• Heartburn, often worse on recumbency
• Sliding hiatal hernia on upper GI series
• Endoscopic biopsy evidence of esophagitis
• Decreased resting pressure in lower esophageal sphincter
• Abnormal esophageal acid exposure on prolonged pH monitoring
• Most patients (80%) with GERD have a sliding hiatal hernia (type I) in which the gastroesophageal junction (GEJ) is displaced upward into the posterior mediastinum, exposing the lower esophageal sphincter to intrathoracic pressure, which is less than intra-abdominal pressure
• The principal barrier to reflux is the lower esophageal sphincter, the competence of which is a function of sphincter pressure, sphincter length, and the length exposed to intra-abdominal pressure
• Bile acids may also play a role in esophagitis, especially in patients with previous gastric surgery
• 15% of patients have severe symptoms refractory to optimal medical treatment and will require surgery
• Retrosternal and epigastric burning pain that occurs after eating and while sleeping or lying in a recumbent position and is relieved by drinking liquids, antacids, or by standing or sitting
• Regurgitation of bitter or sour-tasting fluid
• Pulmonary symptoms (wheezing, dyspnea) as the result of aspiration
• Dysphagia, which results from inflammatory edema in the lower esophagus
• Upper GI contrast radiography: Protrusion of the stomach upward through the esophageal hiatus
• Esophagoscopy and biopsy: Determine the presence and degree of esophagitis and Barrett metaplasia
• Manometry: Decreased mean resting pressure in the lower esophageal sphincter
• Abnormal lower esophageal peristalsis: Low amplitude and decreased velocity of propagation of the peristaltic wave
• pH monitoring: Increased exposure of the lower esophagus to acid, correlating with symptom onset
• Upper GI contrast radiography may indicate a sliding hiatal hernia and evidence of contrast reflux
• Upper GI endoscopy with biopsy to assess presence and degree of esophagitis and evaluate for Barrett metaplasia
• pH monitoring to document acid reflux and association with symptoms
• Manometry to assess status of lower esophageal sphincter and force of peristalsis
• Persistent or recurrent symptoms despite good medical therapy
• Complete mechanical incompetence of the sphincter (pressure < 6 mm Hg)
• Presence or development of strictures
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