GERD is most common in those over 40 years of age but also occurs in infants and children. The most frequently reported symptoms are heartburn, dysphagia, and, less often, noticeable regurgitation of sour-tasting gastric contents. Rarely, chronic GERD is punctuated by attacks of severe chest pain that may be mistaken for heart disease. Treatment with proton pump inhibitors reduces gastric acidity and typically provides symptomatic relief. While the severity of symptoms is not closely related to the degree of histologic damage, the latter tends to increase with disease duration. Complications of reflux esophagitis include esophageal ulceration, hematemesis, melena, stricture development, and Barrett esophagus, a precursor lesion to esophageal carcinoma.
Hiatal hernia is characterized by separation of the diaphragmatic crura and protrusion of the stomach into the thorax through the resulting gap. Congenital hiatal hernias are recognized in infants and children, but many are acquired in later life. Hiatal hernia is symptomatic in fewer than 10% of adults; symptoms when present resemble GERD since hiatal hernia can cause LES incompetence.
Eosinophilic esophagitis is a chronic immunologically mediated disorder that is being increasingly recognized. Symptoms include food impaction and dysphagia in adults and feeding intolerance or GERD-like symptoms in children. The cardinal histologic feature is epithelial infiltration by large numbers of eosinophils, particularly superficially (Fig.
15.9B ) and at sites far from the gastroesophageal junction. Their abundance can help to differentiate eosinophilic esophagitis from GERD, Crohn disease, and other causes of esophagitis. Endoscopically evident rings in the upper and
Fig. 15.9 Esophagitis.(A)Refluxesophagitiswithscatteredintraepithelialeosinophils.(B)Eosinophilicesophagitiswithnumerousintraepithelialeosinophils.
(C)Endoscopyrevealscircumferentialringsintheproximalesophagusofthispatientwitheosinophilicesophagitis.(Endoscopic image courtesy of Dr. Ira Hanan, The University of Chicago, Chicago, Illinois.) http://ebooksmedicine.net mid portions of the esophagus (
Fig. 15.9C ), may also help to distinguish eosinophilic esophagitis from GERD. Patients with eosinophilic esophagitis are typically refractory to high-dose proton pump inhibitor treatment. Most patients are atopic, and many have atopic dermatitis, allergic rhinitis, asthma, or modest peripheral eosinophilia. Treatments include dietary restrictions to prevent exposure to food allergens, such as cow milk and soy products, and topical or systemic corticosteroids.