Review article: the role of sleep in the pathogenesis of gastro-oesophageal reflux disease

Night-time heartburn is common in patients with gastro-oesophageal reflux disease and its consequences in terms of sleep disturbance and subsequent effects on daytime functioning are substantial.

Most patients with night-time heartburn indicate that it is more bothersome than daytime heartburn. A significant odds ratio has been described between night-time heartburn and daytime sleepiness and fatigue.

Sleep-related gastro-oesophageal reflux has characteristics that distinguish it from waking reflux and that have been shown to enhance the risk of the development of reflux oesophagitis. Swallowing and salivary flow are markedly diminished during sleep and behavioural arousal responses to acid mucosal contact are blunted due to the depressed consciousness of the sleeping state. These sleep-related changes conspire to prolong acid mucosal contact, which in turn increases the likelihood of significant hydrogen ion back-diffusion and the risk of oesophageal damage.

An awareness of the presence of night-time heartburn suggests significant sleep-related gastro-oesophageal reflux and this should be assessed in order to optimally treat gastro-oesophageal reflux disease patients.

Consideration of PPI treatment should involve an assessment of its effectiveness in maintaining acid suppression throughout the sleeping interval.