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DIAGNOSTIC CHALLENGES: Differentiating Nighttime GERD

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Key points and recommendations
  • Reflux episodes with nighttime GERD occur less frequently but are more prolonged than those with daytime GERD. (SOR: B)
  • Esophageal complications are generally more severe and nonesophageal complications more common in nighttime than in daytime GERD. (SOR: B)
  • Nighttime GERD-induced alterations in sleep cause significant patient morbidity and reduced quality of life and productivity. (SOR: B)
  • Several factors are associated with nighttime GERD, including increased body mass index, carbonated soft drink consumption, hypertension, benzodiazepine use, obstructive sleep apnea, and asthma. (SOR: B)
  • The history and physical examination generally provide the most useful information in making the diagnosis. (SOR: C)
  • Sleep-induced physiologic alterations are thought to be important factors responsible for the more common and severe symptoms and complications in nighttime vs daytime GERD. (SOR: C)

Prevalence estimates for gastroesophageal reflux disease (GERD) range from 8% to 40%, depending on the definition and diagnostic criteria.1-4 While heartburn and regurgitation are considered the hallmark symptoms, GERD actually represents a spectrum of disorders that generally result from transient relaxations of the lower esophageal sphincter (LES), so that gastric refluxate comes into contact with the esophageal epithelium. Additionally, differences in rates of acid secretion and clearance and the time since food ingestion affect symptoms, potentially leading to differing presentations of GERD associated with daytime and nocturnal episodes. To facilitate accurate diagnosis of GERD, it may be helpful for clinicians to distinguish between the symptoms that occur during the day or in an upright position and those that occur at night or when a person is supine.4 This paper reviews the differences in symptoms and explains the pathophysiologic mechanisms involved.

Issues of GERD and quality of life

Patients’ quality of life and ability to function is negatively impacted by factors associated specifically with nocturnal episodes of GERD. Patients who experience GERD primarily at night may complain of sleep disturbances. Symptoms associated with nighttime GERD generally are more severe,5 and the complications more diverse and frequent,4 due to the prolonged length of nighttime reflux.6 For these reasons, determining if the underlying cause of a group of symptoms is nighttime episodes of GERD is an important treatment step.

Complications of reflux: associations with nighttime occurrences

Esophageal complications of GERD include erosive esophagitis, esophageal hemorrhage, ulceration, and strictures and appear to be more severe in patients with nighttime episodes of GERD than in those complaining of daytime reflux. An early study showed that patients who experience reflux only in the supine position have a higher incidence of esophagitis compared with patients who only refluxed in an upright position.7 Prolonged acid contact time increases the risk that esophagitis will become erosive. This was demonstrated in a study that concluded particularly that the presence of nocturnal reflux events lasting more than 5 minutes was a powerful predictor of erosive damage.6

Overall, approximately 7% to 12% of patients with chronic GERD develop Barrett’s esophagus compared with fewer than 1% of those in the general population.8 Potentially, more severe nocturnal symptoms may be among the factors that increase the risk of Barrett’s esophagus.9,10 Esophageal adenocarcinoma also is more likely in patients with nocturnal episodes of GERD: In a national, population-based, case-controlled trial, an 11-fold increased risk for esophageal adenocarcinoma was reported in patients who experienced once-weekly episodes of nighttime heartburn, regurgitation, or both. Overall, an 8-fold increased risk of esophageal adenocarcinoma was observed in all patients with GERD.11

Impact of nighttime episodes on sleep

Not surprisingly, sleep is significantly affected by nighttime GERD episodes. A recent Internet-based survey of full-time working adults in the United States identified 1002 patients with symptomatic GERD.12 Using the validated GERD Symptom and Medication Questionnaire, symptomatic GERD was defined as a score of 10 or greater for at least one episode of heartburn or acid regurgitation within the past 7 days. Symptomatic nighttime GERD was defined as at least 2 nights with symptoms during the past 7 days. GERD-related sleep problems were twice as frequent in patients with nighttime compared with daytime GERD. Patients with nighttime episodes of GERD experienced GERD-related sleep impairment an average of 1.6 to 1.9 nights per week compared with 0.3 to 0.4 nights per week for the daytime GERD group.

In both groups, the most commonly reported sleep problem was awakening due to symptoms (75% vs 37%, respectively). Sixty-five percent of nighttime and 28% of daytime GERD patients indicated that GERD symptoms prevented them from feeling rested in the morning.12 In addition, respondents with nighttime GERD experienced an additional 2.7 hours per week of lost work productivity when compared to those with daytime GERD.13 A similar survey also found that in those with nighttime GERD, the number of nights with sleep interference was associated with reduced work productivity.14


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