What treatment options are available for chronic esophageal reflux? Is surgery ever preferable to long-term treatment with a proton-pump inhibitor (PPI)? — Kandace McCarver, PA-C, Clermont, Fla.
Treatment of chronic reflux begins with lifestyle modifications. Patients should be encouraged to eat small, frequent meals and lying down should be avoided for at least two hours after eating. Overweight and obesity should be confronted, as these conditions increase the risk of reflux. Cigarette smoking and alcohol should be avoided.
Patients should also avoid any foods that trigger their particular reflux symptoms; common trigger foods include tomato products, hot/spicy foods, fatty or fried foods, chocolate and mint. Anatacids provide symptomatic relief, but long-term use results in rebound heartburn symptoms, diarrhea or constipation.
Longer-term control can be sought through administration of H2 receptor blockers (e.g., cimetidine [Tagamet), ranitidine [Zantac]) or PPIs (e.g., omeprazole [Prilosec], lansoprazole [Prevacid]). Although both types of medications result in reduced acid production and resolution of symptoms, PPIs are more likely to promote healing.
Prokinetic agents (metoclopramide [Reglan], cisapride [Propulsid]) promote gastric emptying, thereby reducing risk of reflux, and also tighten the gastroesophageal sphincter. Medication types can be combined for greater efficacy.
Reserve such surgical procedures as fundoplication, endoluminal gastroplication and electrocautery for severely symptomatic individuals who fail lifestyle and medication management. There is also anecdotal evidence supporting such alternative treatments as herbal remedies (e.g., licorice, slippery elm, chamomile), relaxation therapy and acupuncture. — Claire Babcock O’Connell, MPH, PA-C (156-6)