QUESTIONS & ANSWERS
GERD, ACID REFLUX,
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QUESTIONS & ANSWERS
|GERD, ACID REFLUX,|
|SAGES GUIDELINES FOR SURGICAL TREATMENT OF GERD|
Antacids and alginates are effective in improving heartburn symptoms in patients with mfld disease. However, they have onlyan adjunctive role in the healing of esophagitis, management or prevention of complications, or maintenance therapy.
European studies show that promotility drugs, such as cisapride, more effectively improved symptoms of heartburn and healing mild-tomoderate esophagitis than placebo. Studies in the United States are mixed, suggesting that cisapride is most effective in relieving symptoms of nocturnal heartburn and healing mild esophagitis. There is no evidence that they prevent the complications of GERD, but they may be useful in maintenance therapy of mild esophagitis.
H2 receptor antagonists, in both regular and high doses, improve and sometimes eliminate the symptoms of heartburn with mild-to-moderate disease. Likewise, they are effective in healing esophagitis in these patients. High doses of H2 receptor antagonists may prevent or retard the development of some complications of GERD, especially esophageal ulcers and peptic strictures.
The proton pump inhibitors are the best agents to control esophageal acid exposure in GERD. When appropriately dosed, they can eliminate nearly all symptoms of heartburn and regurgitation. Furthermore, they effectively heal all grades of esophagitis, prevent or manage complications of GERD, including bleeding, esophageal ulcers, and peptic strictures in most patients. The proton pump inhibitors maintain remission in all grades of esophagitis. Likewise, surgery appears to be as effective as the proton pump inhibitors in the four goals for treating GERD.
The average 8-week cost of drugs used to heal esophagitis is summarized here. It is worth noting that increasing the dose of H2 receptor antagonists or combination therapy with cisapride increases drug therapy costs at least two- to threefold. Again, in the more difficult to treat patients, the proton pump inhibitors are cheaper and may be considered first-line therapy based on both efficacy and cost.
This algorithm indicates the preferred approach to the patient with GERD who has an inadequate response to a trial of empiric therapy (i.e., standard dose H2RA or promotility agent). Endoscopy is recommended to confirm a diagnosis of GERD and to define the severity of esophagitis if present (occurs in 50% of cases). The patient showing a normal endoscopy or only mild esophagitis (erythema and edema) should begin therapy with life-style modifications plus the addition of a higher dose of an H2 receptor antagonist, a combination of an H2 receptor antagonist and a promotility agent, or a proton pump inhibitor. The patient with severe esophagitis (multiple erosions, confluent erosions, ulceration, stricture, Barrett's esophagus) can be expected to require more definitive therapy to obtain remission. Here, the choice should include life-style modifications plus either a proton pump inhibitor or fundoplication. Maintenance therapy of GERD is the essential goal in most patients because of the chronic, recurring nature of this condition. Much of the evidence currently available indicates that the severity of the esophagitis on endoscopy helps predict the long-term approach to managing the patient, which is similar to that in the algorithm.
Prevalence of heartburn
- 7% daily
- 14% weekly
- 44% monthly
Most common symptoms
- Acid regurgitation
Did you know that GERD can cause?
- Asthma - Hoarseness
- Chest pain - Laryngeal cancer
- Cough - Sore throat
- Dental erosion - Vocal cord polyps
Using the cardinal symptom of heartburn to identify GERD, 61 million Americans or 44% of the adult population in the United States take some type of indigestion tablets at least once a month and 14% twice a week; 7% have heartburn daily. Approximately half of the patients presenting with symptoms of GERD have endoscopic evidence of esophagitis.
Heartburn and acid regurgitation are the most common symptoms of GERD. Heartburn presents as substernal burning and/or regurgitation. It occurs after meals, is aggravated by change in position, and is relieved by antacids.
GERD can cause a variety of other esophageal symptoms such as chest pain and extra-esophageal symptoms, such as sore throat, hoarseness, dental erosions, vocal cord polyps, laryngeal cancer, cough, and asthma.
Diagnostic tests for GERD should be based on specific problems in individual patients. The barium swallow is the best initial diagnostic study for patients with reflux symptoms and dysphagia and identifies anatomic lesions such as hiatal hernia or esophageal strictures as well as esophageal dysmotility. A barium swallow has limited ability to detect mucosal abnormalities. Radiographic studies of the esophagus are widely available and relatively inexpensive.
Endoscopy with biopsy is the best diagnostic study for evaluating mucosal injury. It is the gold standard for identifying esophagitis or Barrett's epithelium and can identify anatomic lesions, such as hiatal hernia, strictures, or gastric abnormalities. This procedure is extremely safe and has few disadvantages. Elderly patients, patients with chronic or refractory symptoms, or patients with odynophagia benefit from endoscopy as an initial diagnostic study.
pH ambulatory monitoring is the best study to confirm the diagnosis of GERD and to quantify reflux with or without associated symptoms. It may be the only abnormal study in many patients, especially those with atypical reflux symptoms. One can monitor pH in both the proximal and distal esophagus and correlate symptoms with reflux episodes. Limitations include availability and cost, especially if patients must miss 2 days of work.
Esophageal manometry has a limited role in the diagnosis of GERD. It is best used to assess LES pressure and peristalsis and should be performed in all patients before anti-reflux surgery to identify severe dysfunction in esophageal peristalsis, namely achalasia, scleroderma, or non-functioning esophagus. Availability of esophageal manometry is limited.
Manage or prevent complications
Treatment of GERD should be planned with four goals in mind. The acute phase revolves around elimination of symptoms and effective healing of esophagitis. Long-term goals focus on prevention or management of complications, such as peptic stricture. Effective maintenance of symptomatic and endoscopic remission is the key for chronic, relapsing GERD.
Life-style modifications are the cornerstone for aR therapy, If antacids and alginates are not effective, one might consider either a drug that acts directly on motility abnormalities or an acid suppressant. Ideally, the promotility agents, such as cisapride, are meant to improve esophageal peristaltic clearance, maintain increased LES tone, and improve gastric emptying. It is questionable whether they wiR produce afl of these effects.
Acid suppression is the backbone of pharmacologic therapy for GERD and may be accomplished with either the H2 receptor antagonists or the proton pump inhibitors. The proton pump inhibitors provide more rapid and complete resolution of symptoms as wefl as more rapid and complete healing of esophagitis than the H2 receptor antagonists.