Expired CME Article

Management of Gastroesophageal Reflux Disease

Authors: Julia J. Liu, MD, John R. Saltzman, MD

Abstract

Gastroesophageal reflux disease is the most common and expensive digestive disease with complex and multi-factorial pathophysiologic mechanisms. Transient inappropriate relaxation of the lower esophageal sphincter is the predominant mechanism in the majority of patients with mild to moderate disease. Hiatal hernias and a reduced lower esophageal sphincter pressure have a significant role in patients with moderate to severe disease. Typical manifestations of gastroesophageal reflux disease include heartburn, regurgitation, and dysphagia. Atypical symptoms, such as noncardiac chest pain, pulmonary manifestations of asthma, cough, aspiration pneumonia, or ENT manifestations of globus and laryngitis, can be seen in patients with or without typical symptoms of gastroesophageal reflux disease. Endoscopy and ambulatory pH tests are best to evaluate the anatomic and physiologic impact of gastroesophageal reflux disease. Complications of chronic gastroesophageal reflux disease include peptic strictures and Barrett metaplasia. Barrett esophagus is a major risk factor for esophageal adenocarcinoma, and upper endoscopy with surveillance biopsies is recommended for patients with Barrett esophagus. Medical therapy with anti-secretory agents (H2 blockers and proton pump inhibitors) is effective for most patients with gastroesophageal reflux disease. Surgical fundoplications and endoscopic treatment modalities are mechanical treatment options for patients with gastroesophageal reflux disease.


Key Points


* Understanding the pathophysiology of gastroesophageal reflux disease leads to improved patient management through the identification and treatment of contributing factors.


* Gastroesophageal reflux disease may have typical symptoms of heartburn and regurgitation or may present in an atypical manner with ENT symptoms, pulmonary manifestations or noncardiac chest pain.


* Screening for Barrett esophagus should be considered in patients with long-standing gastroesophageal reflux disease, as it is the most important risk factor for esophageal adenocarcinoma.


* Testing is not required in most patients with suspected gastroesophageal reflux disease, but patients with alarm symptoms or persistent symptoms despite medical therapy should undergo upper endoscopy and/or ambulatory pH studies.


* Medical therapy is safe and effective in most patients with gastroesophageal reflux disease.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. A Gallup Survey on Heartburn Across America. Princeton, The Gallup Organization, Inc, 1988.
 
2. Dent J, Dodds WJ, Frieman RH, et al. Mechanism of gastroesophageal reflux in recumbent asymptomatic human subjects. J Clin Invest 1980;65:256–267.
 
3. Dodds WJ, Dent J, Hogan WJ, et al. Mechanisms of gastroesophageal reflux in patients with reflux esophagitis. N Engl J Med 1982;307:1547–1552.
 
4. Barham CP, Gotley DC, Mills A, et al. Precipitating causes of acid reflux episodes in ambulant patients with gastro-oesophageal reflux disease. Gut 1995;36:505–510.
 
5. Horowitz M, Su YG, Rayner CK, et al. Gastroparesis: prevalence, clinical significance and treatment.Can J Gastroenterol 2001;15:805–813.
 
6. Kahrilas PJ, Shi G, Manka M, et al. Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia. Gastroenterology2000;118:688–695.
 
7. Lagergren J, Bergstrom R, Lindgren A, et al. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Engl J Med 1999;340:825.
 
8. Morales CP, Souza RF, Spechler SJ. Hallmarks of cancer progression in Barrett oesophagus. Lancet2002;360:1587–1589.
 
9. Dulai GS, Guha S, Kahn KL, et al. Preoperative prevalence of Barrett esophagus in esophageal adenocarcinoma: a systematic review. Gastroenterology 2002;122:26–33.
 
10. Spechler SJ. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans: the Department of Veteran Affairs Gastroesophageal Reflux Disease Study Group.N Engl J Med 1992;326:786–792.
 
11. Inadomi JM, Sampliner R, Lagergren J, et al. Screening and surveillance for Barrett esophagus in high risk groups: a cost-utility analysis. Ann Intern Med 2003;138:176–186.
 
12. Gerson LB, Groeneveld PW, Triadafilopoulos G. Cost-effective model of endoscopic screening and surveillance in patients with gastroesophageal reflux disease. Clin Gastroenterol Hepatol 2004;2:868–879.
 
13. Provenzale D, Schmitt C, Wong JB. Barrett esophagus: a new look at surveillance based on emerging estimates of cancer risk. Am J Gastroenterol 1999;94:2043–2053.
 
14. Schnell TG, Sontag SJ, Chejfec G, et al. Long-term nonsurgical management of Barrett esophagus with high-grade dysplasia. Gastroenterology 2001;120:1607–1619.
 
15. El-Serag HB, Aguirre TV, Davis S, et al. Proton pump inhibitors are associated with reduced incidence of dysplasia in Barrett’s esophagus. Am J Gastroenterol 2004;99:1877–1883.
 
16. Hofstetter WL, Peters JH, DeMeester TR, et al. Long-term outcome of antireflux surgery in patients with Barrett’s esophagus. Ann Surg 2001;234:532–538.
 
17. Spechler SJ, Lee E, Ahnen D, et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: a follow-up of a randomized controlled trial. JAMA 2001;285:2331–2338.
 
18. Ye W, Chow WH, Lagergren J, et al. Risk of adenocarcinoma of the esophagus and gastric cardia in patients with gastroesophageal reflux disease and after antireflux surgery. Gastroenterology2001;121:1286–1293.
 
19. Corey KE, Schmitz SM, Shaheen NJ. Does a surgical antireflux procedure decrease the incidence of esophageal adenocarcinoma in Barrett esophagus? A meta-analysis. Am J Gastroenterol2003;98:2390–2394.
 
20. van den, Boogart J, van Hillegersberg R, et al. Endoscopic ablation therapy for Barrett esophagus with high grade dysplasia: a review. Am J Gastroenterol 1999;94:1153–1160.
 
21. Sampliner RE. Endoscopic ablative therapy for Barrett esophagus: current status. Gastrointest Endosc 2004;59:66–69.
 
22. Van Laethem JL, Peny MO, Salmon I, et al. Intramucosal adenocarcinoma arising under squamous re-epithelialisation of Barrett esophagus. Gut 2000;46:574–577.
 
23. Numans ME, Lau J, de Wit NJ, et al. Short-term treatment with proton pump inhibitors as a test for gastroesophageal reflux disease: a meta-analysis of diagnostic test characteristics. Ann Internal Med2004;140:518–527.
 
24. DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol 2005;100:190–200.
 
25. Sellar RJ, De Caestecker JS, Heading RC. Barium radiology: a sensitive test for gastro-esophageal reflux. Clin Radiol 1987;38:303–307.
 
26. Monnier P, Savary M. Contribution of endoscopy to gastroesophageal reflux disease. Scand J Gastroenterol 1984;19(suppl 106):26.
 
27. Kahrilas PJ, Quigley EM. Clinical esophageal pH recording: a technical review for practice guideline development. Gastroenterology 1996;110:1982–1996.
 
28. Kahrilas PJ, Clouse RE, Hogan WJ. American Gastroenterological Association technical review on the clinical use of esophageal manometry. Gastroenterology 1994;107:1865–1884.
 
29. Locke GR III, Talley NJ, Fett SL, et al. Risk factors associated with symptoms of gastroesophageal reflux. Am J Med 1999;106:642–649.
 
30. Chiba N, De Gara CJ, Wilkinson JM, et al. Speed of healing and symptom relief in grade II to IV gastroesophageal reflux disease: a meta-analysis. Gastroenterology 1997;112:1798–1810.
 
31. Freston JW. Omeprazole, hypergastrinemia, and gastric carcinoid tumors. Ann Intern Med1994;121:232–233.
 
32. Klinkenberg-Knol EC, Nelis F, Dent J, et al Long-term omeprazole treatment in resistant gastroesophageal reflux disease: efficacy, safety, and influence on gastric mucosa. Gastroenterology2000;118:661–669.
 
33. Serfaty-Lacrosniere C, Wood RJ, Voytke D, et al. Hypochlorhydria from short-term omeprazole treatment does inhibit intestinal absorption of calcium, phosphorous, magnesium or zinc from food in humans. J Am Coll Nutr 1995;14:364–368.
 
34. Marcuard SP, Albernaz L, Khazanie PG. Omeprazole therapy causes malabsorption of cyanocobalamin: vitamin B12 Ann Intern Med 1994;120:211–215.
 
35. Saltzman JR, Kemp JA, Golner BB, et al. Effect of hypochlorhydria due to omeprazole treatment or atrophic gastritis on protein-bound vitamin B12 absorption. J Am Coll Nutr 1994;13:584–591.
 
36. Saltzman JR, Kowdley KV, Pedrosa MC, et al. Bacterial overgrowth without clinical malabsorption in elderly hypochlorhydric subjects. Gastroenterology 1994;106:615–623.
 
37. Laheij RJ, Sturkenboom MC, Hassing JR, et al. Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. JAMA 2004;292:1955–1960.
 
38. Dial S, Delaney JAC, Barkun AN, et al. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA 2005;294:2989–2995.
 
39. Inadomi JM, Jamal R, Murata GH, et al. Step-down management of gastroesophageal reflux disease. Gastroenterology 2001;121:1095–1000.
 
40. Inadomi JM, McIntyre L, Bernard L, et al. Step-down from multiple- to single-dose proton pump inhibitors (PPI’s): a prospective study of patients with heartburn or acid regurgitation completely relieved with PPIs. Am J Gastroenterol 2003;98:1940–1944.
 
41. Dent J, Yeomans ND, Mackinnon M, et al. Omeprazole versus ranitidine for prevention of relapse in reflux oesophagitis: a controlled double blind trial of their efficacy and safety. Gut 1994;35:590–598.
 
42. Vigneri S, Termini R, Leandro G, et al. A comparison of five maintenance therapies for reflux esophagitis. N Engl J Med 1995;333:1106–1110.
 
43. Hetzel DJ, Dent J, Reed WD, et al. Healing and relapse of severe peptic esophagitis after treatment with omeprazole. Gastroenterology 1988;95:903–912.
 
44. Spechler SJ, Lee E, Ahnen D, et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial. JAMA 2001;285:2331–2338.
 
45. Corley DA, Katz P, Wo JM, Stefan A. Improvement of gastroesophageal reflux symptoms after radiofrequency energy: a randomized, sham-controlled trial. Gastroenterology 2003;125:668–676.
 
46. Triadafilopoulos G, DiBaise JK, Nostrant TT, et al. The Stretta procedure for the treatment of GERD: 6 and 12 month follow-up of the US open label trial. Gastrointest Endosc 2002;55:149–156.
 
47. Liu JJ, Glickman JN, Carr-Locke DL, et al. gastroesophageal junction smooth muscle remodeling after endoluminal gastroplication. Am J Gastroenterol 2004;99:1895–1901.
 
48. Filipi CJ, Lehman G, Rothstein RI, et al. Transoral endoscopic suturing for gastroesophageal reflux disease: a multicenter trial. Gastrointest Endosc 2001;53:416–422.
 
49. Liu JJ, Carr-Locke DL, Osterman MT, et al. Endoscopic treatment for atypical manifestations of gastroesophageal reflux disease. Am J Gastroenterol 2006;101:440–445.