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.
- Acid reflux disease
- Retrograde movement of stomach contents into esophagus
causing troublesome symptoms and/or complications.
- Defective lower esophageal sphincter (LES) pressure or
- Abnormal esophageal anatomy
- Improper esophageal clearance of gastric fluids
- Reduced mucosal resistance to acid
- Delayed or ineffective gastric emptying
- Reduced salivary buffering of acid
- 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.
- 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.
- Heartburn (substernal sensation of warmth or burning rising
up from abdomen that may radiate to neck), water brash (hypersalivation),
- Pain may wax and wane and be aggravated by activities that
worsen reflux (e.g., recumbent position, bending over, or high-fat
- Extraesophageal symptoms may include chronic cough, laryngitis,
asthma, and dental enamel erosion.
- Alarm symptoms include dysphagia, odynophagia, and unexplained
- Tissue injury–based GERD (with or without symptoms)
may present with esophagitis, esophageal strictures, Barrett esophagus,
or esophageal carcinoma.
Means of Confirmation
- Clinical history, including symptoms and risk factors.
- Patients with mild, typical symptoms do not usually require
- 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.
- Barium radiography not routinely used—lacks sensitivity
and specificity, and cannot identify Barrett esophagus.
- Endoscopy preferred for assessing mucosa for esophagitis,
identifying Barrett esophagus, and diagnosing complications.
- Camera-containing capsule swallowed by patient can visualize
- 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.
- Angina pectoris
- Peptic ulcer disease
- Infectious esophagitis (Candida,
herpes simplex virus, cytomegalovirus)
- Pill-induced esophagitis
- Esophageal motility disorders (e.g., achalasia, esophageal
- Zollinger-Ellison syndrome
- Reduce or eliminate symptoms.
- Decrease frequency and duration of reflux.
- Promote healing of injured mucosa.
- Prevent development of complications.
- Treatment strategies can: