Gastric reflux requires meds plus prevention

Recurrences can lead to serious complications. Fortunately, OTC drugs plus lifestyle changes are all it will take for most patients to live GERD-free.

Gastroesophageal reflux disease (GERD) is common, chronic, and relapsing, and it can have a highly negative impact on patients’ quality of life. Although there are an estimated 18.6 million cases of GERD annually in the United States, most people do not seek treatment.1 Here is what you can do to spot, treat, and prevent this troublesome and sometimes dangerous disorder.

A spectrum of symptoms

GERD is usually diagnosed by clinical symptoms, most often substernal postprandial burning, or heartburn. Additional symptoms may include indigestion, atypical chest pain, vomiting, hoarseness, and cough. Patients also complain of postprandial regurgitation and nausea, both of which are exacerbated by lying supine.

Several GERD symptoms warrant referral to a GI specialist for upper endoscopy. Watch for unintentional weight loss, especially when associated with iron deficiency anemia, and heartburn that is unresponsive to appropriate treatment or has been problematic for longer than seven years. Dysphagia or hematemesis are alarm symptoms that should prompt immediate evaluation by a gastroenterologist.

Twin goals: treatment and prevention

Initial treatment includes lifestyle modification and medical therapy to decrease or suppress acid, including antacids, H2 blockers, or proton pump inhibitors (PPIs). All of these medications are available OTC. It is also important to prevent symptomatic recurrences, which can lead to potentially serious complications, such as esophagitis, esophageal strictures, and Barrett’s esophagus.

Regardless of disease severity, it is important to counsel GERD patients about lifestyle changes that help prevent reflux, such as quitting smoking and reducing alcohol consumption; decreasing fat intake; and avoiding large meals as well as food and beverages that promote relaxation of the lower esophageal sphincter (LES). The LES relaxation can be triggered by alcohol, carbonated beverages, citrus juices, caffeinated drinks, chocolate, peppermint, tomato-based products, and spicy foods.

Other measures include losing weight, finishing the evening meal at least three hours before bedtime, and elevating the head of the bed by about six inches. This can be achieved by placing blocks under the feet at the head of the bed or sleeping with the upper body on a wedge to raise the esophagus above the stomach.

When prescribing medication, start with an H2 blocker once a day. This can be increased to twice a day if needed. Patients who do not respond completely often need long-term therapy with a PPI. Once symptoms are controlled, PPI withdrawal can be attempted with all patients except those who have severe esophagitis. If GERD recurs, options for further treatment and prevention include, in this order: step-down strategy, on-demand strategy, continuous therapy, and surgery.

Step-down therapy involves PPI withdrawal through progressive dose reductions or changing from a PPI to an H2 blocker. This strategy has been successful in many cases; in one study, 58% of patients were asymptomatic and off PPI after one year. However, some patients will need additional treatment with acid-suppressive therapy.2

On-demand therapy with a PPI has shown good results for nonerosive GERD and mild esophagitis. Patients with severe reflux esophagitis or those presenting with complications like esophageal strictures or Barrett’s esophagus should be managed with long-term continuous PPI therapy.

When medical therapy is inadequate, antireflux surgery can be considered but usually requires evaluation by a gastroenterologist. LES-tightening surgery, or Nissen fundoplication, has been shown to have only slightly better results than PPI therapy. Predictive factors for a good surgical outcome seem to be age younger than 50 and complete symptomatic response to PPI therapy.3 Even when surgery is a success, patients may suffer from such side effects as dysphagia, flatulence, and frequent belching. Moreover, surgery doesn’t always offer a permanent solution; more than 50% of GERD patients treated with surgery are back on antireflux medication within 10 years.

Barrett’s esophagus: a serious complication

Barrett’s esophagus (BE), the presence of intestinal columnar metaplasia in the esophagus, is a result of prolonged exposure to acid reflux. Patients whose GERD symptoms have lasted for at least five years have three times the risk of developing BE as patients who have had symptoms for less than a year.4 Longer segments of BE and Caucasian race are risk factors for progression to dysplasia. A small number of BE patients—<1% annually—go on to develop esophageal cancer. Once a diagnosis of BE is made, based on endoscopy with biopsy confirmation, patients should be monitored endoscopically. Treatment options include a PPI or antireflux surgery. In a few studies, these approaches have yielded similar results in preventing progression to adenocarcinoma. Following treatment, surveillance is generally done every three years; if low-grade dysplasia is present, annual endoscopy is recommended.

When high-grade dysplasia is present, management consists of short-interval endoscopy or surgery. Ablation techniques are currently being evaluated.

Dr. Stepan, a visiting physician from the Carol Davila University of Medicine in Bucharest, Romania, is currently working in the Pathology Department, University of Washington, Seattle. Dr. Surawicz, professor of medicine, is assistant dean for faculty development, and chief of gastroenterology at Harborview Medical Center at the University of Washington, Seattle.

References

1. Scott M, Gelhot AR. Gastroesophageal reflux disease: diagnosis and management. Am Fam Physician. 1999;59:1161-1169, 1199.

2. Inadomi JM, Jamal R, Murata GH, et al. Step-down management of gastroesophageal reflux disease. Gastroenterology. 2001;121:1095-1100.

3. DeVault KR, Castell DO. Updated guidelines for diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol. 2005;100:190-200.

4. Shalauta MD, Saad R. Barrett’s esophagus. Am Fam Physician. 2004;69:2113-2118, 2120.

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