Diagnosis and Management of Gastroesophageal Reflux Disease and Dyspepsia among Older Adults

Sander Veldhuyzen van Zanten, MD, PhD

Disclosures

Geriatrics and Aging. 2008;11(6):363-367. 

In This Article

Abstract and Introduction

Abstract

Dyspepsia is defined as an epigastric pain or discomfort thought to originate in the upper gastrointestinal (GI) tract. There is discussion, especially in uninvestigated patients, about whether gastroesophageal reflux disease (GERD) can be separated from dyspepsia. If heartburn and regurgitation are the dominant symptoms, GERD is the likely diagnosis. Among older adults, more severe esophagitis is often seen, while at the same time patients report less severe symptoms. The use of nonsteroidal anti-inflammatory drugs (NSAIDs), acetylsalicylic acid (ASA), and cyclo-oxygenase 2 selected inhibitors is associated with an increased frequency of dyspepsia and, more importantly, ulcers and upper GI bleeding. In new-onset dyspepsia among older adults, endoscopy should be considered given the increased risk of an upper GI malignancy. Among individuals taking NSAIDs, the medication should ideally be discontinued if it is thought to be the cause of dyspepsia. For NSAID prophylaxis, there is evidence that use of a once-daily proton pump inhibitor or misoprostol 200 μg two to four times per day decreases the risk of upper GI ulcers. NSAID prophylaxis is underused among older adults taking non-ASA NSAIDs, and the reasons for this and its consequences require further study.

Introduction

Gastroesophageal reflux disease (GERD) is defined as the reflux of gastric contents into the esophagus causes symptoms severe enough to adversely affect quality of life.[1] Dyspepsia is distinct from GERD and is defined as chronic or frequently recurring epigastric pain or discomfort, which is believed to originate in the gastroduodenal region.[2] Dyspepsia may be associated with other upper gastrointestinal (GI) symptoms, such as postprandial fullness and early satiety. There is consensus that heartburn and regurgitation are the cardinal symptoms of GERD if either or both are the only symptoms the patient complains of or are the dominant symptom.[1,2] There has been discussion about whether heartburn and regurgitation should be also be considered symptoms that are part of the dyspepsia complex. In clinical practice, it is probably not realistic to completely exclude heartburn and regurgitation from dyspepsia symptoms. When evaluating studies dealing with GERD and dyspepsia, it is important to note whether the diagnoses have been confirmed by investigations, usually by upper GI endoscopy, or symptoms alone resulted in the diagnosis.

As shown in Table 1 , individuals with GERD can be classified in one of three groups. Patients who have normal results on endoscopy and no dominant symptoms of GERD are labelled as having functional dyspepsia. This review evaluates GERD; dyspepsia; dyspepsia and ulceration induced by nonsteroidal anti-inflammatory drugs (NSAIDs), acetylsalicylic acid (ASA), or cyclo-oxygenase 2 (COX-2)-selective inhibitors; and Helicobacter pylori infection.

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