Management of gastroesophageal reflux disease

The primary treatment goals in patients with gastroesophageal reflux disease are relief of symptoms, prevention of symptom relapse, healing of erosive esophagitis, and prevention of complications of esophagitis. In patients with reflux esophagitis, treatment is directed at acid suppression through the use of lifestyle modifications (e.g., elevating the head of the bed, modifying the size and composition of meals) and pharmacologic agents (a histamine H2-receptor antagonist [H2RA] taken on demand or a proton pump inhibitor IPPI] taken 30 to 60 minutes before the first meal of the day). The preferred empiric approach is step-up therapy (treat initially with an H2RA for eight weeks; if symptoms do not improve, change to a PPI) or step-down therapy (treat initially with a PPI; then titrate to the lowest effective medication type and dosage). In patients with erosive esophagitis identified on endoscopy, a PPI is the initial treatment of choice. Diagnostic testing should be reserved for patients who exhibit warning signs (i.e., weight loss, dysphagia, gastrointestinal bleeding) and patients who are at risk for complications of esophagitis (i.e., esophageal stricture formation, Barrett's esophagus, adenocarcinoma). Antireflux surgery, including open and laparoscopic versions of Nissen fundoplication, is an alternative treatment in patients who have chronic reflux with recalcitrant symptoms. Newer endoscopic modalities, including the Stretta and endocinch procedures, are less invasive and have fewer complications than antireflux surgery, but response rates are lower.     

Managing gastroesophageal reflux disease

A common condition, gastroesophageal reflux disease (GERD) involves the reflux of gastric contents into the esophagus. GERD may contribute to asthma, noncardiac chest pain, and other problems. This article presents trends in GERD management, including pathophysiology, diagnosis, and treatment. The authors also explore lifestyle modifications, pharmacologic therapy, and gastroenterology referral.     

Diagnosing gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common condition with a variety of clinical manifestations and potentially serious complications. This article reviews available methods for diagnosing GERD. A clinical history of the classic symptoms of GERD, heartburn or acid regurgitation, is sensitive enough to establish the diagnosis in patients without other complications. Esophagogastroduodenoscopy is the best way to evaluate suspected complications of GERD, but endoscopic findings are insensitive for the presence of pathological reflux, and therefore they cannot reliably exclude GERD. The "gold standard" study for confirming or excluding the presence of abnormal gastroesophageal reflux is the 24-hour ambulatory esophageal pH monitoring test, and this study should be used for the evaluation of refractory symptoms and extraesophageal manifestations of GERD. A formal acid-suppression test is helpful in the evaluation of the atypical GERD symptom of noncardiac chest pain. Optimal use of currently available tests for GERD may allow for more efficient diagnosis and better characterization of the pathological manifestations associated with GERD.     

Treatment of gastroesophageal reflux disease

Therapeutic modalities for gastroesophageal reflux disease (GERD) continue to evolve despite the introduction of proton pump inhibitors (PPIs), the most successful antireflux class of drugs. On-demand modalities such as antacids and alginates as well as histamine type-2 receptor antagonists continue to be popular with GERD patients who seek temporary relief of symptoms. The PPIs have revolutionized the treatment of patients with severe erosive esophagitis, complications of GERD, and atypical or extraesophageal manifestations of GERD. Antireflux surgery, commonly performed via laparoscopy, remains popular among patients who do not wish to take medications long term. In addition, the recent introduction of various endoscopic techniques offers GERD patients a long-term solution with less morbidity and lower cost than antireflux surgery.     

胃食管反流病的诊断

胃食管反流性疾病(gastroesophageal reflux disease，GERD)是由于胃、十二指肠内容物反流人食管引起的一组临床症状和食管的组织损害。主要表现为烧心、反流、胸骨后疼痛三大症状。酸(碱)反流导致的食管黏膜破损称为反流性食管炎(reflux esophagitis，RE)。新近的研究证明，胃食管反流(GER)与部分哮喘，咳嗽，夜间呼吸暂停，心绞痛样胸骨后疼痛有关。若食管炎症长期存在，可发展成为具有一定癌变倾向的Barrett食管。西方国家人群中7％～15％有GER症状。男女患病比例相似。     

胃食管反流病的治疗

胃食管反流病(gastroesophageal reflux disease，GERD)是消化系统的常见病和多发病，严重影响人民的生活质量。在西方国家患病率近人口的半数左右，在我国发病率尚缺少大样本的调查，在北京等地区的发病率在5％～6％。该病主要是由于过多的胃、十二指肠内容物反流入食道，引起反酸、反食、烧心和胸骨后疼痛等症状。胃食管反流病可分为两个亚型，内镜下可见食管黏膜破损者，称糜烂性食管炎(erosive esophagitis，EE)。如果内镜检查没有明显的食管黏膜的破损，但有因胃食管反流引起的烧心、反酸等症状，24小时pH监测有异常酸暴露者，称为非糜烂性食管炎(nonerosive negative reflux disesase，NERD)。     

胃食管反流病的生活方式干预

胃食管反流病是由胃内容物反流引起不适症状或并发症的一种疾病,是由多种因素所致的上消化系统动力障碍性疾病。临床治疗中以促进食管运动、增强食管下段括约肌收缩压力以及改变胃动力的促动力药物为主,同时,以调整生活方式、注意饮食调养、配合心理干预为内容的生活方式干预对胃食管反流病患者改善临床症状必不可少。     

Test of refractory gastroesophageal reflux disease

It should be considered that the causes of refractory gastroesophageal reflux disease (GERD) are multifactorial. Esophageal manometry study is useful when we make distinguish patients with esophageal motility disorders from those with refractory GERD. Endoscopic ultrasonography is also performed to observe the thickness of esophageal wall which represents the disturbance of esophageal motor function. Esophageal pH monitoring is useful to detect the acid clearance disturbance and phenomenon of nocturnal acid breakthrough. Both are occurred at night, and are recently considered to be responsible for refractory GERD. Catheter-free pH monitoring system, Bravo, makes it possible to measure esophageal pH under quite physiological conditions. Genotype of CYP2C19 is sometimes checked in patients with PPI resistance GERD. Intra-gastric pH with omeprazole and lansoprazole depends on patient's genotype of CYP2C19. Monitoring of 24-hour bilirubin, Bilitec, is also useful to detect duodeno-gastro-esophageal reflux.     

Atypical presentations of gastroesophageal reflux disease

Gastroesophageal reflux disease typically manifests as heartburn and regurgitation, but it may also present with atypical or extraesophageal symptoms, including asthma, chronic cough, laryngitis, hoarseness, chronic sore throat, dental erosions, and noncardiac chest pain. Diagnosing atypical manifestations of gastroesophageal reflux disease is often a challenge because heartburn and regurgitation may be absent, making it difficult to prove a cause-and-effect relationship. Upper endoscopy and 24-hour pH monitoring are insensitive and not useful for many patients as initial diagnostic modalities for evaluation of atypical symptoms. In patients with gastroesophageal reflux disease who have atypical or extraesophageal symptoms, aggressive acid suppression using proton pump inhibitors twice daily before meals for three to four months is the standard treatment, although some studies have failed to show a significant benefit in symptomatic improvement. If these symptoms improve or resolve, patients may step down to a minimal dose of antisecretory therapy over the following three to six months. Surgical intervention via Nissen fundoplication is an option for patients who are unresponsive to aggressive antisecretory therapy. However, long-term studies have shown that some patients still require antisecretory therapy and are more likely to develop dysphagia, rectal flatulence, and the inability to belch or vomit.     

胃食管反流病的健康教育体会

目的探讨健康教育在胃食管反流病中的作用。方法对40例胃食管反流病患者随机分成健康教育组和对照组,两组患者均口服兰索拉唑、莫沙比利治疗,疗程12周,健康教育组在对照组的基础上实施健康教育。两组均在治疗后每2周进行随访,定期复查胃镜,比较两组的治疗效果。结果健康教育组疗效优于对照组(P<0.05)。结论健康教育可帮助患者有意识地改变一些不良生活方式,可以提高治疗效果。     

Extraesophageal manifestations of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) may manifest as laryngitis, asthma, cough, or noncardiac chest pain. Diagnosing these extraesophageal manifestations may be difficult for primary care physicians because most patients do not have heartburn or regurgitation. Diagnostic tests have low specificity, and a cause-and-effect association between GERD and extraesophageal symptoms is difficult to establish. Response to aggressive acid suppression is often the best indication of GERD etiology in a patient with extraesophageal symptoms.     

胃食管反流病的临床问题

胃食管反流病(GERD)是一类由胃食管动力障碍引起。通过酸反流导致的疾病，亚洲的发病率较西方为低，但近几年有增加的趋势，有人认为与饮食结构的改变和对胃内幽门螺杆菌(H．pylori，HP)的根除有关。亚洲的GERD特征是症状轻微、内镜下正常的非糜烂性胃食管反流性病(NERD)同洛杉矶A级或B级食管炎，罕见有Barrett’s食管或食管狭窄。关于GERD，以下几个临床问题值得注意：     

Endoscopic treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease is a common chronic disorder which has a severe effect on the patient's quality of life. In view of the high cost of medical therapy and the limitations of surgery, a variety of endoscopic techniques have been developed for the treatment of this condition, and these have shown apparently encouraging results, at least in the short term. However, promising results have been obtained in only around two-thirds of patients over a short-term follow-up period of about 6 months. Moreover, several inconsistencies have emerged between the efficacy of this form of treatment in improving symptoms and quality of life and a lack of improvement of objective parameters, such as lower esophageal sphincter pressure and esophageal acid exposure. The authors strongly endorse the need for comprehensive evaluation of clinical evidence on this topic. After an extensive evaluation of existing literature, we suggest that controlled studies are urgently needed in order to clarify the potential of endoscopic therapy, either in terms of cost-effectiveness or in comparison with standard therapy. Meanwhile, with regard to current practice, the use of endoscopic treatment should be limited to clinical trials, which should incorporate the provision of comprehensive and unbiased information to study patients.     

GERD (gastroesophageal reflux disease)]

Both GERD (gastroesophageal reflux disease) and asthma are common disease and the association between GERD and asthma are recently proved in many reports. Patient with GERD have a higher prevalence of asthma and aggressive antireflux therapy in patient with asthma and GERD results in improvement in asthma outcome. I examined the prevalence of GERD symptom using a questionnaire in asthma patients and about 80% have GERD among the patient with asthma. Endoscopic examination revealed that the prevalence of esophageal mucosal disease in patient with asthma was about 58%. In this paper I review the role of GERD in asthma.     

Endoscopic therapy for gastroesophageal reflux disease

A variety of endoscopic techniques for the treatment of gastroesophageal reflux disease (GERD) have been developed as alternatives to PPI therapy or antireflux surgery. These techniques include the delivery of radiofrequency energy to the gastroesophageal junction, injection of agents into the lower esophageal sphincter zone, and suture plication of the proximal fundic folds. Each of these endoscopic techniques is designed to alter the anatomy or physiology of the gastroesophageal junction to decrease gastroesophageal reflux. However, only limited data are available on the mechanism of action of the various endoscopic techniques. Most studies of endoscopic therapy have only limited follow-up information, and safety issues remain unresolved. Further sham-controlled clinical trials will be required for endoscopic device and technique.     

Endoscopic treatment for gastroesophageal reflux disease

The endoscopic treatment as a minimally invasive method to gastroesophageal reflux disease (GERD) came to be tried in addition to medication and laparoscopic antireflux surgery. Clinical trials, such as the Endoluminal Gastroplication method, the Full Thickness Plicator method, the Stretta method, the Enteryx method, and the Gatekeeper method, are advancing in the United States and Europe. It is necessary to consider the efficacy, safety, durability, cost effectiveness, an indication, etc. using data from a randomized controlled trial with sufficient observation period. If the usefulness of endoscopic treatment is confirmed in the future, the new minimally invasive strategy over GERD will be established.