Gastroesophageal reflux disease (GERD) is defined by symptoms and/or histopathological alterations (esophagitis) caused by reflux of gastric contents into the esophagus. Manifestations of GERD range from mild episodes of heartburn and acid regurgitation, without esophagitis, to chronic mucosal inflammation with erosive esophagitis and ulceration, complicated in severe cases by stricture and bleeding. While it is still unclear whether the incidence and prevalence of GERD symptoms increase with aging, several studies suggest that frequency of esophagitis is significantly higher in the elderly than in adult or young subjects. Indeed, older age was found to be a significant risk factor in the development of severe forms of GERD in both epidemiological and clinical studies from the United States, Japan, and Europe.
Pathophysiological changes in esophageal functions that occur with aging may be responsible, at least in part, for the high prevalence of GERD in old age. These include (1) a shorter intra-abdominal segment of the lower esophageal sphincter (LES), (2) a reduction of secondary peristalsis, (3) an increase in the prevalence of tertiary contractions, (4) alterations in salivary secretion, (5) a reduction in gastric emptying, (6) a decreased esophageal mucosal resistance resulting from impaired epithelial cell regeneration, and (7) duodenogastroesophageal reflux of bile salts (Table 91-1). Elderly subjects have a high prevalence of other risk factors that predispose the aging esophagus to lesions (Table 91-1): (1) difficulty in maintaining an upright position after meals; (2) hiatus hernia associated with both repeated episodes of acid reflux and with more severe diseases sucs as Barrett esophagus; (3) increased drug use, including those that may have a directly damaging effect on esophageal mucosa or an indirect effect on reducing LES pressure; and (4) delayed esophageal transit time of many drugs, creating a potentially dangerous situation when it coexists with acid reflux, as reported for alendronate and nonsteroidal anti-inflammatory drugs (NSAIDs) (Table 91-2).
Table 91-1 Pathophysiological Changes in Esophageal Functions that Occur with Aging |Favorite Table|Download (.pdf)
Table 91-1 Pathophysiological Changes in Esophageal Functions that Occur with Aging
Impaired motility of the esophagus
Reduced LES pressure and length
Difficulty in maintaining an upright position
Normal gastric acid secretion
Delayed gastric emptying transit time
Reduced salivary secretion
Decreased tissue resistance as a result of impaired epithelial cell regeneration
Duodenogastroesophageal reflux of bile salts
Table 91-2 Drugs that May Increase the Risk of Severe GERD |Favorite Table|Download (.pdf)
Table 91-2 Drugs that May Increase the Risk of Severe GERD
DIRECT EFFECT ON ESOPHAGEAL MUCOSA
REDUCTION IN LES PRESSURE
Particular attention has been given to the clinical presentation of GERD in the elderly since ...