Gastroesophageal Reflux Disease and Heartburn

Description

Alternative Names

Treatment

Acid suppression continues to be the mainstay for treating GERD. The aim of drug therapy is to reduce the amount of acid present and improve any abnormalities in muscle function of the lower esophagus sphincter (LES), the esophagus, or the stomach.

Most cases of gastroesophageal reflux are mild and can be managed with lifestyle changes and over-the-counter medications and antacids.

Drug Treatments

Patients with moderate to severe symptoms that do not respond to lifestyle measures or who are diagnosed at a late stage may be started on more or less or potent agents depending on complications at diagnosis. Experts argue, however, about the best way to initiate drug treatment for GERD in most of these patients. The two major treatment options are known as the step-up and step-down approach:

• Step-up. With a step-up drug approach the patient first tries an H2 blocker drug, which is available over the counter. They include famotidine (Pepcid AC), cimetidine (Tagamet HB), ranitidine (Zantac 75), and nizatidine (Axid AR). If the condition fails to improve, therapy is "stepped up" to the more powerful proton-pump inhibitor, usually omeprazole (Prilosec).
• Step-down. A step-down approach first uses a more potent agent, most often a proton-pump inhibitor (PPIs), such as omeprazole (Prilosec). When the patient has been symptom-free for two months or longer, he or she is then "stepped down" to a half-dose. If symptoms do not recur, the drug is withdrawn. If symptoms recur, the patient is put on high-dose H2 blockers. In one study using this step-down approach, 58% of patients remained symptom free after a year, with 27% not using any medications at all. Some physicians argue that that the step-down approach should be used for most patients with moderate to severe GERD.

Even when symptoms are completely relieved by medication, they usually return within a few months after drug treatment has stopped. Long-term maintenance may be necessary.

If neither approach relieves symptoms, the physician should look for other conditions. Endoscopy and other tests might be used to confirm GERD and rule out other disorders. In some cases, bile, not acid, may be responsible for symptoms, so that acid-reducing or blocking agents would not be helpful. (Bile is a fluid that is present in the small intestine and gallbladder.)

Surgery

Surgery may be indicated under certain circumstances:

• If lifestyle changes and drug treatments have failed.
• In patients with other medical complications.
• In younger people with chronic GERD, who face a lifetime of expense and inconvenience with maintenance drug treatment.

Some physicians are recommending surgery as treatment of choice for many more patients with chronic GERD, particularly since minimally invasive surgical procedures are becoming more widely available. Also only surgery improves regurgitation. Furthermore, persistent GERD appears to be much more serious than previously believed, and the long-term safety of acid suppression using medication is still uncertain.

Nevertheless, anti-GERD procedures have many complications and high failure rates (ranging from 30% at five years to 63% at 10 years) and, as with medications, current surgical procedures cannot cure GERD. About 15% of patients still require anti-GERD medications after surgery. Furthermore, about 40% of surgical patients are at risk for new symptoms after surgery (e.g., gas, bloating, trouble swallowing), with most occurring more than a year after surgery. Other studies have reported similar results. Finally, evidence -- notably an important 2002 Swedish study -- now strongly suggests that the procedure does not reduce the risk for esophageal cancer in high-risk patients, such as those with Barrett's esophagus. New procedures may improve current results, but at this time patients should consider surgical options very carefully with both a surgeon and medical physician.