A Systematic Review of the Definitions, Prevalence, and Response to Treatment of Nocturnal Gastroesophageal Reflux Disease

Background & Aims

More than half of patients with chronic gastroesophageal reflux (GERD) report nocturnal symptoms. We performed systematic literature review to define nocturnal heartburn and to determine potential causality between nocturnal reflux and extraesophageal manifestations.

Methods

We performed a search of literature published from 1974–2007. Each study was examined by 2 reviewers and rated on the basis of study type and outcome.

Results

Screening of 445 trials identified 59 (13%) studies relevant for analysis. Twenty-two (5%) of the trials described potential changes in sleep parameters resulting from treatment of heartburn. In most studies, nocturnal reflux was defined as heartburn symptoms that impacted sleep quality and duration. On the basis of 5 large population studies, the mean ± standard deviation prevalence of nocturnal heartburn was 54% ± 22%. Consequences of nocturnal reflux included poor sleep quality, daytime fatigue, difficulty initiating sleep or arousals from sleep, and impaired work productivity. The strength of the association between the occurrence of nocturnal reflux and late evening meals was flawed as a result of the confounding effect of the evening meal content. There was no evidence supporting causality between nocturnal heartburn and asthma or obstructive sleep apnea. Subjective, but not objective, measures of sleep improved with antireflux therapy. Head of bed elevation, proton pump inhibitor therapy, H2-receptor antagonists, and Nissen fundoplication alleviated nocturnal heartburn and associated sleep disturbances.

Conclusions

Nocturnal GERD is common and is associated with adverse sleep parameters. It can be effectively managed with medical and surgical therapy.

Abbreviations used in this paper: BE, Barrett's esophagus, BMI, body mass index, CI, confidence interval, CPAP, continuous positive airway pressure, GERD, gastroesophageal reflux disease, HOB, head of bed, IQR, interquartile range, IR-OME, immediate-release omeprazole, NAB, nocturnal gastric acid breakthrough, OR, odds ratio, OSA, obstructive sleep apnea, PPI, proton pump inhibitor, SD, standard deviation, SF-36, short-form health survey