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In the US: Approximately 7% of the Western population experiences symptoms of heartburn daily. An abnormal esophageal exposure to gastric juice probably is present in 20-40% of this population. Because many individuals control symptoms with over-the-counter medications without consulting a physician, the problem likely is underreported.

Mortality/Morbidity:
In addition to the typical symptoms (heartburn, regurgitation, dysphagia), abnormal reflux can cause atypical symptoms such as coughing, chest pain, and wheezing and also damage to the lungs (pneumonia, asthma, idiopathic pulmonary fibrosis), vocal cords (laryngitis, cancer), ear (otitis media), and teeth (enamel decay).

Approximately 50% of patients with reflux develop esophagitis, which is classified into 4 grades based on severity. Grade I is erythema, grade II is linear nonconfluent erosions, grade III is circular confluent erosions, and grade IV is stricture or Barrett esophagus. Barrett esophagus (grade IV) is thought to be due to the chronic reflux of gastric juice into the esophagus. It occurs when the squamous epithelium of the esophagus is replaced by intestinal columnar epithelium. It is present in 8-15% of patients with GERD and may progress to adenocarcinoma.

Race:
White males are more at risk for Barrett esophagus and adenocarcinoma than other populations.

Sex:
No sex predilection exists. Males tend to develop esophagitis (2:1-3:1) and Barrett esophagus (10:1) more frequently than females.

Age:
GERD occurs in all age groups. Prevalence increases after age 40 years.

Typical symptoms include the following:

Heartburn:
This is the most common symptom. It is felt as a retrosternal sensation of burning or discomfort that occurs usually after eating or when lying down or bending over.

Regurgitation:
This is effortless return of gastric and/or esophageal contents into the pharynx. It can induce respiratory complications if gastric contents spill into the tracheobronchial tree.

Dysphagia:
This occurs in approximately one third of patients due to a mechanical stricture or a functional problem (nonobstructive dysphagia secondary to abnormal esophageal peristalsis). Patients feel that food is stuck, particularly in the retrosternal area.

Atypical symptoms include the following:

Cough and/or wheezing:
These are respiratory symptoms resulting from aspiration of gastric contents into the tracheobronchial tree or from the vagal reflex arc producing bronchoconstriction. Approximately 50% of patients who have GERD-induced asthma do not experience heartburn.

Hoarseness:
This results from irritation of the vocal cords by gastric refluxate. It often is experienced in the morning.

Chest pain:
Reflux is the most common cause of noncardiac chest pain and accounts for approximately 50% of cases. Patients can present to the emergency department with pain resembling myocardial infarction. Reflux should be ruled out (if necessary using esophageal manometry and 24-hr pH testing) once a cardiac cause has been excluded.  Alternatively, a therapeutic trial of high-dose proton pump inhibitor therapy can be tried. Importantly, a diagnosis of GERD based on the presence of typical symptoms is correct in only 70% of patients.

Marco Patti, MD, is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Gastroenterological Association, American Medical Association, Association for Academic Surgery, International Electrogastrography Society, International Society for Diseases of the Esophagus, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal Endoscopic Surgeons, Southwestern Surgical Congress, and Western Surgical Association

Editor(s): John Gunn Lee, MD, Director of Pancreaticobiliary Service, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, University of California at Irvine School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Noel Williams, MD, Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada; Alex J Mechaber, MD, FACP, Director of Clinical Skills Program, Assistant Professor, Department of Internal Medicine, Division of General Internal Medicine, University of Miami School of Medicine; and Julian Katz, MD, Professor, Department of Internal Medicine, Division of Gastroenterology, MCP Hahnemann University

Disclaimer:  These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease.