Snapshot A 65-year-old male presents with complaints of heartburn, belching, epigastic pain which is aggravated by drinking coffee and eating fatty foods. He says it gets better when he takes antacids. Introduction Symptomatic reflux of gastric contents into the esophagus Transient lower esophageal spincter relaxation is the most common cause Other causes include pregnancy decreased motility secondary to progesterone gastric acidity gastric outlet obstruction decreased esophageal motility hiatal hernia obesity Associated with: tobacco alcohol scleroderma decreased gastrin production Presentation Symptoms heartburn 30-90 minutes after a meal worse with reclining improves with antacids sour taste regurgitation dysphagia wheezing Evaluation Diagnosis based on history, with empiric acid suppresion therapy appropriate in patients with new onset of symptoms and without alarm symptoms. Upper endoscopy should be performed if patient has long standing symptoms look for Barrett's and adenocarcinoma 24 hour intraesophageal pH monitoring gold standard Manometry reveals decreased LES pressure Differential PUD, CAD, infections, chemical esophagitis, gallbladder disease, achalasia, esophageal spasms, pericarditis Treatment 1st line - lifestyle changes don't lie down after eating avoid spicy foods eat small servings 2nd line proton pump inhibitors (omeprazole, lansoprazole) 3rd line H2 receptor antagonists(cimetidine, ranitidine) or a promotility agent (cisapride) in patients with LES 4th line Surgical Nissen fundoplication or hiatal hernia repair Prognosis, Prevention, and Complications Always monitor for Barrett's or esophageal adenocarcinoma with serial endoscopy Esophageal ulceration GI bleeds Peptic stricture results in gradual solid food dysphagia requires aggressive PPI treatment or surgery