Snapshot A 65 year-old male presents complaining of heartburn, belching, and epigastic pain. His symptoms are aggravated by drinking coffee and eating fatty foods. His heartburn improves when he takes calcium carbonate. X-ray showing radiocontrast agent injected into the stomach entering the esophagus due to severe reflux. Introduction Symptomatic reflux of gastric contents into the esophagus Transient lower esophageal spincter relaxation is the most common cause Other causes include pregnancy ↓ motility secondary to progesterone ↑ gastric acidity gastric outlet obstruction ↓ esophageal motility hiatal hernia obesity Associated with: tobacco alcohol scleroderma Presentation Symptoms heartburn 30-90 minutes after a meal worse with reclining improves with antacids regurgitation dysphagia may mimic asthma/MI can cause dyspepsia (epigastric discomfort that is worse with food) Evaluation Diagnosis based on history Upper endoscopy should be performed if patient has longstanding symptoms look for Barrett's esophagus and adenocarcinoma 24-hour intraesophageal pH monitoring gold standard Manometry reveals decreased LES pressure Treatment 1st line - lifestyle changes don't lie down after eating avoid spicy foods eat small servings 2nd line H2 receptor antagonists (cimetidine, ranitidine) or a promotility agent in patients with pathologic LES relaxation/hypotension no longer as commonly used due to moderate efficacy and side effect profiles 3rd line proton pump inhibitors (omeprazole, lansoprazole) PPI's are often used as the best initial therapy and are both diagnostic and therapeutic mechanism is irreversible inhibition of hydrogen-potassium ATPase 4th line surgical fundiplication or hiatal hernia repair wrapping of stomach around GE junction