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Source: William DB, Schade RR. Gastroesophageal Reflux Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7977509. Accessed June 12, 2012.

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  • Heartburn
  • Acid reflux disease
  • GERD

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  • Retrograde movement of stomach contents into esophagus causing troublesome symptoms and/or complications.

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  • Defective lower esophageal sphincter (LES) pressure or function
  • Abnormal esophageal anatomy
  • Improper esophageal clearance of gastric fluids
  • Reduced mucosal resistance to acid
  • Delayed or ineffective gastric emptying
  • Reduced salivary buffering of acid

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  • Decreased LES pressure may result from spontaneous transient LES relaxations, transient increases in intraabdominal pressure, atonic LES, or ingestion of certain foods and medications.
  • Substances that promote esophageal damage upon reflux include gastric acid, pepsin, bile acids, and pancreatic enzymes.
  • Composition and volume of refluxate and duration of exposure are most important factors in determining clinical consequences.
  • Complications from long-term acid exposure include esophagitis, esophageal strictures, Barrett esophagus, and esophageal adenocarcinoma.

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  • Most common in persons older than 40 years.
  • 10–20% of adults in Western countries suffer from GERD symptoms on weekly basis.
  • Prevalence of GERD highest in Western countries.
  • No difference in incidence between men and women, except for higher incidence during pregnancy.

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Signs and Symptoms

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  • Heartburn (substernal sensation of warmth or burning rising up from abdomen that may radiate to neck), water brash (hypersalivation), belching, regurgitation.
  • Pain may wax and wane and be aggravated by activities that worsen reflux (e.g., recumbent position, bending over, or high-fat meals).
  • Extraesophageal symptoms may include chronic cough, laryngitis, asthma, and dental enamel erosion.
  • Alarm symptoms include dysphagia, odynophagia, and unexplained weight loss.
  • Tissue injury–based GERD (with or without symptoms) may present with esophagitis, esophageal strictures, Barrett esophagus, or esophageal carcinoma.

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Means of Confirmation and Diagnosis

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  • Clinical history, including symptoms and risk factors.
  • Patients with mild, typical symptoms do not usually require invasive evaluation.
  • Clinical diagnosis can be assumed in patients who respond to appropriate therapy.
  • Perform diagnostic tests in patients who do not respond to therapy or who present with alarm symptoms.

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Imaging

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  • Barium radiography not routinely used—lacks sensitivity and specificity, and cannot identify Barrett esophagus.

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Diagnostic Procedures

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  • Endoscopy preferred for assessing mucosa for esophagitis, identifying Barrett esophagus, and diagnosing complications.
  • Camera-containing capsule swallowed by patient can visualize esophageal mucosa.
  • Ambulatory pH monitoring helps correlate symptoms with abnormal esophageal acid exposure.
  • Combined impedance–pH monitoring measures both acid and nonacid reflux.
  • Esophageal manometry used to evaluate esophageal peristalsis and motility prior to antireflux surgery.

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Differential Diagnosis

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  • Angina pectoris
  • Peptic ulcer disease
  • Gastritis
  • Infectious esophagitis (Candida, herpes simplex virus, cytomegalovirus)
  • Pill-induced esophagitis
  • Esophageal motility disorders (e.g., achalasia, esophageal spasm, scleroderma)
  • Zollinger-Ellison syndrome

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  • Reduce or eliminate symptoms.
  • Decrease frequency and duration of reflux.
  • Promote healing of injured mucosa.
  • Prevent development of complications.

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  • Treatment strategies can:
    • Decrease acidity of refluxate
    • Reduce gastric volume
    • Improve ...

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