Colin W. Howden, MD Professor of Medicine, Division of Gastroenterology, Northwestern University, Feinberg School of Medicine, Chicago, IL William D. Chey, MD Associate Professor, Division of Gastroenterology, Director of the GI Physiology Laboratory, University of Michigan Health System, Ann Arbor, MI *This special section of The Journal of Family Practice is provided by an unrestricted grant fromTAPPharmaceutical Products, Inc. The authors received a stipend for this work. Dr. Howden reports that he serves on the speakers bureaus for Merck &Co., Inc., Novartis, TAP, and Wyeth, and he has been a consultant to Novartis, Prometheus Laboratories, Inc., Takeda Pharmaceuticals North America, TAP, and Wyeth. Dr. Chey reports that he has received grants and/or serves on speakers bureaus for AstraZeneca, Janssen, and TAP.
Heartburn on 2 or more days a week warrants medical attention, as patients are likely to suffer from gastroesophageal reflux disease (GERD).Chronic GERD can lead to the development of complications including erosive esophagitis, stricture formation, and Barrett’s esophagus, which increases the risk of esophageal adenocarcinoma.
A trial with a proton pump inhibitor (PPI) is the quickest and most cost-effective way to diagnose GERD, and is at least as sensitive as 24-hour intraesophageal pH monitoring.
As PPIs only bind to actively secreting proton pumps, they should be dosed 30 to 60 minutes before a meal.Despite these recommendations, a recent survey of over 1000 US primary care physicians found that 36% instructed their patients to take a PPI with or after a meal or did not specify the timing of dosing.
The patients who will have the best response to surgical therapy for GERD are those who had clearly documented acid reflux with typical symptoms, and who have responded to PPI treatment. Unfortunately, the same survey found that most physicians recommend antireflux surgery for patients in whom medical therapy has failed.
Gastroesophageal reflux disease (GERD) is a common, multifactorial condition that often results in decreased quality of life with interruptions of sleep, work, and social activities. Patients have reported that GERD affects emotional well-being to a greater degree than diabetes or hypertension.1,2 GERD is also associated with well-established complications, including Barrett’s esophagus. The role of reflux in carcinogenesis is controversial; the possibility of an association, however, implies that GERD should be treated aggressively and early.3
Symptoms of gerd
The typical symptoms of GERD are heartburn and regurgitation. Heartburn is best defined as a burning retrosternal discomfort starting in the epigastrium or lower chest and moving upwards towards the neck. Regurgitation is the effortless movement of gastric contents up into the esophagus or pharynx.
Most patients with GERD do not have endoscopically visible lesions; a careful analysis of symptoms generally forms the basis of a preliminary diagnosis.
The occurrence of heartburn on 2 or more days a week has been suggested as a basis for further investigation for GERD.4 However, symptoms vary greatly. Patients may be asymptomatic or experience symptoms that more closely resemble gastric disorders, infectious and motor disorders of the esophagus, biliary tract disease, or even coronary artery disease.
Extraesophageal manifestations
Adding to the complexity of diagnosis, GERD has been shown to have extraesophageal manifestations, including chronic cough, asthma, recurrent aspiration, chronic sore throat, reflux laryngitis, and paroxysmal laryngospasm or voice changes.
Although the relationship between asthma and GERD remains unclear, it has been estimated that 24% to 98% of patients with asthma also have GERD.5 Some patients with asthma have been shown to have excess acid reflux into the esophagus. Reflux-like symptoms may precede episodes of asthma that occur after meals or when lying down.68
Additionally, GERD has been noted in 10% to 50% of patients with non-cardiac chest pain.9,10
