Elsevier

Disease-a-Month

Volume 66, Issue 1, January 2020, 100848
Disease-a-Month

Natural history, pathophysiology and evaluation of gastroesophageal reflux disease,

https://doi.org/10.1016/j.disamonth.2019.02.001Get rights and content

Abstract

Gastroesophageal reflux disease (GERD) is one of the most common diseases encountered by both internists and gastroenterologists. GERD can cause a wide variety of symptoms ranging from heartburn and regurgitation to more atypical symptoms such as cough, chest pain, and hoarseness. The diagnosis is often times made on the basis of history and clinical symptomatology. The prevalence of GERD is currently estimated to be 8–33% with the incidence of disease only expected to increase over time. Although most cases of GERD can be diagnosed based on symptoms and clinical presentation, the diagnosis of GERD can be challenging when symptoms are atypical. In this review, we provide a comprehensive summary of the epidemiology, pathophysiology, evaluation and diagnosis of gastroesophageal reflux disease.

Introduction

Gastroesophageal reflux disease (GERD) is one of the most common diseases encountered by both interests and gastroenterologists. The estimated prevalence of disease ranges from 8 to 33% with the incidence of disease only expected to increase over time.1, 2, 3, 4, 5, 6, 7 GERD is a condition that occurs when the reflux of gastric contents causes troublesome symptoms and complications in patients. Despite the understanding of numerous risk factors, evaluation modalities, and diagnostic tests, GERD continues to affect a large fraction of patients. In this report we provide a comprehensive review of the epidemiology, pathophysiology, evaluation and diagnosis of GERD.

Section snippets

Epidemiology

GERD is a chronic, commonly encountered disease in both the primary and specialty clinic settings. The prevalence of GERD in the Western world is estimated to range from 10% to 25%, while the prevalence in Asia is reported to be <5%.1, 2, 3, 4,6,8 The prevalence of GERD symptoms had risen about 50% until 1995, but has since remained constant.9 In addition, GERD carries a significant economic burden with its evaluation and management, and is estimated to be greater than $10 billion per year.10

Pathophysiology

Gastroesophageal reflux disease (GERD) is a chronic relapsing condition that occurs when the reflux of gastric contents from the stomach causes troublesome symptoms and/or complications in patients.22, 23, 24, 25 The reflux from the stomach provokes symptoms and complications, which generally includes heartburn and regurgitation.15,25 GERD is thought to progress when factors that are harmful to the esophagus overcome many of the mechanisms that are protective – the gastroesophageal (GE)

Natural history

The natural history of GERD is difficult to discern despite the increase prevalence of the condition.35 This is due to the lack of longitudinal, prospective studies prior to the universal availability of proton pump inhibitor (PPI) therapy and ambiguity in the condition's classification when overlapped with similar symptoms of other functional gastrointestinal tract disorders.35,36 GERD is categorized into two major subtypes: erosive reflux disease (ERD) and non-erosive reflux disease (NERD).35,

Risk factors

GERD is influenced by both heritable and environmental factors.39 Recognized risk factors include obesity, genetics, tobacco smoking, pregnancy, hiatal herniation, and certain medications and foods.40,41

Typical signs and symptoms

The two most common symptoms associated with GERD are heartburn and regurgitation (Fig. 1). Heartburn is described as a burning sensation in the retrosternal region of chest, and is typically postprandial.24 Regurgitation is the feeling of gastric contents refluxing back into the mouth or throat.24 Other signs include nausea, dysphagia, chest pain, globus sensation, and/or hypersalivation. Majority of cases of GERD can be diagnosed clinically based on history and symptomatology, however, it may

Evaluation of GERD

The evaluation of GERD can be complicated at times, and requires a combination of subjective and objective findings. Evaluation of GERD begins with a thorough history regarding patient's clinical symptoms, objective findings on physical exam and testing, evaluation of anatomical variances, and exclusion of other common causes of patient's symptoms.78

Diagnosis of GERD

As mentioned above, that the diagnosis of GERD is usually a clinical one. However, if the presumptive diagnosis is insufficient or the patient does not experience resolution of symptoms after initiation of treatment, other diagnostic modalities are used to confirm the diagnosis of GERD.6,7 Understanding the utility and evidence behind these tests in the diagnosis of GERD is essential.

Conclusion

GERD remains one of the most common conditions encountered in primary care and gastroenterology clinics. Despite its increased prevalence, the variation in presentation of GERD can make the evaluation and diagnosis challenging. There continue to be knowledge gaps in our understanding of the risk factors, diagnostic modalities, and evaluation of GERD. In majority of the cases, clinical symptomatology alone is sufficient in making the diagnosis. However, in patients with atypical symptoms and

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      Citation Excerpt :

      The etiology of GERD is believed to be multifactorial. Despite a large body of systematic reviews and meta-analyses devoted to examining environmental factors and GERD [7–8], there are no systematic efforts to summarize and critically appraise this body of evidence [9–11]. We therefore summarized the factors examined through meta-analyses, assessed the quality of the methodology used, investigated potential biases, and determined which associations are supported by robust epidemiologic evidence.

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    Disclaimers: None.

    Sources of support/funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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