Dr. Morganstern is Medical Resident, Division of Gastroenterology, Department of Medicine, Mount Sinai Medical Center, New York, New York.

Dr. Anandasabapathy is Associate Professor of Medicine, Director of Endoscopy, Division of Gastroenterology, Department of Medicine, Mount Sinai Medical Center.

Disclosure: The authors state they have nothing to disclose.

Chronic gastroesophageal reflux disease (GERD) is a risk factor for the development of Barrett's esophagus, the predominant precursor to esophageal adenocarcinoma. It is important for the primary care physician to identify those at greatest risk of developing Barrett's esophagus for referral for appropriate endoscopic screening. Many older patients display atypical symptoms or may be asymptomatic. The primary care physician must maintain a high index of suspicion and refer anyone who may potentially be at risk of Barrett's esophagus to a gastroenterologist. Once a diagnosis of Barrett's esophagus is made, appropriate endoscopic surveillance is indicated. For patients who have progressed to dysplasia, endoscopic therapy has become the preferred treatment modality because of its comparable efficacy to surgical resection with lower morbidity and mortality.

Morganstern B, Anandasabapathy S. GERD and Barrett's esophagus: Diagnostic and management strategies in the geriatric population. Geriatrics. 2009;64(7):9-12.

Key words: acid reflux, heartburn, Barrett's esophagus, esophageal adenocarcinoma, endoscopy, proton-pump inhibitors, H2 blockers, endoscopic mucosal resection

Gastroesophageal reflux disease (GERD) has rapidly become one of the most prevalent medical disorders in the Western world. In fact, estimates of the prevalence of GERD have approached 20%, with prescriptions for proton pump inhibitors (PPI) totaling more than 100 million annually, according to IMS Health.¹ Although episodic reflux occurs in most of the population, it is chronic GERD that is of particular concern because of its association with Barrett's esophagus (BE), a known risk factor for the development of esophageal adenocarcinoma (EAC).² Barrett's esophagus is defined as a change in the distal esophageal epithelium that can be recognized as columnar mucosa on endoscopy, with confirmed intestinal metaplasia by biopsy.² Although most patients with BE will never progress to EAC, it remains important to identify those at risk of developing BE because EAC has been shown to have one of the fastest rising incidence rates of any cancer in the United States, with a 300% to 500% increase in incidence since 1973.³ Given the fact that the average age of diagnosis is in the sixth and seventh decades of life,⁴ a clear understanding of the diagnosis and management of both reflux disease and BE is crucial to the care of the elderly patient and the prevention of an increasingly prevalent cancer.

Symptoms in the elderly

In the general population, the prevalence of GERD has been estimated to be approximately 20%.⁵ The symptoms of GERD can be extremely variable. Although both young and older patients may present with typical symptoms of GERD, including heartburn or acid reflux, there is evidence to suggest that older patients may have atypical symptoms in addition to or in lieu of typical symptoms. Atypical symptoms in the elderly can include chest pain, dysphagia, hoarseness, postprandial fullness, respiratory symptoms, vomiting, and belching.^4,6 In fact, older patients may have decreased sensitivity to the sensation of reflux in the setting of more severe esophageal injury and may actually be less likely to report symptoms. In a Veterans Administration study, it was noted that older patients with BE had significantly lower symptom severity scores than younger patients with similar pathology, with scores more comparable to those of asymptomatic controls.⁷ This atypical clinical presentation is particularly concerning because it greatly complicates appropriate screening to identify which patients should be referred for upper endoscopy to rule out BE.