Esophageal Reflux Disease and Its Complications



Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disorders in older adults and can lead to both severe complications and reduced quality of life. The prevalence of GERD is increasing across all ages including the elderly. Older individuals are more likely to develop severe disease, esophagitis, and complications. Age-related physiologic changes seen in the aged, along with comorbidity and polypharmacy, promote LES incompetence and/or injure the esophageal mucosa play a role in the development of GERD and increased complications in this population. While GERD and its complications are more common in the elderly, typical heartburn is often not evident in this age group, with atypical manifestations such as dysphagia, vomiting, and extraesophageal symptoms more apparent. A more severe complication of GERD is Barrett’s metaplasia, which increases the risk of esophageal adenocarcinoma exponentially. Differential diagnosis includes infections such as Candida esophagitis, autoimmune mucocutaneous disorders, radiation esophagitis, and pill esophagitis. Therefore, efforts to clarify the diagnosis and treatment of GERD are warranted in this group. Proton pump inhibitor (PPI) therapy is the cornerstone of treatment and provides a safe and cost-effective modality of treatment in the overwhelming majority of elderly patients. However, potential complications of PPI therapy including potential drug–drug interaction and their management should be well recognized by all gastroenterologists.


Proton Pump Inhibitor Lower Esophageal Sphincter Esophageal Adenocarcinoma Antireflux Surgery GERD Symptom 


  1. 1.
    Pandolfino JE, Kwiatek MA, Kahrilas PJ. The pathophysiologic basis for epidemiologic trends in gastroesophageal reflux disease. Gastroenterol Clin North Am. 2008;37(4):827–43, viii.Google Scholar
  2. 2.
    Becher A, Dent J. Systematic review: ageing and gastro-oesophageal reflux disease symptoms, oesophageal function and reflux oesophagitis. Aliment Pharmacol Ther. 2011;33(4):442–54.PubMedCrossRefGoogle Scholar
  3. 3.
    Pilotto A, Franceschi M, Leandro G, et al. Clinical features of reflux esophagitis in older people: a study of 840 consecutive patients. J Am Geriatr Soc. 2006;54(10):1537–42.PubMedCrossRefGoogle Scholar
  4. 4.
    Johnson DA, Fennerty MB. Heartburn severity underestimates erosive esophagitis severity in elderly patients with gastroesophageal reflux disease. Gastroenterology. 2004;126(3):660–4.PubMedCrossRefGoogle Scholar
  5. 5.
    Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol. 2006;101(8):1900–20; quiz 1943.Google Scholar
  6. 6.
    Lee J, Anggiansah A, Anggiansah R, et al. Effects of age on the gastroesophageal junction, esophageal motility, and reflux disease. Clin Gastroenterol Hepatol. 2007;5(12):1392–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Andrews JM, Heddle R, Hebbard GS, et al. Age and gender affect likely manometric diagnosis: audit of a tertiary referral hospital clinical esophageal manometry service. J Gastroenterol Hepatol. 2009;24(1):125–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Bitar K, Greenwood-Van Meerveld B, Saad R, Wiley JW. Aging and gastrointestinal neuromuscular function: insights from within and outside the gut. Neurogastroenterol Motil. 2011;23(6):490–501.PubMedCrossRefGoogle Scholar
  9. 9.
    Urita Y, Domon K, Yanagisawa T, et al. Salivary gland scintigraphy in gastro-esophageal reflux disease. Inflammopharmacology. 2007;15(4):141–5.PubMedCrossRefGoogle Scholar
  10. 10.
    Kamiya T, Adachi H, Joh T. [Relationship between gastric motility and the pathophysiology of GERD]. Nihon Rinsho. 2007;65(5):836–9.PubMedGoogle Scholar
  11. 11.
    Koek GH, Sifrim D, Lerut T, et al. Multivariate analysis of the association of acid and duodeno-gastro-oesophageal reflux exposure with the presence of oesophagitis, the severity of oesophagitis and Barrett’s oesophagus. Gut. 2008;57(8):1056–64.PubMedCrossRefGoogle Scholar
  12. 12.
    Patti MG, Goldberg HI, Arcerito M, et al. Hiatal hernia size affects lower esophageal sphincter function, esophageal acid exposure, and the degree of mucosal injury. Am J Surg. 1996;171(1):182–6.PubMedCrossRefGoogle Scholar
  13. 13.
    Pilotto A, Franceschi M, Vitale D, et al. Drug use by the elderly in general practice: effects on upper gastrointestinal symptoms. Eur J Clin Pharmacol. 2006;62(1):65–73.PubMedCrossRefGoogle Scholar
  14. 14.
    Dore MP, Maragkoudakis E, Fraley K, et al. Diet, lifestyle and gender in gastro-esophageal reflux disease. Dig Dis Sci. 2008;53(8):2027–32.PubMedCrossRefGoogle Scholar
  15. 15.
    Jadcherla SR, Hogan WJ, Shaker R. Physiology and pathophysiology of glottic reflexes and pulmonary aspiration: from neonates to adults. Semin Respir Crit Care Med. 2010;31(5):554–60.PubMedCrossRefGoogle Scholar
  16. 16.
    Shaker R, Hogan WJ. Normal physiology of the aerodigestive tract and its effect on the upper gut. Am J Med. 2003;115(Suppl 3A):2S–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Gao L, Weck MN, Rothenbacher D, Brenner H. Body mass index, chronic atrophic gastritis and heartburn: a population-based study among 8936 older adults from Germany. Aliment Pharmacol Ther. 2010;32(2):296–302.PubMedCrossRefGoogle Scholar
  18. 18.
    Hamada H, Haruma K, Mihara M, et al. High incidence of reflux oesophagitis after eradication therapy for Helicobacter pylori: impacts of hiatal hernia and corpus gastritis. Aliment Pharmacol Ther. 2000;14(6):729–35.PubMedCrossRefGoogle Scholar
  19. 19.
    Wang C, Yuan Y, Hunt RH. Helicobacter pylori infection and Barrett’s esophagus: a systematic review and meta-analysis. Am J Gastroenterol. 2009;104(2):492–500; quiz 491, 501.Google Scholar
  20. 20.
    Qian B, Ma S, Shang L, et al. Effects of Helicobacter pylori eradication on gastroesophageal reflux disease. Helicobacter. 2011;16(4):255–65.PubMedCrossRefGoogle Scholar
  21. 21.
    Berstad A, Hatlebakk JG. The predictive value of symptoms in gastro-oesophageal reflux disease. Scand J Gastroenterol Suppl. 1995;211:1–4.PubMedCrossRefGoogle Scholar
  22. 22.
    Raiha IJ, Impivaara O, Seppala M, Sourander LB. Prevalence and characteristics of symptomatic gastroesophageal reflux disease in the elderly. J Am Geriatr Soc. 1992;40(12):1209–11.PubMedGoogle Scholar
  23. 23.
    Morozov SV, Stavraki ES, Isakov VA. [The prevalence of heartburn in the elderly patients in urban outpatient clinics in Russia]. Eksp Klin Gastroenterol. 2010;12:17–23.PubMedGoogle Scholar
  24. 24.
    Hsu CS, Wang PC, Chen JH, et al. Increasing insulin resistance is associated with increased severity and prevalence of gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2011;34(8):994–1004.PubMedCrossRefGoogle Scholar
  25. 25.
    Gastal OL, Castell JA, Castell DO. Frequency and site of gastroesophageal reflux in patients with chest symptoms. Studies using proximal and distal pH monitoring. Chest. 1994;106(6):1793–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Pandak WM, Arezo S, Everett S, et al. Short course of omeprazole: a better first diagnostic approach to noncardiac chest pain than endoscopy, manometry, or 24-hour esophageal pH monitoring. J Clin Gastroenterol. 2002;35(4):307–14.PubMedCrossRefGoogle Scholar
  27. 27.
    Vaezi MF, Richter JE, Stasney CR, et al. Treatment of chronic posterior laryngitis with esomeprazole. Laryngoscope. 2006;116(2):254–60.PubMedCrossRefGoogle Scholar
  28. 28.
    Kiljander TO, Junghard O, Beckman O, Lind T. Effect of esomeprazole 40 mg once or twice daily on asthma: a randomized, placebo-controlled study. Am J Respir Crit Care Med. 2010;181(10):1042–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Mastronarde JG, Anthonisen NR, Castro M, et al. Efficacy of esomeprazole for treatment of poorly controlled asthma. N Engl J Med. 2009;360(15):1487–99.PubMedCrossRefGoogle Scholar
  30. 30.
    Giannini EG, Zentilin P, Dulbecco P, et al. Management strategy for patients with gastroesophageal reflux disease: a comparison between empirical treatment with esomeprazole and endoscopy-oriented treatment. Am J Gastroenterol. 2008;103(2):267–75.PubMedCrossRefGoogle Scholar
  31. 31.
    Festi D, Scaioli E, Baldi F, et al. Body weight, lifestyle, dietary habits and gastroesophageal reflux disease. World J Gastroenterol. 2009;15(14):1690–701.PubMedCrossRefGoogle Scholar
  32. 32.
    Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med. 2006;166(9):965–71.PubMedCrossRefGoogle Scholar
  33. 33.
    Behar J, Sheahan DG, Biancani P, et al. Medical and surgical management of reflux esophagitis. A 38-month report of a prospective clinical trial. N Engl J Med. 1975;293(6):263–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Lipsy RJ, Fennerty B, Fagan TC. Clinical review of histamine2 receptor antagonists. Arch Intern Med. 1990;150(4):745–51.PubMedCrossRefGoogle Scholar
  35. 35.
    Wang WH, Huang JQ, Zheng GF, et al. Head-to-head comparison of H2-receptor antagonists and proton pump inhibitors in the treatment of erosive esophagitis: a meta-analysis. World J Gastroenterol. 2005;11(26):4067–77.PubMedGoogle Scholar
  36. 36.
    Khan M, Santana J, Donnellan C, et al. Medical treatments in the short term management of reflux oesophagitis. Cochrane Database Syst Rev. 2007;(2):CD003244.Google Scholar
  37. 37.
    Metz DC, Pratha V, Martin P, et al. Oral and intravenous dosage forms of pantoprazole are equivalent in their ability to suppress gastric acid secretion in patients with gastroesophageal reflux disease. Am J Gastroenterol. 2000;95(3):626–33.PubMedCrossRefGoogle Scholar
  38. 38.
    Pilotto A, Leandro G, Franceschi M. Short- and long-term therapy for reflux oesophagitis in the elderly: a multi-centre, placebo-controlled study with pantoprazole. Aliment Pharmacol Ther. 2003;17(11):1399–406.PubMedCrossRefGoogle Scholar
  39. 39.
    Niklasson A, Lindstrom L, Simren M, et al. Dyspeptic symptom development after discontinuation of a proton pump inhibitor: a double-blind placebo-controlled trial. Am J Gastroenterol. 2010;105(7):1531–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Gilard M, Arnaud B, Cornily JC, et al. Influence of omeprazole on the antiplatelet action of clopidogrel associated with aspirin: the randomized, double-blind OCLA (Omeprazole CLopidogrel Aspirin) study. J Am Coll Cardiol. 2008;51(3):256–60.PubMedCrossRefGoogle Scholar
  41. 41.
    Laine L, Hennekens C. Proton pump inhibitor and clopidogrel interaction: fact or fiction? Am J Gastroenterol. 2010;105(1):34–41.PubMedCrossRefGoogle Scholar
  42. 42.
    Dublin S, Walker RL, Jackson ML, et al. Use of proton pump inhibitors and H2 blockers and risk of pneumonia in older adults: a population-based case-control study. Pharmacoepidemiol Drug Saf. 2010;19(8):792–802.PubMedCrossRefGoogle Scholar
  43. 43.
    Fohl AL, Regal RE. Proton pump inhibitor-associated pneumonia: not a breath of fresh air after all? World J Gastrointest Pharmacol Ther. 2011;2(3):17–26.PubMedCrossRefGoogle Scholar
  44. 44.
    Laheij RJ, Sturkenboom MC, Hassing RJ, et al. Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. JAMA. 2004;292(16):1955–60.PubMedCrossRefGoogle Scholar
  45. 45.
    Leonard J, Marshall JK, Moayyedi P. Systematic review of the risk of enteric infection in patients taking acid suppression. Am J Gastroenterol. 2007;102(9):2047–56; quiz 2057.Google Scholar
  46. 46.
    Dial S, Alrasadi K, Manoukian C, et al. Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case-control studies. CMAJ. 2004;171(1):33–8.PubMedCrossRefGoogle Scholar
  47. 47.
    Wright MJ, Proctor DD, Insogna KL, Kerstetter JE. Proton pump-inhibiting drugs, calcium homeostasis, and bone health. Nutr Rev. 2008;66(2):103–8.PubMedCrossRefGoogle Scholar
  48. 48.
    Dalton BR, Lye-Maccannell T, Henderson EA, et al. Proton pump inhibitors increase significantly the risk of Clostridium difficile infection in a low-endemicity, non-outbreak hospital setting. Aliment Pharmacol Ther. 2009;29(6):626–34.PubMedCrossRefGoogle Scholar
  49. 49.
    Kaye JA, Jick H. Proton pump inhibitor use and risk of hip fractures in patients without major risk factors. Pharmacotherapy. 2008;28(8):951–9.PubMedCrossRefGoogle Scholar
  50. 50.
    Oelschlager BK, Quiroga E, Parra JD, et al. Long-term outcomes after laparoscopic antireflux surgery. Am J Gastroenterol. 2008;103(2):280–7; quiz 288.Google Scholar
  51. 51.
    Galmiche JP, Hatlebakk J, Attwood S, et al. Laparoscopic antireflux surgery vs esomeprazole treatment for chronic GERD: the LOTUS randomized clinical trial. JAMA. 2011;305(19):1969–77.PubMedCrossRefGoogle Scholar
  52. 52.
    Brunt LM, Quasebarth MA, Dunnegan DL, Soper NJ. Is laparoscopic antireflux surgery for gastroesophageal reflux disease in the elderly safe and effective? Surg Endosc. 1999;13(9):838–42.PubMedCrossRefGoogle Scholar
  53. 53.
    Wang W, Huang MT, Wei PL, Lee WJ. Laparoscopic antireflux surgery for the elderly: a surgical and quality-of-life study. Surg Today. 2008;38(4):305–10.PubMedCrossRefGoogle Scholar
  54. 54.
    Poh CH, Navarro-Rodriguez T, Fass R. Review: treatment of ­gastroesophageal reflux disease in the elderly. Am J Med. 2010;123(6):496–501.PubMedCrossRefGoogle Scholar
  55. 55.
    Spechler SJ. AGA technical review on treatment of patients with dysphagia caused by benign disorders of the distal esophagus. Gastroenterology. 1999;117(1):233–54.PubMedCrossRefGoogle Scholar
  56. 56.
    Repici A, Hassan C, Sharma P, et al. Systematic review: the role of self-expanding plastic stents for benign oesophageal strictures. Aliment Pharmacol Ther. 2010;31(12):1268–75.PubMedCrossRefGoogle Scholar
  57. 57.
    Reynolds JC, Rahimi P, Hirschl D. Barrett’s esophagus: clinical characteristics. Gastroenterol Clin North Am. 2002;31(2):441–60.PubMedCrossRefGoogle Scholar
  58. 58.
    Hayeck TJ, Kong CY, Spechler SJ, et al. The prevalence of Barrett’s esophagus in the US: estimates from a simulation model confirmed by SEER data. Dis Esophagus. 2010;23(6):451–7.PubMedCrossRefGoogle Scholar
  59. 59.
    Spechler SJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ. American Gastroenterological Association technical review on the management of Barrett’s esophagus. Gastroenterology. 2011;140(3):e18–52; quiz e13.Google Scholar
  60. 60.
    Devesa SS, Blot WJ, Fraumeni Jr JF. Changing patterns in the incidence of esophageal and gastric carcinoma in the United States. Cancer. 1998;83(10):2049–53.PubMedCrossRefGoogle Scholar
  61. 61.
    Menon S, Jayasena H, Nightingale P, Trudgill NJ. Influence of age and sex on endoscopic findings of gastrooesophageal reflux disease: an endoscopy database study. Eur J Gastroenterol Hepatol. 2011;23(5):389–95.PubMedCrossRefGoogle Scholar
  62. 62.
    Bytzer P, Christensen PB, Damkier P, et al. Adenocarcinoma of the esophagus and Barrett’s esophagus: a population-based study. Am J Gastroenterol. 1999;94(1):86–91.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Department of Gastroenterology and HepatologyHahnemann University HospitalPhiladelphiaUSA
  2. 2.Department of MedicineDrexel University College of Medicine/Hahnemann University HospitalPhiladelphiaUSA

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