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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.


Gastroesophageal reflux disease (GERD) is the most common and costly digestive disease. It accounts for over 8 million outpatient visits in the United States each year, and annual prescriptions for proton pump inhibitors (PPIs) to diagnose and manage GERD are estimated to exceed 8.2 billion, totalling over 10 billion in cost. 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. Hiatal hernia, reduced LES pressure, or delayed gastric emptying may also play a role in patients with moderate to severe disease.

Peery  AF, Dellen  ES, Lund  J  et al.. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology. 2012;143:1179–1187.  [PubMed: 22885331]
Shaheen  NJ, Hansen  RA, Morgan  DR  et al.. The burden of gastrointestinal and liver diseases. Am J Gastroenterol. 2006;101:2128–2138.  [PubMed: 16848807]

A. Epidemiology

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, and the increasing rate of obesity has been proposed as a cause of growth in GERD incidence. 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]  

B. Pathogenesis

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 ...

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