Gastroesophageal reflux disease (GERD) refers to the reflux of excessive gastric and duodenal contents into the esophagus, causing symptoms such as heartburn and chest pain. G E R D is divided into non-erosive gastroesophageal reflux disease (N E R D), which has no pathological damage on endoscopy but has obvious reflux symptoms and affects the patient’s quality of life, and non-erosive esophageal reflux disease (N E R D), which is most common in G E R D. E E E E, or reflux esophagitis, has pathological damage on endoscopy. R E ) is the second most common form of esophagitis, and E E can be combined with esophageal stricture, esophageal ulcer and upper gastrointestinal bleeding; there is also the less common B a r r e t t esophagus ( B E ) , which refers to the replacement of squamous epithelium by columnar epithelium during the process of esophageal mucosal repair. Recently, more and more studies have shown that N ER D, E E and B E are three diseases with completely different natural course in G E RD in terms of pathogenesis, treatment outcome and potential complications . Geriatric GERD is one of the most common gastrointestinal diseases among general practitioners and geriatricians. Although the incidence of heartburn and acid reflux, typical symptoms of G E RD, is relatively similar across age groups, studies have shown that endoscopic lesions and pathologic changes are more common in elderly patients with G E RD; many atypical symptoms of G E RD in the elderly are difficult to distinguish from those commonly associated with other diseases; many medications used in elderly patients directly damage the esophageal mucosa or cause the lower esophageal sphincter ( 1 o w e r e s o p h a g e a l s p h i n c t e r , L E S ) pressure and result in increased exposure to esophageal acid. These issues present a challenge to the diagnosis and management of elderly patients with G ER D. I. Prevalence The reported prevalence of GE RD symptoms in Europe and North America is generally 1 5 % to 2 0 %. The prevalence reported in the Asia-Pacific region is lower than in Western countries, ranging from 2.3% to 6 .6%, but the prevalence of symptoms of G E RD has tended to increase with lifestyle changes. The prevalence of heartburn and acid reflux, typical symptoms of G E RD, was relatively similar in all age groups. In 1997, Li Zhaoshen et al. reported an epidemiological survey of 25,000 people, showing that the peak age of GERD-related symptoms in the adult population in Shanghai was 30-59 years old, with a slightly lower incidence in the elderly group. The flow survey of GERD symptoms in the elderly in Beijing showed that the incidence of symptomatic GERD in the elderly was 8.63%, but there was no significant difference between the different age groups. The flow survey of GE R D in the community of Guangdong Province showed that the relatively high prevalence of GE R D in the population aged ≥6.5 years (3.5%), but the difference in the prevalence of GE R D among the age groups was not statistically significant. The mechanisms of esophageal defense against reflux of gastric acid and duodenal contents under normal conditions include the anti-reflux barrier of the LES and diaphragmatic esophageal membrane, esophageal contouring function, and esophageal mucosal defense function. Gastroesophageal reflux can be caused by excessive transient LES relaxation (t LES R), esophageal hiatal hernia, decreased esophageal motility, decreased esophageal bicarbonate, and delayed gastric emptying. Altered esophageal sensitivity plays a role in the pathogenesis of G E R D . Acid exposure in the distal esophagus leads to an enlarged gap in the esophageal epithelium, which allows acid to enter the epithelium and stimulate sensory nerve cells. Recently, it has been suggested that widening of the esophageal mucosal cell gap is a more sensitive indicator for the diagnosis of N E R D. The relationship between H. pylori (Hl p) infection and G E R D has been more debated, with some arguing that H. pylori infection is not necessarily associated with GERD, f as any effect of infection on G E R D is a consequence of Hp-associated gastritis and its effect on gastric acid secretion. Esophageal hiatal hernia is more common in the elderly, especially hiatal hernia > 3 c m is significantly associated with E E in the elderly, S u g i u r a study of 1 5 6 elderly people with a mean age of 7 4 years confirmed that the weakened esophageal contouring function affects the protection mechanism of the esophagus against acid exposure. S o n n e n b e r g et al. demonstrated that in older adults ( 5 9 ± 1 2 years 1 , the salivary secretory response was lower in both volume and bicarbonate concentration when the esophageal acid was perfused. Saliva is important in the neutralization and clearance of esophageal acid, and diminished quantity and quality of saliva may also exacerbate the degree of G E R D in the elderly. Florelli et al. demonstrated that elderly people aged 70 to 80 years had lower esophageal constriction and longer reflux episodes compared to younger age groups. Tier et al. also demonstrated longer reflux episodes in the elderly, suggesting that the esophageal mucosa is in prolonged contact with gastric contents, which could partially explain the increased esophageal mucosal lesions in these patients. Although it was previously suggested that the acidity of the stomach is reduced in elderly patients, one study confirmed that almost 90% of patients aged 9 years and older were able to achieve a p H of gastric acid less than 3.5. The increased use of certain medications in the elderly may also affect the anti-reflux mechanism, thereby triggering or aggravating G E RD. Clinical manifestations The classic symptoms of G E RD, such as heartburn and acid reflux, are significantly reduced in elderly patients compared with young and middle-aged patients, but atypical clinical manifestations, such as nausea, vomiting, upper abdominal discomfort, weight loss, and anemia, increase with age.2 1 0 Cardiopulmonary symptoms, such as chest pain, cough, non-seasonal asthma, or laryngitis, may increase in the elderly. laryngitis may be difficult to distinguish from other common diseases in the elderly. Complications include upper gastrointestinal bleeding, esophageal stricture, and B a r r e t esophagus. Despite the high prevalence of B a r r e t t chemosis and E E in elderly patients, studies have found that 3 0 % of elderly patients with severe E E do not have symptoms such as heartburn, and there is no significant difference in the severity of heartburn in patients 6 0 years and older compared to control young adults. The endoscopic lesions seen in older adults do not imply a concomitant increase in symptoms in these patients. Patients 65 years and older complained of heartburn half as often as those under 65 years of age, and the incidence of esophageal strictures was twice as high in older adults as in younger controls. The lack of these typical symptoms may reflect the decreased sensitivity of the esophagus as aging progresses. Some investigators have found that patients 65 years of age and older can tolerate about 1/3 more volume of chest pain with endoesophageal balloon dilatation than those under 65 years of age. Despite reaching maximum balloon dilation, many older adults do not feel any symptoms. For the same degree of esophagitis, older patients are less responsive to acid drip testing than nonelderly patients I 1 4 ] 0 In terms of esophageal sensitivity, decreased sensitivity with advancing age could explain the relative lack of symptoms in the older population. Although heartburn is less frequent, older adults often present with more severe esophageal disease, including upper gastrointestinal bleeding due to erosive esophagitis ( with underlying worsening cardiopulmonary disease), peptic strictures, and B E. This may be related to the fact that G ER D is a chronic disease. The incidence of B E and precancerous transformation of the esophageal mucosa from normal squamous epithelium to specially stained intestinal epithelial metaplasia is increased in older patients with a higher grade of esophagitis than in younger patients. Some prescribed medications in the elderly may exacerbate reflux itself by reducing LES pressure, and some may cause direct esophageal mucosal damage such as analgesics, sedatives, tricyclic antidepressants, theophylline, anticholinergics, and calcium channel blockers. Clinicians should closely monitor the use of these drugs in patients with G E R D symptoms and consider switching to paracetamol or C O X-2 inhibitors in patients with arthritis associated with G E RD. The diagnosis of G E R D depends on the typical clinical manifestations such as heartburn and acid reflux, endoscopic changes and evidence of excessive gastroesophageal reflux. The main tests are esophageal 2 4 hp H monitoring, gastroscopy, barium meal and diagnostic drug therapy. In recent years, B r a v o p H measurements, esophageal impedance testing, and high-resolution manometry have been used to more accurately evaluate anatomic and dynamic functional abnormalities in LES and esophageal hiatus hernia. E E can be diagnosed by endoscopy, while B E can be diagnosed by endoscopy combined with pathologic biopsy and, if necessary, stained or magnified endoscopy. The diagnosis of N E R D currently relies mainly on symptomatological features, and a preliminary diagnosis can be made when the patient complains of heartburn, if other diseases that may cause heartburn symptoms can be excluded, and if no esophageal mucosal lesions are seen on endoscopy.2 4-h esophageal p H monitoring has been considered the “gold standard” for the diagnosis of G E R D, but In recent years, it has been reported that less than 50% of patients with NERD have pathologic acid reflux on 2 4-h esophageal p H monitoring, which clearly requires a comprehensive approach to the diagnosis of NERD. The proton pump inhibitor (PPI) test is currently the most clinically useful method for the diagnosis of N E RD and has the best price-effectiveness ratio. Although the therapeutic test is a noninvasive method to determine whether symptoms are caused by GE R D, effective treatment should not preclude the aforementioned endoscopy, especially in elderly patients with alarming symptoms such as dysphagia, weight loss, and anemia should not use the therapeutic diagnostic test, but rather early endoscopy to rule out malignant, stricture, B m ‘ r e t t esophagus, or drug-related esophageal ulcers. lesions. The reflux questionnaire (R D Q) can also be used as a screening test for the diagnosis of G E R D in the elderly.1 1 6 1 ~ The barium meal is a safe and easily tolerated test in the elderly, but lacks specificity for the diagnosis of reflux disease. When a patient has symptoms such as dysphagia, a barium meal may reveal mucosal lesions, esophageal strictures, and esophageal hiatal hernia. Esophageal manometry usually uses a continuous water perfusion manometry system to determine the pressure in the lumen of the esophagus, which has some limitations in determining GERD. Gastroesophageal nuclear imaging can be used to estimate gastroesophageal reflux and can be used as a differential diagnosis for patients with pulmonary lesions. Most patients with GE R D are chronic and recurrent. The treatment of GE R D is mainly through lifestyle modification, drug therapy, surgery and endoscopic treatment. The effectiveness of lifestyle modification has been challenged by the use of PIPI. No specific benefits of lifestyle changes have been reported in the elderly population, but these recommendations are usually used in conjunction with pharmacological therapy. H receptor antagonists (HRA) are only indicated for initial treatment of mild to moderate GERD or for maintenance therapy in remission. The most effective drug for G E R D is P P I. 90% of E E heals after 8 weeks of treatment, and P P I has been clinically shown to improve the symptoms and endoscopy of E E better than H R A alone or the addition of gastroprokinetic agents. The efficacy of P P I in patients with N E RD has been demonstrated in several clinical trials to be less effective in heartburn and extraesophageal manifestations than in patients with E E. Adequate doses of P P I and good patient compliance are needed to achieve better outcomes. Many patients with G E RD require maintenance therapy. Maintenance therapy can be individualized and maintained at half or the lowest effective dose, or “weekend therapy”. On-demand therapy is a form of gap therapy, i.e., it is used only at the onset of symptoms, and is a simple and effective treatment for patients with N e r d. P p i has a good safety profile, and the main side effects are headache, diarrhea, constipation, and rash, but are uncommon. No dose adjustment is required for hepatic or renal insufficiency: this is particularly beneficial for the elderly. However, care should be taken when using it in conjunction with drugs related to the cytochrome P450 system. P P I-induced acid inhibition can cause decreased absorption of ketoconazole, itraconazole, and digoxin, which are commonly used in the elderly aged 6 5 years and older. Drug-drug interactions also include antiepileptics (phenytoin sodium), anxiolytics (benzodiazepines), and anticoagulants (warfarin). Long-term high-dose use of PIPI may produce a Vit B12 deficiency. The notion that chronic acid suppression with PPI may exacerbate atrophic gastritis with Hp infection remains controversial. In more than a decade of use, there have been no reports of an increased risk of human or gastric cancer with long-term P P I use, and there is a risk of delayed diagnosis due to masking of symptoms of gastric cancer with long-term use. Prokinetic and mucosal protective agents have limited value in the treatment of G E R D. Baclofen (baclofen), a type b agonist of ly-aminobutyric acid (GABA), inhibits the release of excitatory amino acids at spinal cord synapses, reduces central skeletal muscle tone, and is a “potent inhibitor” of transient relaxation of LE S. It significantly reduces the number of gastroesophageal reflux in patients with GERD, but has a high incidence of side effects. It has a high incidence of side effects, such as vertigo, depression or euphoria in the elderly, and seizures when the drug is stopped suddenly. The standard surgical treatment is fundoplication, both classical open surgery and laparoscopic surgery, which aims to increase the pressure of the LES to prevent acid reflux and to repair the presence of an esophageal hiatal hernia. With the development of laparoscopic techniques, there has been an increase in laparoscopic surgery in recent years. Anti-reflux surgery has been shown to have comparable or even better than pharmacological treatment in the near to medium term in terms of symptom relief, healing of esophagitis, and improvement of quality of life compared to PPCI. The mortality and complications of laparoscopic Nissequestration have been reported to be very low, with dysphagia being the most important complication. Laparoscopic neurofolding is also safe and effective in the elderly. A significant proportion of patients (1 l to 60 %) who undergo anti-reflux surgery still require anti-reflux medication, and the procedure does not reduce the risk of esophageal cancer in patients with G E R D. The cost-effectiveness ratio of laparoscopic Nissequen folding outweighs the need for medication for more than 10 years, and minimally invasive surgery has a better price-benefit ratio for younger people, while it may increase the risk of surgery for older people. Therefore, the decision to perform antireflux surgery should be made by experienced specialists, with proper patient selection and preoperative evaluation, and carefully based on the patient’s wishes. Due to the development of minimally invasive treatment techniques, several endoscopic techniques have been used for the treatment of GERD, including endoscopic fundoplication, pancreatic suture ligation, radiofrequency in the area of the LS, and endoscopic drug implantation and reinforcement of the LS in GERD. These procedures can improve symptoms, improve quality of life, and reduce drug use, but have also been reported to cause perforation, hemorrhage, and even death (especially with radiofrequency treatment). However, further comparisons of the advantages and disadvantages of these endoscopic techniques with drugs and laparoscopic anti-reflux surgery, including in elderly patients, have been lacking until now. The symptoms of G E R D in elderly patients are often atypical and difficult to distinguish from other common diseases. Endoscopic lesions and pathologic changes are more common in elderly patients with G E R D. Endoscopically significant pathologic changes with minimal disease symptoms should be evaluated and managed promptly. Older adults with alarming symptoms should be given immediate attention and further endoscopic diagnosis. P P I provides a safe and effective treatment for the relief of G E R D symptoms and mucosal healing in the elderly. Future directions may focus on further research into the pathogenesis of G E R D through improved diagnostic techniques, development of more perfect acid inhibitors, new drugs that specifically modulate esophageal dynamics and increase relaxation of L E S pressure, and improvements in minimally invasive surgery.