Gastroesophageal Reflux Disease: Treatments and Lifestyle Modification
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Gastroesophageal Reflux Disease: Treatments and Lifestyle Modification

The goal is to decrease gastric acid secretion to minimize mucosal injury in the esophagus. Accordingly, acid suppression therapy is the mainstay treatment of GERD––providing mucosal healing and symptom relief.

Lifestyle modifications

Elevation of the head of the bed, avoiding heavy meals and the supine position for 3 hours after a meal, reducing intake of caffeine and chocolate and smoking cessation are helpful logical measures to decrease the risk of acid reflux even though there is no overwhelming evidence proving their effectiveness.

Medical therapy

The goal is to decrease gastric acid secretion to minimize mucosal injury in the esophagus. Accordingly, acid suppression therapy is the mainstay treatment of GERD––providing mucosal healing and symptom relief. The degree of success parallels the degree of acid suppression.

Acid suppressants

• PPIs are the most potent available acid suppressants, and have an excellent success rate for the management of erosive esophagitis.

• Both histamine H2 receptor blockers and PPIs have modest success rates in controlling symptoms in patients with NERD (60%).

• In a patient who is receiving a twice a day PPI and continues to have nocturnal breakthrough symptoms, adding a bedtime dose of an H2 blocker can be beneficial. Unfortunately, most patients lose the benefit very quickly (days) due to tolerance.

• When doses of equivalent potency are given, there is no significant difference in the success rates between different PPIs.

• Despite a clinically insignificant increase in gastrin levels with long-term use of PPIs, there is no evidence that this leads to carcinoid tumors.

Prokinetic Agents

• These drugs improve esophageal motility and gastric emptying and increase LES pressure.

• These effects, if achieved, can decrease reflux and improve symptoms.

• Metoclopramide and cisapride are prokinetic agents that fulfill this profile.

• Cisapride is no longer available in the United States because of the potential for cardiac dysrhythmias.

• Metoclopramide crosses the brain barrier and can be associated with extrapyramidal symptoms and hyperprolactinemia when used long term.

• Until newer agents are developed, there is currently no role for prokinetic drugs in the management of GERD unless associated with gastroparesis.

Surgical treatment

  • The aim is to restore the gastroesophageal mechanical barrier to provide a curative solution. It is a laparoscopic, minimally invasive surgical procedure
  • Involves reconstruction of the diaphragmatic hiatus
  • Reinforcement of the LES by fundoplication
  • The ideal candidates are young patients who have documented GERD with a good response to PPIs but are concerned about taking medications long term and patients with nocturnal regurgitation and pulmonary complications.
  • Success rate is 80% to 90% when the patient is appropriately selected and the surgeon is experienced.

Postoperative expectations

  • 5% of patients will develop persistent dysphagia.
  • Bloating (inability to belch) and diarrhea (dumping due to loss of fundus space) can occur.
  • 33% will still require long-term use of PPIs.

Endoscopic therapy

Designed to improve the mechanical gastroesophageal barrier but is still an area of development with new modalities emerging and others fading away due to safety concerns.

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Comments (1)

I did not know the acid was so corrosive until recently. Good article.

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