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trocsophageal Reflux Dise Peter J. Kahrilas, MD This journal feature begins with a case vignette hightig various strategies is the presented, followed be ON ac “ ic 'ommon clinical problem. Evidence supporting The article ends With the y Areview 7 o te vie ” of formal guidelines, when they exist 20r"s clinical recommendations : A 53 rears old man, who is otherwi reports having had Worsening heartburn fi , Or the past 12 months, w; sleep. He reports having had no dysphagia, gastrointestinal biscdin recently gained 20 1b (9kg). What would you advise regarding his y of occasional heartburn, h daily Symptoms that disturb hís Mg, Or weight loss and in fact has evaluation and treatment? THE CLINICAL PROB LEM j OOOO] o Dased on ee prevalenco of self-reported chronic heartbum. A current definition of the disorder 4 ps when the reflux of stomach contents causes troublesome symptoms (i.e., at least two heartburn episodes per week) and/or complications.” Several extraesophageal manifestations of the disease are well recognized, including laryngitis and cough. With respect to the esophagus, the spectrum of injury includes esophagitis, stricture, the development of columnar metaplasia in place of the normal squamous epitelium (Barrett's esophagus), and adenocarcinoma. Of particular concern is the rising incidence of esophageal adenocarcinoma, and epidemiologic trend strongly linked to the increasing incidence of this condition. There were about 8000 incident cases of esophageal adenocarcinoma in the United States in 2004, which represents an increase by a factor of 2 to 6 in disease burden during the past 20 years, Esophagitis occurs when excessive reflux of acid and pepsin results in necrosis of surface layers of esophageal mucosa, causing erosions and ulcers. Impaired clearance of the refluxed gastric juice from the esophagus also contributes to damage in many patients. Whereas some gastroesophageal reflux is normal (and relates to the ability to belch), several factors may predispose patients to pathologic reflux, including hiatus hernia, lower esophageal sphincter hypotension, loss of esophageal peristaltic function, abdominal obesity, increased compliance of the hiatal canal, gastric hypersecretory states, delayed gastric emptying and overeating. Often multiple risk factors are present. A consistent paradox in gastroesophageal reflux discase is the imperfect correspondence between sy mproms attributed to the condition and endoscopic features of the disease. In a population-based endoscopy NN " wchich 1000 northern Europeans were randomly sampled, the prevalence of Barrett 5 esophagus and pe : mn of those who were found to have esophagitis reported having reflux E a patients reporting reHux symptoms had no esophagitis. Furthermote, although eta o most common cause of heartburn, other disorders (c.g., achalasia and cosinophilic esophagitis cause or contribute to heartburn. 
