Snapshot A 45-year-old man with hypertension and obesity presents with complaints of heartburn and regurgitation with a sour taste that is aggravated by drinking coffee and eating spicy foods. He also endorses intermittent night time coughing when he eats a late dinner with occasional sore throat and hoarseness. He has tried an antacid with slight improvement but his symptoms are still bothersome. Introduction Clinical definition reflux of gastric contents into the esophagus Associated conditions hiatal hernia gastric outlet obstruction scleroderma Epidemiology Demographics common increases with age Risk factors alcohol smoking coffee pregnancy obesity ETIOLOGY Pathogenesis ↓ lower esophageal sphincter (LES) tone allowing gastric contents to reflux into the esophagus ↓ esophageal motility leading to ↓ clearance of retrograde gastric contents ↓ gastric emptying Presentation Symptoms classic postprandial retrosternal pain, may radiate to neck or chest regurgitation or sour taste other hypersalivation dysphagia or globus sensation odynophagia cough hoarseness early satiety weight loss Physical exam dental enamel erosion wheezing benign abdominal exam imaging Esophagogastroduodenoscopy (EGD) with biopsy visualize erosive disease, complications, and other anatomical abnormalities first test of choice for atypical presentations Studies Diagnostic testing diagnostic approach classic presentation does not require work up below may require ruling out cardiac etiology studies manometry evaluate LES and motility indicated if empirical therapy fails or atypical work up 24-hour intraesophageal pH monitoring gold standard diagnostic test but not always indicated indicated for atypical history or inconclusive EGD Differential Angina pectoralis distinguishing factor not associated with eating Chemical esophagitis distinguishing factor no reflux Peptic ulcer disease distinguishing factor localized epigastric or central abdominal pain that does not radiate Treatment Management approach empiric treatment with lifestyle modification and acid suppression therapy for classic presentation step-up therapy for mild or intermittent symptoms histamine H2 receptor antagonist → proton pump inhibitor step-down therapy for severe or erosive symptoms for faster relief proton pump inhibitor → histamine H2 receptor antagonist All patients lifestyle modification avoid triggering foods (fatty, caffeine, acidic, and alcohol) stop smoking sleep in an elevated position antacids Mild to intermittent symptoms histamine H2 receptor antagonist cimetidine, famotidine, or ranitidine Moderate to severe symptoms proton pump inhibitor omeprazole or lansoprazole side effects include pneumonia, Clostridium difficile, hypergastrinemia, fractures, and hypomagnesemia Surgical fundoplication for failed medical management or complications Complications Barrett esophagus Esophageal cancer Esophageal ulcer with bleeding or perforation Peptic stricture Pulmonary aspiration