Gastroesophageal reflux disease (GERD) is a complex condition with diverse clinical presentations, ranging from typical heartburn and regurgitation symptoms to extraesophageal manifestations and alarm symptoms. Determining which patients should be tested first versus those who should receive empirical treatment remains a key clinical challenge. If not recently performed, initial patient testing, commonly involving upper endoscopy, is recommended for patients presenting with alarm or refractory symptoms and for those at high risk for Barrett’s esophagus. Additionally, testing should be prioritized for patients with underlying comorbidities, such as scleroderma, increased body mass index, or a suspected large hiatal hernia. Older patients with atypical symptom presentations and those with extraesophageal symptoms or signs, especially in the absence of typical GERD symptoms, should also be referred for endoscopy if recent endoscopic results are not available. In contrast, patients with typical GERD symptoms in the absence of alarm features and those with extraesophageal symptoms accompanied by typical GERD symptoms could begin empirical treatment with a proton pump inhibitor (PPI) or potassium competitive acid blocker (PCAB). For individuals without alarm symptoms who do not respond to once-daily PPI therapy, escalation to twice-daily PPI therapy or switching to a PCAB, without further testing, is appropriate. Overall, an individualized approach is recommended, with patient presentation guiding the decision to test or treat first.

Extraesophageal symptoms and signs of gastroesophageal reflux disease (GERD), such as throat clearing, globus sensation, hoarseness, cough, asthma, pulmonary fibrosis, otitis, sinusitis, and dental erosions, are common and pose diagnostic and therapeutic challenges. Proton pump inhibitors (PPIs) are the mainstay of treatment for GERD, but have demonstrated a limited effectiveness for extraesophageal symptoms and signs in several meta-analyses. Potassium-competitive acid blockers (P-CABs) offer more rapid and sustained acid inhibition than PPIs; therefore, P-CABs may have the potential to be at least as good or superior to PPIs in relieving extraesophageal symptoms and signs of GERD. To date, there have been 4 prospective randomized trials demonstrating similar efficacy of P-CABs to PPIs in the treatment of extraesophageal symptoms and signs, but more rapid and greater efficacy in patients with severe symptoms. Therefore, P-CABs appear to have a treatment role in extraesophageal symptoms and signs of GERD. However, considering that P-CABs are not superior to PPIs, large-scale, multi-center studies with double dose P-CABs over a prolonged period of time may elucidate a subgroup of patients in whom P-CABs are beneficial in ameliorating extraesophageal symptoms and signs.

Gastroesophageal reflux disease (GERD) is a complex condition with diverse clinical presentations, ranging from typical heartburn and regurgitation symptoms to extraesophageal manifestations and alarm symptoms. Determining which patients should be tested first versus those who should receive empirical treatment remains a key clinical challenge. If not recently performed, initial patient testing, commonly involving upper endoscopy, is recommended for patients presenting with alarm or refractory symptoms and for those at high risk for Barrett’s esophagus. Additionally, testing should be prioritized for patients with underlying comorbidities, such as scleroderma, increased body mass index, or a suspected large hiatal hernia. Older patients with atypical symptom presentations and those with extraesophageal symptoms or signs, especially in the absence of typical GERD symptoms, should also be referred for endoscopy if recent endoscopic results are not available. In contrast, patients with typical GERD symptoms in the absence of alarm features and those with extraesophageal symptoms accompanied by typical GERD symptoms could begin empirical treatment with a proton pump inhibitor (PPI) or potassium competitive acid blocker (PCAB). For individuals without alarm symptoms who do not respond to once-daily PPI therapy, escalation to twice-daily PPI therapy or switching to a PCAB, without further testing, is appropriate. Overall, an individualized approach is recommended, with patient presentation guiding the decision to test or treat first.

Gastroesophageal reflux disease (GERD) is a complex condition with diverse clinical presentations, ranging from typical heartburn and regurgitation symptoms to extraesophageal manifestations and alarm symptoms. Determining which patients should be tested first versus those who should receive empirical treatment remains a key clinical challenge. If not recently performed, initial patient testing, commonly involving upper endoscopy, is recommended for patients presenting with alarm or refractory symptoms and for those at high risk for Barrett’s esophagus. Additionally, testing should be prioritized for patients with underlying comorbidities, such as scleroderma, increased body mass index, or a suspected large hiatal hernia. Older patients with atypical symptom presentations and those with extraesophageal symptoms or signs, especially in the absence of typical GERD symptoms, should also be referred for endoscopy if recent endoscopic results are not available. In contrast, patients with typical GERD symptoms in the absence of alarm features and those with extraesophageal symptoms accompanied by typical GERD symptoms could begin empirical treatment with a proton pump inhibitor (PPI) or potassium competitive acid blocker (PCAB). For individuals without alarm symptoms who do not respond to once-daily PPI therapy, escalation to twice-daily PPI therapy or switching to a PCAB, without further testing, is appropriate. Overall, an individualized approach is recommended, with patient presentation guiding the decision to test or treat first.

Extraesophageal symptoms and signs of gastroesophageal reflux disease (GERD), such as throat clearing, globus sensation, hoarseness, cough, asthma, pulmonary fibrosis, otitis, sinusitis, and dental erosions, are common and pose diagnostic and therapeutic challenges. Proton pump inhibitors (PPIs) are the mainstay of treatment for GERD, but have demonstrated a limited effectiveness for extraesophageal symptoms and signs in several meta-analyses. Potassium-competitive acid blockers (P-CABs) offer more rapid and sustained acid inhibition than PPIs; therefore, P-CABs may have the potential to be at least as good or superior to PPIs in relieving extraesophageal symptoms and signs of GERD. To date, there have been 4 prospective randomized trials demonstrating similar efficacy of P-CABs to PPIs in the treatment of extraesophageal symptoms and signs, but more rapid and greater efficacy in patients with severe symptoms. Therefore, P-CABs appear to have a treatment role in extraesophageal symptoms and signs of GERD. However, considering that P-CABs are not superior to PPIs, large-scale, multi-center studies with double dose P-CABs over a prolonged period of time may elucidate a subgroup of patients in whom P-CABs are beneficial in ameliorating extraesophageal symptoms and signs.

Gastroesophageal reflux disease (GERD) is a complex condition with diverse clinical presentations, ranging from typical heartburn and regurgitation symptoms to extraesophageal manifestations and alarm symptoms. Determining which patients should be tested first versus those who should receive empirical treatment remains a key clinical challenge. If not recently performed, initial patient testing, commonly involving upper endoscopy, is recommended for patients presenting with alarm or refractory symptoms and for those at high risk for Barrett’s esophagus. Additionally, testing should be prioritized for patients with underlying comorbidities, such as scleroderma, increased body mass index, or a suspected large hiatal hernia. Older patients with atypical symptom presentations and those with extraesophageal symptoms or signs, especially in the absence of typical GERD symptoms, should also be referred for endoscopy if recent endoscopic results are not available. In contrast, patients with typical GERD symptoms in the absence of alarm features and those with extraesophageal symptoms accompanied by typical GERD symptoms could begin empirical treatment with a proton pump inhibitor (PPI) or potassium competitive acid blocker (PCAB). For individuals without alarm symptoms who do not respond to once-daily PPI therapy, escalation to twice-daily PPI therapy or switching to a PCAB, without further testing, is appropriate. Overall, an individualized approach is recommended, with patient presentation guiding the decision to test or treat first.

Extraesophageal symptoms and signs of gastroesophageal reflux disease (GERD), such as throat clearing, globus sensation, hoarseness, cough, asthma, pulmonary fibrosis, otitis, sinusitis, and dental erosions, are common and pose diagnostic and therapeutic challenges. Proton pump inhibitors (PPIs) are the mainstay of treatment for GERD, but have demonstrated a limited effectiveness for extraesophageal symptoms and signs in several meta-analyses. Potassium-competitive acid blockers (P-CABs) offer more rapid and sustained acid inhibition than PPIs; therefore, P-CABs may have the potential to be at least as good or superior to PPIs in relieving extraesophageal symptoms and signs of GERD. To date, there have been 4 prospective randomized trials demonstrating similar efficacy of P-CABs to PPIs in the treatment of extraesophageal symptoms and signs, but more rapid and greater efficacy in patients with severe symptoms. Therefore, P-CABs appear to have a treatment role in extraesophageal symptoms and signs of GERD. However, considering that P-CABs are not superior to PPIs, large-scale, multi-center studies with double dose P-CABs over a prolonged period of time may elucidate a subgroup of patients in whom P-CABs are beneficial in ameliorating extraesophageal symptoms and signs.

Gastroesophageal reflux disease (GERD) is a complex condition with diverse clinical presentations, ranging from typical heartburn and regurgitation symptoms to extraesophageal manifestations and alarm symptoms. Determining which patients should be tested first versus those who should receive empirical treatment remains a key clinical challenge. If not recently performed, initial patient testing, commonly involving upper endoscopy, is recommended for patients presenting with alarm or refractory symptoms and for those at high risk for Barrett’s esophagus. Additionally, testing should be prioritized for patients with underlying comorbidities, such as scleroderma, increased body mass index, or a suspected large hiatal hernia. Older patients with atypical symptom presentations and those with extraesophageal symptoms or signs, especially in the absence of typical GERD symptoms, should also be referred for endoscopy if recent endoscopic results are not available. In contrast, patients with typical GERD symptoms in the absence of alarm features and those with extraesophageal symptoms accompanied by typical GERD symptoms could begin empirical treatment with a proton pump inhibitor (PPI) or potassium competitive acid blocker (PCAB). For individuals without alarm symptoms who do not respond to once-daily PPI therapy, escalation to twice-daily PPI therapy or switching to a PCAB, without further testing, is appropriate. Overall, an individualized approach is recommended, with patient presentation guiding the decision to test or treat first.

Background/Aims: Noncardiac chest pain (NCCP) of esophageal origin is a challenging clinical problem of diverse etiology that affects more than 80 million Americans yearly. We assess the prevalence and impact of psychological disorders on NCCP of esophageal origin, describe possible mechanisms associated with this condition, and review psychological therapy options. Methods: Online search using PubMed and Medline from January 1, 1966, to April 30, 2023. Results: Psychological disorders have been reported in up to 79% of patients with NCCP of esophageal origin. Several psychological disturbances have been identified with this condition, including depression, anxiety, panic disorder, phobias, and obsessivecompulsive and somatoform disorders. It is unclear whether the psychological disorders trigger the chest pain or vice versa. Multiple psychological mechanisms have been linked to chest pain and may contribute to its pathogenesis and severity. These mechanisms include cardiophobia, poor coping strategies, negative social problem solving, stress and perceived control, hypervigilance to cardiopulmonary sensations, altered pain perception, and alexithymia. Psychological therapies for NCCP of esophageal origin include cognitive behavioral therapy, hypnotherapy, physical and relaxation training, breathing retraining, and alternative medicine. Among the therapeutic options, cognitive behavioral therapy has been shown to be an effective treatment for NCCP of esophageal origin. Conclusion This review raises awareness about the high prevalence of psychological disorders in NCCP of esophageal origin and highlights the need for clinical trials and trained therapists to address the management of this taxing clinical problem.

Background/Aims: Presently, there is paucity of information about clinical predictors, especially esophageal motor abnormalities, for long segment Barrett’s esophagus (LSBE) as compared with short segment Barrett’s esophagus (SSBE). The aims of this study are to compare the frequency of esophageal function abnormalities between patients with LSBE and those with SSBE and to determine their clinical predictors. Methods: This was a multicenter cohort study that included all patients with a diagnosis of BE who underwent high-resolution esophageal manometry. Motility disorders were categorized as hypercontractile disorders or hypocontractile disorders and their frequency was compared between patients with LSBE and those with SSBE. Multivariable logistic regression modeling was used to calculate the odds of being diagnosed with LSBE relative to SSBE for demographics, comorbidities, medication use, endoscopic findings, and the type of motility disorders. Results: A total of 148 patients with BE were identified, of which 89 (60.1%) had SSBE and 59 (39.9%) LSBE. Patients with LSBE had a significantly larger hiatal hernia and higher likelihood of erosive esophagitis than patients with SSBE (P = 0.002). Patients with LSBE had a significantly lower mean LES resting pressure, distal contractile integral, distal latency, and significantly higher failed swallows and hypocontractile motility disorders than those with SSBE (P < 0.05). Hiatal hernia and hypocontractile motility disorder increased the odds of LSBE by 38.0% and 242.0%, as opposed to SSBE. Conclusions The presence of a hypocontractile motility disorder increased the risk for LSBE. Furthermore, the risk for LSBE was directly associated with the length of the hiatal hernia.