Joel E. Richter, MD, FACP, MACG, Editor

The issue begins with an article on the epidemiology of GERD. Did you know the prevalence of GERD plateaued in the middle 1990s but it still incurs the highest annual direct costs of all digestive diseases in the United States? The next article has a European flavor, reviewing the pathophysiology of GERD with new information on the acid pocket and its interactions with sliding and fixed hiatal hernias.

The next five articles update the clinician on our diagnostic testing for GERD. These tests are of increasing importance as we understand the poor sensitivity of GERD symptoms and the unreliability of the proton pump test in the general community. Endoscopy will always be the first test for investigating GERD, but we are “seeing” so much more with narrow band imaging, high magnification endoscopy, and the newest technologies, confocal laser endomicroscopy and optical coherence tomography. However, don’t forget the simple barium esophagram, which has a critical role in the preoperative assessment of the GERD patient and if postsurgical problems occur. High-resolution manometry can help us exclude esophageal outflow obstruction mimicking GERD and is fast becoming a preoperative test that can help alter surgical decisions. We have multiple available reflux tests, but there is confusion about which test to perform and whether to perform “on or off” proton pump inhibitors therapy. Furthermore, there has been much discussion about non-acid reflux, but is its identification alone in intractable patients’ criteria for surgery or do we still need to define the presence of our old reliable friend—acid reflux?

The last four articles tackle treatments of GERD and extraesophageal GERD as well as specific issues in our elderly and/or obese patients. Did you know the Restech device is poorly validated in extraesophageal GERD and that many patients with chronic cough may have a sensory neuropathic cough potentially responding well to gabapentin? Why did the potassium-competitive acid blockers and GABA-B agonist–like medications fail in their clinical trials and is there anything new on the medical horizon? Surgical therapies have had their “ups and downs” but seem to be coming back with concerns about the long-term side effects of proton pump inhibitors. However, there are still worries about postop symptoms of dysphagia and gas bloat. Endoscopic surgical treatments are again appearing on the scene, but totally novel treatments like lower esophageal sphincter augmentation with magnetic beads and electrical stimulation of the lower esophageal sphincter may be the surgical wave of the future. Older patients have changes in their esophageal physiology that predispose them to more severe GERD and sometimes mask the severity of their disease. Finally, the obesity epidemic is a major contributing factor to the rise in GERD prevalence and all of its associated complications. Patients with reflux frequently undergo bariatric surgery and clinicians need to be aware that some of these operations can markedly worsen GERD.

I personally want to thank all the authors and coauthors for their excellent contributions to this edition of Gastroenterology Clinics of North America . I’m confident that you will find the information in these pages to be current, comprehensive, and highly clinically relevant.