A 60-year old male pressents with progressive difficulty in swallowing, vomiting and occasional regurgitation for the past 3 months. Barium studies showed marked dilatation of the upper esophagus with narrowing of the lower segment. Manometry showed absent esophageal peristalsis. He woulld also present to clinician with

Gastro-oesophageal reflux resulting in heaburn affects approximately 30% of the general population. Pathophysiology Occasional episodes of gastro-oesophageal reflux are common in healthy individuals. Reflux is normally followed by oesophageal peristaltic waves that efficiently clear the gullet, alkaline saliva neutralises residual acid and symptoms do not occur. Gastro-oesophageal reflux disease develops when the oesophageal mucosa is exposed to gastroduodenal contents for prolonged periods of time, resulting in symptoms and, in a propoion of cases, oesophagitis. Abnormalities of the lower oesophageal sphincter . The lower oesophageal sphincter is tonically contracted under normal circumstances, relaxing only during swallowing.Some patients with gastro-oesophageal reflux disease have reduced lower oesophageal sphincter tone, permitting reflux when intra-abdominal pressure rises. In others, basal sphincter tone is normal but reflux occurs in response to frequent episodes of inappropriate sphincter relaxation. Hiatus hernia Hiatus hernia causes reflux because the pressure gradient is lost between the abdominal and thoracic cavities, which normally pinches the hiatus. In addition, the oblique angle between the cardia and oesophagus disappears. Many patients who have large hiatus hernias develop reflux symptoms but the relationship between the presence of a hernia and symptoms is poor. Hiatus hernia is very common in individuals who have no symptoms, and some symptomatic patients have only a very small or no hernia. Neveheless, almost all patients who develop oesophagitis, Barrett's oesophagus or peptic strictures have a hiatus hernia. Delayed oesophageal clearance Defective oesophageal peristaltic activity is commonly found in patients who have oesophagitis. It is a primary abnormality, since it persists after oesophagitis has been healed by acid-suppressing drug therapy. Poor oesophageal clearance leads to increased acid exposure time. Gastric contents Gastric acid is the most impoant oesophageal irritant and there is a close relationship between acid exposure time and symptoms. Pepsin and bile also contribute to mucosal injury. Defective gastric emptying Gastric emptying is delayed in patients with gastro-oesophageal reflux disease. The reason is unknown. Increased intra-abdominal pressure Pregnancy and obesity are established predisposing causes. Weight loss may improve symptoms. Dietary and environmental factors Dietary fat, chocolate, alcohol, tea and coffee relax the lower oesophageal sphincter and may provoke symptoms. The foods that trigger symptoms vary widely between affected individuals. Patient factors Visceral sensitivity and patient vigilance play a role in determining symptom severity and consulting behaviour in individual patients Clinical features The major symptoms are heaburn and regurgitation, often provoked by bending, straining or lying down. 'Waterbrash', which is salivation due to reflex salivary gland stimulation as acid enters the gullet, is often present. The patient is often overweight. Some patients are woken at night by choking as refluxed fluid irritates the larynx. Others develop odynophagia or dysphagia. A variety of other features have been described, such as atypical chest pain that may be severe and can mimic angina; it may be due to reflux-induced oesophageal spasm. Others include hoarseness ('acid laryngitis'), recurrent chest infections, chronic cough and asthma. The true relationship of these features to gastro-oesophageal reflux disease remains unclear Ref Davidson edition23rd pg 729