Sander Veldhuyzen van Zanten, MD, PhD, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB.

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.
Key words: dyspepsia, gastroesophageal reflux disease, NSAIDs, ASA, H. pylori.

Alexandra Nevin, BSc

Gastroesophageal Reflux Disease (GERD) is the pathological manifestation of a normal physiological process, and is associated with a range of clinical symptoms and complications of varying severity. In normal individuals, gastric acid reflux into the esophagus occurs without any accompanying signs or symptoms of mucosal damage. The majority of these events are the result of transient lower esophageal sphincter relaxation (TLESR).^1,2 Normally, TLESR is not accompanied by inadequate innate esophageal protective mechanisms which characterize the development of GERD. The wide spectrum of presenting symptoms makes definitive and accurate diagnosis and management of GERD a clinical challenge. This is especially true for physicians who treat the elderly and have to contend with the increased absolute incidence of GERD, the number of concurrent medical conditions, changing physiology of the aging esophagus, and the prevalence of atypical symptoms and complications.

The incidence and natural history of GERD
In the United States, 44% of the adult population surveyed reported experiencing heart burn, the most frequently noted symptom of GERD sufferers, at least once every month.^3,4 The absolute incidence of GERD has been shown to increase with age, with an initial dramatic rise in incidence after 40 years of age, and significant increases at age 60 and then again at age 70.