206 SECTION 3 • MEDICAL PROBLEMS IN THE ATHLETE
reflux rates similar to healthy individuals (Hirschowitz,
1991). The critical factor in symptom development
appears to be that the contact time between refluxed
material and the epithelium is so excessive that the
normal gastric contents overwhelm the epithelial pro-
tective mechanisms. Alternatively, symptoms may
develop when normal contact time occurs in the face of
insufficient protective mechanisms.- Symptomatic reflux episodes during exercise are likely
multifactorial, but correlate best with transient lower
esophageal sphincter relaxations (TLESR’s). This
vagally-mediated reflex facilitates lower esophageal
sphincter (LES) relaxation and gas venting in response
to gaseous stomach distention. The decrease in LES
tone and reflux associated with TLESRs last longer
and are not accompanied by a swallow-induced peri-
staltic sweep, leading to prolonged acid exposure.
Supine or forward-flexed posture during particular
modes of exercise increases intra-abdominal pressure
overcoming the mechanical protection of the LES and
negating bolus acid clearance achieved by gravity.
Increasing exercise intensity is associated with
increased reflux episodes and duration of acid exposure
(Soffer et al, 1993). As exercise intensity increases,
the frequency, duration, and amplitude of esophageal
contractions progressively decrease. High intensity
exercise also reduces splanchnic blood flow, which
may inhibit restoration of acid base balance and
deprive the epithelium of the oxygen and nutrients
needed for damage repair.- If the history and physical raise red flags, symptoms
are particularly severe, or the diagnosis is unclear, the
athlete should be referred for gastroenterology evalu-
ation (Fig. 35-1). In patients with extraintestinal man-
ifestations or atypical GERD symptoms, providers
can consider an initial therapeutic trial. If empiric
FIG. 35-1 Evaluation of GERD.