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GASTRO-ESOPHAGEAL REFLUX DISEASE (GERD)!

MANAGEMENT OF GASTRO-ESOPHAGEAL REFLUX DISEASE 

"GERD refers to the endoscopically determined esophagitis or endoscopy-negative reflux disease".

"GERD is the term used to describe any symptomatic clinical condition or histopathological alteration resulting from episodes of reflux of acid, pepsin and occasionally, bile into the esophagus from the stomach".

  • Patients with uninvestigated "reflux-like" symptoms should be managed as patients with uninvestigated dyspepsia. There is currently no evidence that H.pylori should be investigated in patients with GERD.


Symptoms:

  • Heartburn is the characteristic symptom of GERD.
  • Acid regurgitation
  • Dysphagia
  • Belching
  • Upper abdominal discomfort
  • Bloating and postprandial fullness
  • Chest pain
  • Hoarseness
  • Cough

Complications include:

  • Esophageal ulceration
  • Formation of specialized columnar-lined esophagus at the gastro-esophageal junction known as Barretts Esophagus.

Mechanism of Acid Reflux:

  • The mechanism of acid reflux is multifactorial and involves transient lower esophageal sphincter relaxations, reduced tone of the lower esophageal sphincter, hiatus hernia and abnormal esophageal acid clearance. The severity of inflammation of the esophageal mucosa is described as categories of esophagitis. However, approximately two-thirds of patients with GERD have normal mucosa on endoscopy.
  • Hypersensitivity to normal acid exposure may be the cause of symptoms in this group of patients. Progression from non-erosive reflux disease to erosive esophagitis and Barretts esophagus is rare.

Management:

  • Management of GERD focuses on symptom control rather than endoscopic findings and therefore careful symptom evaluation is required.
  • Patients with alarming features or those who fail to respond to medical treatment should be referred for endoscopic investigations.
  • H.pylori eradication is not recommended in the management of GERD.
  • Strategies for initial treatment include Lifestyle measures such as Weight loss, smoking cessation, in combination with Antacids. (These measures may be effective in patients with no significant impairment of quality of life).
  • When quality of life is impaired, Acid-suppression therapy is the basis of effective treatment.
  • A course of standard-dose of PPI therapy is most effective for symptom relief, healing of esophagitis and maintenance of remission in patients with GERD.
  • Compared with erosive esophagitis, there is diminished response to Acid-suppression in non-erosive reflux disease, but PPIs remain the most effective agents.
  • Most patients respond after 4 weeks of treatment and initial control of symptoms, therapy can be withdrawn.
  • If symptoms return, intermittent courses can be given, or, alternatively, on-demand single doses can be taken immediately as symptoms occur.
  • Patients who relapse frequently may require continuous maintenance therapy using the lowest dose of Acid-suppression which provides effective symptom relief.
  • Escalating doses can be used in the small number of patients who do not respond to initial treatment. These patients should be investigated to confirm diagnosis.
  • Those with a normal upper endoscopy may require pH monitoring or motility tests.
  • Twice-daily dosing may be required in patients with persistent symptoms.
  • A selected group of patients may benefit from Anti-reflux surgery rather than the escalation of Acid-suppressing treatment.
  • Patients with endoscopically severe esophagitis should be kept on Standard-dose PPIs long-term to maintain symptom relief and prevent the development of complications such as Barretts Esophagus or Esophageal Adenocarcinoma.


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