INTRODUCTION

Reflux esophagitis results from the combination of excessive gastroesophageal reflux of gastric juice and impaired esophageal clearance of the refluxate. (See "Pathophysiology of reflux esophagitis".) Although the relationship is imprecise, the likelihood of developing reflux symptoms or esophageal epithelial injury is a function of a quantitative abnormality of the number of reflux events and/or esophageal acid exposure. Hence, therapy should be titrated to disease severity.

• Mild symptomatic gastroesophageal reflux disease (GERD) can usually be managed empirically; lifestyle and dietary modifications along with antacids and nonprescription histamine-2 (H2) receptor antagonists are usually sufficient.
• Patients with debilitating symptoms usually require more pharmacologically sustained acid-suppressive therapy.
• Between these extremes, matching the potency of therapy with disease severity can be achieved either by a "step up" approach (beginning with lifestyle and dietary measures and incrementally increasing the therapeutic intervention over time until symptom control is achieved) or a "step down" approach (beginning with potent antisecretory agents to achieve rapid symptom control and then incrementally decreasing the intervention until break-through symptoms define the therapy necessary for continued adequate symptom control) (table 1) [1,2].

When heartburn proves refractory to treatment, or is accompanied by dysphagia, odynophagia, or gastrointestinal bleeding, endoscopy should be done to detect other possible causes, such as eosinophilic esophagitis, infectious esophagitis, pill esophagitis, or malignancy. The components of the medical management of GERD will be reviewed here; the treatment of refractory disease, the role of surgery in this disorder, and the influence of Helicobacter pylori on GERD are discussed separately. (See "Approach to refractory gastroesophageal reflux disease in adults" and "Surgical management of gastroesophageal reflux in adults" and "Helicobacter pylori and gastroesophageal reflux disease".)

LIFESTYLE MODIFICATIONS

Minimal, but sensible, therapy for gastroesophageal reflux disease (GERD) patients is comprised of lifestyle modification, dietary modification, as needed antacid use, over-the-counter H2 receptor antagonists, and over-the-counter proton pump inhibitors. Lifestyle modifications are aimed at enhancing esophageal acid clearance, minimizing the incidence of reflux events, or both as with cessation of smoking and avoidance of late meals:

• Head of bed elevation, which can be achieved either by putting 6- to 8-inch blocks under the legs at the head of the bed or a Styrofoam wedge under the mattress. Head of bed elevation is important for individuals with nocturnal or laryngeal symptoms; its necessity in other situations is questionable.
• Dietary modification may be helpful, but prohibition of many enjoyable foods virtually ensures noncompliance. It is more practical to suggest avoidance of a core group of reflux-inducing foods (fatty foods, chocolate, peppermint, and excessive alcohol, which may reduce lower esophageal sphincter pressure) and then to suggest that the patient selectively avoid foods known to cause symptoms. As an example, a number of beverages have a very acidic pH and can exacerbate symptoms. These include colas, red wine, and orange juice (pH 2.5 to 3.9).
• Refraining from assuming a supine position after meals and avoidance of meals two to three hours before bedtime, both of which will minimize reflux.
• Avoidance of tight fitting garments, which reduces reflux by decreasing the stress on a weak sphincter.
• Obesity is a risk factor for GERD, erosive esophagitis, and esophageal adenocarcinoma [3]. However, improvement in symptoms following weight loss is not uniform [4-8]. Nevertheless, because of a possible benefit, and because of its other salutary effects, weight loss should be recommended.
• Promotion of salivation by either chewing gum or use of oral lozenges may also be helpful in mild heartburn. Salivation neutralizes refluxed acid, thereby increasing the rate of esophageal acid clearance.
• Restriction of alcohol use and elimination of smoking; smoking is deleterious in part because it diminishes salivation.