Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) is present when the passage of gastric contents into the oesophagus causes symptoms or damages the mucosa.Potent suppression of gastric acid secretion with proton pump inhibitors is a highly effective and safe treatment for many patients with symptoms associated with reflux.It would be wrong to conclude, however, that proton pump inhibitors had solved the problem of GORD.The relation between reflux symptoms, endoscopic findings, and exposure of the oesophagus to acid is not straightforward.Some patients with a convincing history of heartburn fail to respond well to proton pump inhibitors.Although symptoms may be severe, at endoscopy the oesophagus is often found to be normal, and pH studies may not disclose the cause of symptoms that persist despite treatment for acid suppression.Apart from typical symptoms of reflux many other problems have been linked to GORD, including dysphagia, hoarseness, non-cardiac chest pain, and chronic cough.It can, however, be difficult to identify those patients who will benefit from antireflux treatment.Most serious is the increased risk of oesophageal adenocarcinoma in patients with reflux symptoms, in particular those with Barrett's columnar lined oesophagus.Since the 1980s the incidence of oesophageal carcinoma has increased sixfold, more rapidly than any other common cancer.This review explains how recent research has begun to unravel these problems by explaining what can be learnt from physiological and clinical observations.It seems that however well gastric acid secretion can be suppressed, we are far less successful at managing reflux itself.