department of medicine, temple university school of medicine, philadelphia, pa, usa in the first trimester of pregnancy, basal lower oesophageal sphincter les pressure may not change, but is less responsive to physiological stimuli i.e. Pentagastrin, edrophonium chloride, methacholine or a protein meal that usually increase les pressure. 1, 4 in the later two trimesters, les pressure gradually falls approximately 33 ndash 50% of basal values reaching a nadir at 36 weeks of gestation and rebounds to prepregnancy values 1 ndash 4 weeks postpartum. 5 animal and human studies find that the increased circulating levels of progesterone during pregnancy mediate the les relaxation, but oestrogen is a necessary primer. 1 the secondary role of increased abdominal pressure because of the enlarging gravid uterus is more controversial. It is unknown whether the normal compensatory response of the les to increase to these changes is impaired during pregnancy. 1 others have suggested that abnormal gastric emptying or delayed small bowel transit might contribute to heartburn in pregnancy.

The symptoms of heartburn during pregnancy do not differ from the classical presentation in the general adult population. The majority of patients report exacerbation of symptoms with eating and at bedtime. 2 some patients will eat only one meal a day because of intense postprandial symptoms and others will need to sleep upright in a chair. Complications of gastro oesophageal reflux disease gerd during pregnancy, especially oesophagitis and stricture formation, are rare. This observation should not be surprising since the reflux of pregnancy is generally of short duration without a background of chronic gerd.

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This journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. a 53 year old man, who is otherwise healthy and has a 20 year history of occasional heartburn, reports having had worsening heartburn for the past 12 months, with daily symptoms that disturb his sleep. He reports having had no dysphagia, gastrointestinal bleeding, or weight loss and in fact has recently gained 20 lb 9 kg. What would you advise regarding his evaluation and treatment? gastroesophageal reflux disease is the most common gastrointestinal diagnosis recorded during visits to outpatient clinics. 1 in the united states, it is estimated that 14 to 20% of adults are affected, although such percentages are at best approximations, given that the disease has a nebulous definition and that such estimates are based on the prevalence of self reported chronic heartburn. 2 a current definition of the disorder is a condition which develops when the reflux of stomach contents causes troublesome symptoms i.e.

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3 several extraesophageal manifestations of the disease are well recognized, including laryngitis and cough table 1 table 1 symptoms and conditions associated with gastroesophageal reflux disease. With respect to the esophagus, the spectrum of injury includes esophagitis figure 1a figure 1 spectrum of esophageal injury in gastroesophageal reflux disease. , stricture figure 1b , the development of columnar metaplasia in place of the normal squamous epithelium barrett's esophagus figure 1c , and adenocarcinoma figure 1d . Of particular concern is the rising incidence of esophageal adenocarcinoma, an epidemiologic trend strongly linked to the increasing incidence of this condition.

4 6 there were about 80 incident cases of esophageal adenocarcinoma in the united states in 2004, 7 which represents an increase by a factor of 2 to 6 in disease burden during the past 20 years. 8,9 esophagitis occurs when excessive reflux of acid and pepsin results in necrosis of surface layers of esophageal mucosa, causing erosions and ulcers. Impaired clearance of the refluxed gastric juice from the esophagus also contributes to damage in many patients. Whereas some gastroesophageal reflux is normal and relates to the ability to belch , several factors may predispose patients to pathologic reflux, including hiatus hernia, 10,11 lower esophageal sphincter hypotension, loss of esophageal peristaltic function, abdominal obesity, 11,12 increased compliance of the hiatal canal, 13 gastric hypersecretory states, 14 delayed gastric emptying, and overeating. A consistent paradox in gastroesophageal reflux disease is the imperfect correspondence between symptoms attributed to the condition and endoscopic features of the disease.

In a population based endoscopy study in which 10 northern europeans were randomly sampled, 15 the prevalence of barrett's esophagus was 1.6%, and that of esophagitis was 15.5%. However, only 40% of subjects who were found to have barrett's esophagus and one third of those who were found to have esophagitis reported having reflux symptoms. Furthermore, although gastroesophageal reflux is the most common cause of heartburn, other disorders e.g.

Achalasia and eosinophilic esophagitis may also cause or contribute to heartburn. Is a digestive disorder that affects the lower esophageal sphincter les , the ring of muscle between the esophagus and stomach. Many people, including pregnant women, suffer from heartburn or acid indigestion caused by gerd. Doctors believe that some people suffer from gerd due to a condition called hiatal hernia. In most cases, gerd can be relieved through diet and lifestyle changes however, some people may require medication or surgery. Therefore, gastroesophageal reflux is the return of the stomach's contents back up into the esophagus. In normal digestion, the lower esophageal sphincter les opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus.

Gastroesophageal reflux occurs when the les is weak or relaxes inappropriately, allowing the stomach's contents to flow up into the esophagus. The severity of gerd depends on les dysfunction as well as the type and amount of fluid brought up from the stomach and the neutralizing effect of saliva. Some doctors believe a hiatal hernia may weaken the les and increase the risk for gastroesophageal reflux. Hiatal hernia occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm diaphragmatic hiatus. Recent studies show that the opening in the diaphragm helps support the lower end of the esophagus. Many people with a hiatal hernia will not have problems with heartburn or reflux.

But having a hiatal hernia may allow stomach contents to reflux more easily into the esophagus. Straining, or sudden physical exertion can cause increased pressure in the abdomen resulting in hiatal hernia. Although considered a condition of middle age, hiatal hernias affect people of all ages. However, treatment may be necessary if the hernia is in danger of becoming strangulated twisted in a way that cuts off blood supply, called a paraesophageal hernia or is complicated by severe gerd or esophagitis inflammation of the esophagus. The doctor may perform surgery to reduce the size of the hernia or to prevent strangulation.