depending on the information desired (Table 1) [23].

Complications

There are few data on the long-term outcome of patients who have varying severities of GERD. Severity and duration of symptoms seem to have a poor correlation with the presence or severity of esophagitis [7]. Furthermore, there is some controversy whether GERD exists as a spectrum of disease severity or as a categoric disease in three distinct groups: nonerosive and erosive reflux disease and Barrett esophagus [24], [47]. The recent European ProGERD study involving nearly 4000 patients sheds

Lifestyle and Over-the-Counter Medications

Numerous dietary and lifestyle modifications are advocated for the treatment of GERD. They are frequently first-line therapy for patients who have mild disease and often adjunct therapy even for patients on PPIs.What is the evidence, however? In a recent evidence-based review, studies of smoking, alcohol, chocolate, fatty foods, and citrus products showed physiologic evidence that their intake can adversely affect symptoms or esophageal pH. There was little evidence, however, that cessation of

Endoscopic Treatment

Various endoscopic techniques for the treatment of GERD have been developed as alternatives to antisecretory therapy or antireflux surgery [87]. These techniques include the delivery of radiofrequency energy to the gastroesophageal junction (Stretta), injection of bulking agents (Eneryx), or implantation of a bioprosthesis (Gatekeeper) into the LES, and suture plication of the proximal gastric folds (Endocinch, Endoscopic Plication System). Studies to date have primarily enrolled PPI-dependent

Surgical Management

Only surgical fundoplication can correct the physiologic factors contributing to GERD and prevent the need for long-term medication. Successful antireflux surgery involves (1) reducing the hiatal hernia back into the abdomen, (2) closing the opening in the diaphragmatic hiatus, (3) lengthening the intra-abdominal portion of the LES, and (4) strengthening the repair with a fundoplication. The most popular fundoplication is the 360° Nissen fundoplication. The partial posterior Toupet

Summary

Gastroesophageal reflux disease is a common problem that is expensive to diagnose and treat in primary and specialty care settings. This review has emphasized the major advances in understanding the diagnosis and treatment of GERD over the last 5 years. These are summarized below.

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    GERD is increasing in prevalence in the Western world, with important risk factors being obesity and healthy stomachs resulting from H. pylori eradication.

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    The sensitivity of classic reflux symptoms is poor (55%) for

Acknowledgment

The author thanks Elizabeth Koniz for excellent secretarial assistance in the preparation of this manuscript.

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