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Gastroesophageal reflux disease (GERD) is a chronic disorder related to the retrograde flow of gastric contents into the esophagus, resulting in a spectrum of symptoms with or without tissue injury.1 Classic GERD symptoms in the absence of esophageal mucosal complications are the hallmarks of nonerosive reflux disease (NERD). Patients with NERD account for up to 70% of those with GERD in the community.2 Antireflux surgery is the only effective and long-term therapy. Although various endoscopic approaches to treat GERD have been introduced, none of them has been able to achieve an efficacy equivalent to antireflux surgery.3,4
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Heartburn (ascending retrosternal burning) and regurgitation are typical GERD symptoms. Epidemiologic studies have demonstrated that heartburn occurs monthly in as many as 40–50% of the Western population. The occurrence of heartburn at night and its effect on quality of life have recently been highlighted by a Gallup poll conducted by the American Gastroenterologic Society (Table 15-1).5 Regurgitation of gastric contents often occurs when the patient is supine or with increases in intra-abdominal pressure, and may result in atypical symptoms, including cough, globus sensation, hoarseness, throat clearing, asthma, aspiration pneumonia, and pulmonary fibrosis. Dysphagia is a typical symptom of GERD and can be divided into (1) an oropharyngeal etiology, which is characterized by difficulty transferring food out of the mouth into the esophagus, and (2) esophageal etiology, which is characterized by the sensation of food sticking in the lower chest. Dysphagia can be a sign of underlying malignancy and should be aggressively investigated with upper endoscopy. Chest pain can be caused by GERD; however, it is very important to exclude a cardiac etiology. DeMeester and colleagues reported that nearly 50% of patients with severe noncardiac chest pain had a positive 24-hour pH study implicating GERD as the underlying etiology.6 Chest pain precipitated by meals, occurring at night while supine, nonradiating, responsive to antacid medication, or accompanied by other symptoms such as dysphagia and/or regurgitation should trigger an evaluation for an esophageal cause. Additionally, it should be noted that the distinction between heartburn and chest pain can be difficult to make, and the perception of these symptoms is highly variable between patients.7,8
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The antireflux mechanism includes four important components: (1) lower esophageal sphincter (LES); (2) crural diaphragm; (3) esophageal peristalsis; and (4) stomach (the ...