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ABSTRACT
Gastroesophageal reflux disease (GERD) affects
approximately 20%of the US population and is
one of the most common acid-related disorders in
US adults.
1
One of the key symptoms of this often
chronic disorder is heartburn. Gastroesophageal
reflux disease is known to cause heartburn, and the
presence of acid in the esophagus for prolonged
periods is now known to place patients at risk for
serious sequelae, such as Barretts esophagus and
esophageal cancer. Therefore, long-termmanage-
ment options are needed, including lifestyle
changes, pharmacological therapy, surgery, and
endoscopic intervention. Proton pump inhibitors
have been found to be superior to other medica-
tions both in inducing symptomresolution and heal-
ing esophagitis. The outcomes reported from
surgical and endoscopic treatments are mixed.
Recent data suggest that approximately one fourth
of surgically treated patients will require continued
antisecretory therapy for persistent GERD symp-
toms postoperation.
1
Though a number of endo-
scopic procedures have been approved for use in
the United States, their effectiveness and their roles
in clinical practice remain controversial.
(Adv Stud Med. 2003;3(3A):S123-S127)
T
he major treatment options, other than
lifestyle changes, for the long-term care of
adult gastroesophageal reflux disease
(GERD) patients are medical therapy,
surgery, and newer endoscopic proce-
dures. This article will review evidence surrounding
each of these treatment options and guide the clinician
in choosing appropriate management plans for
patients heartburn relief, healing of erosive esophagi-
tis, and maintenance of clinical remission.
MEDICAL THERAPY FOR HEARTBURN
HISTAMINE-TYPE 2 RECEPTOR ANTAGONISTS
VERSUS PROTON PUMP INHIBITORS
There are 2 main classes of drugs available today
that are used in the long-term treatment of GERD in
adults: histamine type-2 receptor antagonists (H2RAs)
and proton pump inhibitors (PPIs). However, evi-
dence clearly indicates that of the two, PPIs should be
the mainstay of medical therapy for most patients. In
a large community-based trial conducted by Howden
et al, 593 individuals with symptomatic GERD were
randomized to receive either an initial dose of the
H2RA, ranitidine, or the PPI, lansoprazole. Four
therapeutic strategies were compared in which some
subjects remained on a constant dose of ranitidine 150
mg bid or lansoprazole 30 mg qd for 20 weeks, while
others began initially on either ranitidine 150 mg bid
or lansoprazole 30 mg qd and then were switched to
the other medication. Subjects were asked to keep
diaries of their symptoms, specifically to log the sever-
ity of their daytime and nighttime heartburn as well as
PROCEEDINGS
LO NG-TERM MANAGEMENT O F GERD: PRO TO N PUMP INHIBITO RS
VERSUS NEWER ENDO SCO PIC INTERVENTIO NS VERSUS SURGERY
*
Fever
Chest pain
Dysphagia
Pleural effusion
Mucosal tear
Perforation
Aspiration
Death
ELGP
Pharyngitis
Abdominal pain
Chest pain
Mucosal tear
Hypoxia
Bleeding
Suture perforation
Advanced Studies inMedicine I S127
GERD requiring PPIs, but who either had no
esophagitis or mild esophagitis, the results of this
study were similar to those reported with the Stretta
procedure. Data reported after 6 months showed
improved symptoms and 24-hour pH-metry scores.
However, in this trial, 11 patients required repeat
surgery, and one third of patients experienced pharyn-
gitis. Others developed a myriad of complications
including vomiting, abdominal pain, chest pain, and 1
patient reported 2 cases of bleeding from suture perfo-
ration. It is important to note that as many as one
third of the patients in this study needed to restart acid
suppressive therapy, mostly with PPIs.
17
In summary, only data from small, uncontrolled
trials in patients with nonerosive disease or mild
esophagitis are available for the endoscopic methods of
treating GERD. A number of complications ranging
from fever and chest/abdominal pain to bleeding and
even aspiration and death have been reported (Table
3).
18
Some of these complications are undoubtedly
related to the learning curve for endoscopists perform-
ing these procedures that affects patient outcomes.
Thus, the use of endoscopic therapies should be con-
fined to clinical trials at centers with an appropriate
level of expertise. In so doing, we can be confident that
our patients best interests are being served.
CONCLUSION
Long-term PPI treatment has been proven safe and
effective for GERD patients. Surgery should be con-
sidered only after a positive diagnosis of GERD has
been established and after carefully considering the
risk-benefit ratio in the individual patient. It should be
noted that many GERD sufferers still require medica-
tion postoperatively. Endoscopic treatment still has
not been adequately studied and, therefore, its appli-
cation in medical practice today may be premature.
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PROCEEDI NGS