Gastroesophageal reflux disease

To review the management of gastroesophageal reflux disease (GERD) in adults with esophageal complications (esophagitis, stricture, adenocarcinoma, or Barrett metaplasia) or extraesophageal complications (otolaryngological manifestations and asthma).

Peer-reviewed publications located via MEDLINE or cross-citation.

Emphasis was placed on new developments in diagnosis and therapeutics. Thus, fewer than 10% of identified citations are discussed.

Controlled therapeutic trials were emphasized. The validity of pathophysiological observations and uncontrolled trials were critiqued by the author.

Esophagitis is typically a chronic, recurring disorder treated with long-term antisecretory therapy, titrated to disease severity. Laparoscopic [correction of Laparascopic] antireflux surgery is an alternative strategy, but neither long-term efficacy data nor an appropriate controlled trial comparing it with proton pump inhibitor therapy exists. The main risk of esophagitis is adenocarcinoma arising from Barrett metaplasia, the incidence of which is increasing. Strong evidence suggests that both reflux-induced asthma and otolaryngological complications (subglottic stenosis, laryngitis, pharyngitis, or cancer) can occur without esophagitis. While the otolaryngological manifestations usually respond to antisecretory medications, reflux-induced asthma responds convincingly only to antireflux surgery.

Although esophagitis and GERD symptoms predictably respond to antisecretory medicines, the risk of adenocarcinoma from Barrett metaplasia dictates that if heartburn is refractory to treatment, chronic (>5 years), or accompanied by dysphagia, odynophagia, or bleeding, it should be evaluated by endoscopy. Thereafter, patients with Barrett metaplasia require surveillance endoscopy to control the cancer risk. Reflux-induced asthma remains a vexing problem in the absence of either medical therapy or proven efficacy of a reliable mechanism of prospectively identifying affected patients.