Key Clinical Questions
What is the approach to patients presenting with reflux, heartburn, or noncardiac chest pain?
How should patients with esophagitis and gastroesophageal reflux disease (GERD) be managed in the inpatient setting?
What are the possible complications resulting from esophagitis and GERD?
Gastroesophageal reflux disease (GERD) and other esophageal disorders account for a significant number of physician office visits, hospital admissions, and endoscopic procedures each year. Annual management costs for GERD alone have been estimated to exceed $9 billion and continue to escalate. Gastroesophageal reflux disease results from the backflowing of gastroduodenal contents into the esophagus, leading to a variety of symptoms including heartburn, chest discomfort, regurgitation, and dysphagia. Compromise in the physiological barrier of reflux at the gastroesophageal junction is believed to be the primary mechanism of reflux. Esophagitis is defined as the presence of signs of inflammation of the esophageal mucosal surfaces, both macroscopically and microscopically. Gastroesophageal reflux disease is the most common cause of esophagitis, followed closely by medication-induced and infection-induced inflammation. Symptoms of esophagitis may range from mild chest discomfort to significant dysphagia and odynophagia.
Epidemiological studies have shown that approximately 25% of the Western population report having symptoms of heartburn at least once a month, with up to 5% noting daily symptoms. While the prevalence of heartburn symptoms appears to be similar in both genders, female patients less likely possess objective findings of reflux on physiological studies. Moreover, numerous clinical studies have shown a lower response rate to antireflux treatment for female patients. No definite relationship between age and GERD has been concluded. At least one study has suggested less reflux symptoms in older individuals. However, elderly also seem to possess more severe esophagitis, suggesting a higher prevalence of asymptomatic reflux. An increase in body mass index both causes reflux and exacerbates existing symptoms.
Gastroesophageal reflux disease most typically presents as heartburn, regurgitation, and dysphagia. Patients often describe heartburn as a retrosternal, “burning” discomfort in the lower chest or epigastric region that often travels up toward the neck region. Symptoms often worsen after meals or when patients are in a supine position. As a result, patients may complain of symptoms or exacerbation of symptoms at night that may wake them up from sleep. Physiological studies suggest that gastric distention caused by meals and sleep can each induce transient relaxation of the lower esophageal sphincter (LES), leading to episodes of reflux. Dysphagia is a common symptom of GERD, and it is often a result of refluxate-induced esophageal mucosal inflammation or dysmotility. However, it is also one of the “alarming” signs of GERD that indicate the need for further evaluation to exclude possible underlying malignancy. Other “alarming” signs of GERD include odynophagia, weight loss, signs of gastrointestinal (GI) bleeding, advanced age, and a family history of upper GI tract malignancy. When one or more of the “alarming” signs are ...