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Gastroesophageal Reflux Disease: Overview and Risk Factors

Gastroesophageal reflux disease (GERD) is a syndrome of inappropriate backflow of gastric acid into the esophagus, which can result in inflammation and erosion of the esophageal mucosa. It is the most common upper-gastrointestinal disorder in Western nations, affecting 30% of Americans intermittently and up to 10% on a daily basis.

The pathophysiology involves defective lower esophageal sphincter function, due to inappropriate sphincter relaxation. This condition may be exacerbated by alcohol intake, smoking, fatty foods, caffeine, chocolate, or various medications (eg, anticholinergics, calcium channel blockers); inadequate sphincter size or muscle function; or abnormal sphincter position.

Symptoms include heartburn, dysphagia, hoarseness, regurgitation, belching, a full feeling in the throat, and a persistent, nonproductive cough. Because the characteristic heartburn may mimic cardiac chest pain, it is useful to characterize the heartburn pain to distinguish it from cardiac ischemia. The pain associated with reflux is of a burning quality and may radiate to the back. It usually occurs within 30 minutes after ingesting specific foods, is often exacerbated by recumbancy, and is relieved by antacids. Unlike cardiac chest pain, the symptoms of reflux are not related to exertion and are not associated with shortness of breath, nausea, diaphoresis, or pain radiation to the jaw or arms.

Chronic reflux can result in severe sequelae, including erosion, ulceration, scarring, or stricture of the esophageal mucosa. Further, a possible complication of chronic reflux is the development of Barrett's esophagus, in which metaplasia of the lower esophageal mucosa results in replacement of the squamous epithelium with columnar epithelium. Patients with Barrett's esophagus are at high risk for developing esophageal adenocarcinoma.

Risk Factors

Diet (see Nutritional Considerations).

Disorders and conditions that cause increased gastric pressure. Pregnancy and obesity cause increased intra-abdominal pressure that is translated to the stomach. Diabetes mellitus causes prolonged gastric emptying, resulting in increased gastric contents and gastric pressure. In each case, the increased gastric pressure exerts abnormally high pressure on the lower esophageal sphincter and predisposes the individual to reflux.

Hiatal hernia. In this syndrome, the stomach herniates upward through the diaphragm, displacing the lower esophageal sphincter from its anatomic position. As a result, the sphincter is often not functionally competent.

Disorders that result in esophageal dysmotility. Such disorders, which include scleroderma and Parkinson's disease, can impair esophageal clearance of refluxed gastric acid. Raynaud's phenomenon is also often complicated by reflux.

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Gastroesophageal Reflux Disease: Diagnosis and Treatment >>