We did a MEDLINE search of articles published between 1966 and August, 2005, using the terms “oesophagitis”, “gastro-oesophageal reflux”, “peptic oesophagitis”. All terms were merged using the set operator “OR” and the search was limited to “human” and “English language” studies.
SeminarGastro-oesophageal reflux disease
Introduction
Gastro-oesophageal reflux disease is a common problem and is expensive to manage in both primary and secondary care settings. The annual direct cost for managing the disease is estimated to be more than $9 billion dollars in the USA.1 There have been major advances in the diagnosis, pathophysiology, and treatment of this disease, which we will review here.
Section snippets
Definitions
There is no gold standard test for objectively diagnosing gastro-oesophageal reflux disease, and definitions have therefore relied on a combination of disease characteristics. For example, an international working group2 defined the disease as the reflux of gastric contents into the oesophagus leading to oesophagitis, reflux symptoms sufficient to impair quality of life, or risk of long-term complications. This definition builds on previous ones3, 4 and emphasises that gastro-oesophageal reflux
Epidemiology
There have been a series of systematic reviews that have improved understanding of the epidemiology of the disease.8, 9, 10, 11
Pathophysiology
The primary underlying mechanism could be impaired function of the lower oesophageal sphincter—a segment of smooth muscle in the distal oesophagus that tonically contracts so that the pressure in this area is at least 15 mm Hg above intragastric pressure.49 This mechanism acts as a physiological barrier to prevent gastric contents from refluxing into the oesophagus. The sphincter relaxes in response to oesophageal peristalsis to allow the passage of food, liquid, or saliva into the stomach.
Diagnosis
The lack of a gold standard has hampered the assessment of the accuracy of various approaches to the diagnosis of gastro-oesophageal reflux disease. The absence of a reference standard can be overcome by use of techniques such as latent class analysis and Bayesian analysis, but as yet these methods have not been used in the assessment of the disease.63 The accuracy and use of the different approaches to diagnose the disease are therefore uncertain. The tools available for diagnosis are
Complications and extra-oesophageal manifestations
There is a paucity of data on the long-term outcome of patients with different severities of reflux disease. Patients with severe symptoms over a long duration might intuitively be expected to be at higher risk of more severe reflux disease. Severity and duration of symptoms, however, seem to have a poor correlation with the presence or severity of oesophagitis.91 A US veteran database study of more than 29 500 patients with uncomplicated erosive oesophagitis reported no patients developing
Treatment
Lifestyle advice and antacid therapy is advocated as first-line treatment for the disease. Lifestyle factors are only weakly associated with reflux symptoms, so it is unlikely that these will have a major effect on the disease. Nevertheless, advice such as stop smoking, reduce alcohol intake, and weight loss in obese patients is likely to have wider benefits, even if the effect on reflux symptoms is small. There is some evidence from a randomised trial105 that antacid therapy has a small effect
Management
There have been several guidelines3, 4, 185, 186, 187, 188 published on the management of the disease (table 2). There is a consensus that PPIs are the most effective therapy and should be continued long term at the lowest dose that controls symptoms. All agree that endoscopy has a role in the investigation of the disease, but the threshold at which endoscopy is recommended varies. The guidelines recommend surgery for selected cases. We have constructed a management strategy based on common
Search strategy and selection criteria
References (193)
- et al.
The burden of selected digestive diseases in the United States
Gastroenterology
(2002) Diagnosis of symptomatic gastroesophageal reflux disease
Am J Gastroenterol
(2003)- et al.
The epidemiology of gastroesophageal reflux disease
Am J Med Sci
(2003) - et al.
Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota
Gastroenterology
(1997) - et al.
Natural history of gastroesophageal reflux disease and functional abdominal disorders: a population-based study
Am J Gastroenterol
(2001) - et al.
Heartburn severity underestimates erosive esophagitis severity in elderly patients with gastroesophageal reflux disease
Gastroenterology
(2004) - et al.
Inhibitory effect of coffee on lower esophageal sphincter pressure
Gastroenterology
(1980) - et al.
Risk factors for erosive reflux esophagitis: a case-control study
Am J Gastroenterol
(2001) - et al.
Risk factors associated with symptoms of gastroesophageal reflux
Am J Med
(1999) - et al.
Overweight, but not high dietary fat intake, increases risk of gastro-oesophageal reflux disease hospitalisation: the NHANES I epidemiologic follow up study
Ann Epidemiol
(1999)
Effect of population screening and treatment for Helicobacter pylori on dyspepsia and quality of life in the community: a randomised controlled trial
Lancet
Familial aggregation of gastroesophageal reflux in patients with Barrett's esophagus and esophageal adenocarcinoma
Gastroenterology
Gastroesophageal reflux disease in monozygotic and dizygotic twins
Gastroenterology
Patterns of lower esophageal sphincter function associated with gastroesphageal reflux
Am J Med
Esophagastric junction opeing during relaxation distinguishes nonhernia reflux patients, hernia patients, and normal subjects
Gastroenterology
Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia
Gastroenterology
Hiatal hernia size is the dominant determinant of esophagitis presence and severity in gastroesophageal reflux disease
Am J Gastroenterol
Role of acid and duodenogastroesophageal reflux in gastroesophageal reflux disease
Gastroenterology
Effect of peristaltic dysfunction on esophageal volume clearance
Gastroenterology
The pathogenesis of heartburn in nonerosive disease: a unifying hypothesis
Gastroenterology
Diagnostic tests for gastroesophageal reflux disease
Am J Med Sci
Unsedated peroroal endoscopy with a video ultrathin endoscope: patient acceptance, tolerance and diagnostic accuracy
Am J Gastroenterol
Symptoms in gastro-oesophageal reflux disease
Lancet
The usefulness of the likelihood ratio in the diagnosis of dyspepsia and gastroesophageal reflux disease
Am J Gastroenterol
Clinical esophageal pH recording: a technical review for practice guidelines development
Gastroenterology
Simultaneous intraesophageal impedance and pH measurement of acid and nonacid gastroesophageal reflux: effect of omeprazole
Gastroenterology
Prolonged pH monitoring: Bravo capsule
Gastrointest Endosc Clin N Am
Outcome of erosive reflux esophagitis after Nissen fundoplication
Am J Gastroenterol
Seminar: Barrett's metaplasia
Lancet
Is there publication bias in the reporting of cancer risk in Barrett's esophagus?
Gastroenterology
Oesophageal adenocarcinoma arising from Barrett's metaplasia has regional variations in the West
Gastroenterology
Symptom evaluation in reflux disease: workshop background, processes, terminology, recommendations, and discussion outputs
Gut
American College of Gastroenterology updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease
Am J Gastroenterol
An evidence-based appraisal of reflux disease management: the Genval Workshop Report
Gut
Sufficient control of heartburn in endoscopy-negative gastro-oesophageal reflux disease trials
Scand J Gastroenterol
Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification
Gut
Gastro-oesophageal reflux disease: the extent of the problem
Aliment Pharmacol Ther
Epidemiology of gastro-oesophageal reflux disease: a systematic review
Gut
Systematic review: geographical and ethnic differences in gastro-oesophageal reflux disease
Aliment Pharmacol Ther
Anxiety and depression are co-factors determining health care utilisation in patients with dyspepsia: a Hong Kong population based study
Gastroenterology
High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population: a Kalixanda study report
Scand J Gastroenterol
Epidemiology of reflux disease and reflux esophagitis
Scand J Gastroenterol
The prevalence of gastro-oesophageal reflux symptoms in a UK population and the consultation behaviour of patients with these symptoms
Aliment Pharmacol Ther
Symptoms of gastro-oesophageal reflux: prevalence, severity, duration and associated factors in a Spanish population
Aliment Pharmacol Ther
Ethnicity, gender, and socioeconomic status as risk factors for esophagitis and Barrett's esophagus
Am J Epidemiol
Gastro-oesophageal reflux disease in obesity: pathophysiology and therapeutic considerations
Obes Rev
Elevated body mass disrupts the barrier to gastroesophageal reflux
Arch Surg
Mechanisms of acid reflux associated with cigarette smoking
Gut
The effect of alcohol on nocturnal gastroesophageal reflux
JAMA
Chocolate and heartburn: evidence of increased esophageal acid exposure after chocolate ingestion
Am J Gastroenterol
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