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  • Heartburn, regurgitation, and dysphagia.
  • "Alarm signs"—dysphagia, odynophagia, weight loss, family history of upper gastrointestinal (GI) tract cancers, persistent nausea and emesis, long duration of symptoms (>10 years), and incomplete response to treatment.
  • Atypical manifestations (eg, asthma) are common.

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Gastroesophageal reflux disease (GERD) is the most common and costly digestive disease. It accounts for at least 9 million physician office visits in the United States each year, and annual direct costs for managing GERD are estimated to exceed 9 billion dollars. GERD is a chronic disorder resulting from the retrograde flow of gastroduodenal contents into the esophagus or adjacent organs, and producing a variable spectrum of symptoms, with or without tissue damage. Transient inappropriate relaxation of the lower esophageal sphincter (LES) is the predominant pathophysiologic mechanism in the majority of GERD patients. Gastroparesis and a reduced LES pressure play a significant role in patients with moderate to severe disease.

Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122:1500–1511.   [PubMed: 1984534]

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Epidemiology

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The prevalence of GERD in the United States appears to be increasing. In Western populations, 25% of people report having heartburn at least once a month, 12% at least once per week, and 5% describe having symptoms on a daily basis. There appears to be no gender predominance of heartburn symptoms; men and women are affected equally. The relationship of age and reflux is unclear. One study has suggested an association between advancing age and fewer reflux symptoms but the presence of more severe esophagitis. There is an unequivocal positive association between body mass index and reflux symptoms. Inappropriate relaxation of the LES can be exacerbated by obesity. Even moderate weight gain among persons of normal weight is thought to cause or exacerbate reflux symptoms. These epidemiologic characteristics should be considered when evaluating a patient with typical and atypical GERD.

Johnson DA, Fennerty MB. Heartburn severity underestimates erosive esophagitis severity in elderly patients with gastroesophageal reflux disease. Gastroenterology. 2004;126:660–664.   [PubMed: 14988819]
Moayyedi P, Axon AT. Review article: gastroesophageal reflux disease: the extent of the problem. Aliment Pharmacol Ther. 2005;22(Suppl 1):11–19.   [PubMed: 16042655]

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Pathogenesis

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Pathologic reflux of gastric contents occurs when the refluxate overcomes the antireflux barriers of the gastroesophageal junction, typically in a postprandial state. The antireflux barrier of the gastroesophageal junction is anatomically and physiologically complex and vulnerable to a number of potential mechanisms of reflux. The primary antireflux mechanism is the LES, a segment of smooth muscle in the lower esophagus that is chronically contracted to maintain a pressure that is approximately 15 mm Hg above intragastric pressure. The two main patterns of LES dysfunction are (1) a hypotensive LES and (2) pathologic transient LES relaxations. Anatomic disruption of the gastroesophageal junction, commonly associated with a hiatal hernia, contributes to ...

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