Gastroesophageal reflux disease: diagnosis and management

Gastroesophageal reflux disease (GERD) is defined as the presence of symptoms and/or tissue damage resulting from the reflux of gastric contents into the esophagus. It occurs as a result of transient or persistent reduction in lower esophageal sphincter (LES) pressure, influenced to some degree by the presence or absence of a hiatal hernia, and the failure of the usual clearance mechanisms that normally rid the distal esophagus of noxious materials. Heartburn and regurgitation are the most common symptoms, but extraesophageal symptoms related to aspiration may occur. The clinical presentation itself is often diagnostic, but techniques such as endoscopy, barium swallow, and pH monitoring are confirmatory. Management generally involves life-style changes with or without added pharmacologic therapy. A small percentage of patients require antireflux surgery. Pharmacologic management options include acid-neutralizing agents such as antacids and alginate, prokinetic agents such as metoclopramide and cisapride, and antisecretory drugs such as the histamine H2 blockers and the proton pump inhibitors. Once the patient is healed pharmacologically, maintenance pharmacologic therapy is necessary to prevent relapse. Antireflux surgery may be indicated in patients whose diagnosis is clear, who respond well to pharmacologic therapy, but who, for one reason or another, are not candidates for long-term pharmacologic management. Preventing the advent of Barrett's esophagus is one goal of therapy, because of the risk of developing adenocarcinoma of the esophagus. The management of Barrett's esophagus is discussed.