RISK FACTORS: Foods that lower LES pressure (high-fat content, yellow, onions, chocolate, peppermint), Foods that irritate esophageal mucosa (citrus fruits, spicy tomato drinks), Hiatal hernia - acid trapping, Chronic belching, aerophagia
GENERAL MEASURES
. Elevate head of bed, avoid lying down directly after meals; avoid stooping, bending, tight-fi tting garments
. Avoid drugs that decrease LES pressure
. Weight loss
. Avoid voluntary eructation
. Stepped therapy
* Phase I: lifestyle and diet modifications plus antacids or OTC H2 blockers
* Phase II: H2 blockers in prescription doses; proton pump inhibitors
* Phase III: (1) proton pump inhibitor or high-dose H2 blocker or (2) H2 blockers or proton pump inhibitor plus promotility agent
* Phase IV: surgery
* Endoscopic therapy - designed to increase pressure and/or improve the antireflux barrier
* Radiofrequency energy delivered to LES area (Stretta procedure) improved symptoms, but did not reduce acid exposure or need for medications when compared to a sham procedure
* Plication of the LES by endoscopic suturing system
* Injection of microspheres into the LES
SURGICAL MEASURES : Open or laparoscopic Nissen ot Toupet fundoplication.
Good-excellent response: if abnormal 24 hr pH score, typical primary symptom and poor prior response to medical treatment; poor response: if normal 24 hr pH score, poor esophageal motility, aerophagia
DIET: Avoid chocolate, peppermint, onions, high-fat foods, alcohol, tobacco, coffee, citrus
DRUG(S) OF CHOICE
• Mild to moderate disease: H2 blockers in equipotent oral doses, eg, cimetidine (Tagamet) 800 mg bid or
400 mg qid or ranitidine (Zantac) 150 bid or famotidine (Pepcid) 20 mg bid or nizatidine (Axid) 150 mg bid.
Proton pump inhibitors (eg, omeprazole (Prilosec) 20 mg/d, lansoprazole (Prevacid) 30 mg/d, pantoprazole
(Protonix) 40 mg/d, rabeprazole (Aciphex) 20 mg/d, esomeprazole (Nexium) 40 mg/d may be used as initial
therapy for symptomatic GERD.
• Erosive esophagitis: Proton pump inhibitors are significantly more effective than the H2 blockers in ulcer
healing doses
• Severe disease (refractory to initial therapy): Proton pump inhibitor given once or twice daily or higher
• Extraesophageal symptoms (eg laryngitis, asthma) often require higher doses of proton pump inhibitors (PPI) for prolonged duration
• Nonerosive reflux disease (NERD): PPIs more effective than H2 blockers
• Pantoprazole available in intravenous formulation for patients who cannot take po
ALTERNATIVE DRUGS
• Antacids; alginates e.g., alumina-magnesium (Gaviscon)
• Metoclopramide (Reglan) 5-10 mg before meals used adjunctively with H2 blockers (neuropsychiatric side
effects in 30% limits its usefulness)
• Cisapride (Propulsid) 10-20 mg qid (before meals and at bedtime) available only for investigational limited
access program through the manufacturer
• Baclofen 40 mg/d has reduced acid reflux episodes and belching
PATIENT MONITORING Follow symptomatically; repeat endoscopy at 4-8 weeks for poor symptomatic
response; endoscopy and biopsy for Barrett’s esophagus (to detect dysplasia) every 1-2 years
PREVENTION/AVOIDANCE
. Nocturnal breakthrough of heartburn treated with hs dose of H2 blocker or bid PPI
. Long-term maintenance therapy with H2 blockers or proton pump inhibitors along with lifestyle and diet
modifications to prevent symptomatic relapse
. Peptic strictures may require periodic dilatation (although frequency of dilatation is reduced by PPI
maintenance)
. Proton pump inhibitors are most effective in acute healing doses for chronic maintenance in severe GERD
. Consider antireflux surgery (laparoscopic approach increasingly being used) in patients with severe disease
in lieu of chronic drug therapy
. Annual or every other year endoscopy, biopsy and cytology to detect dysplasia in Barretts epithelium (more
frequently if dysplasia present)
. Photodynamic therapy for Barretts esophagus with dysplasia
POSSIBLE COMPLICATIONS
. Peptic stricture (10-15%)
. Hemorrhage (3%)
. Barrettfs esophagus (10%)
. Pulmonary or ear, nose, throat complications (5-10%)
. Noncardiac chest pain
. Adenocarcinoma from Barretts epithelium
EXPECTED COURSE/PROGNOSIS
. Majority of patients respond well to antisecretory therapy. Overall healing rate at . 12 weeks for PPIs = 84% vs H2 blockers 52%. Speed of healing is 12% per week for PPI vs 6% per week for H2 blockers. Complete
freedom from heartburn is 77% for PPI vs 48% for H2 blockers.
. Symptoms and esophageal infl ammation often return promptly when treatment withdrawn
. Relapse prevention therapy with H2 blockers/proton pump inhibitor often requires the full healing dose to be
maintained
. Antireflux surgery (e.g., fundoplication) for complications or refractory disease; excellent short-term results. But long-term follow up shows many patients eventually require medical therapy for acid suppression; doses of 40 mg/d omeprazole or equivalent yield similar long-term results compared to surgery.
. Regression of Barretts epithelium does not routinely occur despite aggressive medical or surgical therapy
. Cost effectiveness of long-term maintenance therapy has been shown for PPIs and H2 blockers (PPI more
cost effective than high dose H2 blockers)
. Successful eradication of Helicobacter pylori associated with worsening of GERD in some patients
. Long-term safety of omeprazole (up to 11 years) recently demonstrated