Gastroesophageal ebb disease (GERD)...

Gastroesophageal ebb disease (GERD) is defined as an impairment of quality of life caused by means of gastroesophageal reflux. Heartburn, which is characterized by dint of discomfort or burning behind the breastbone arising from the epigastrium and possibly radiating to the neck is the mostly common symptom of GERD. Heartburn generally is intermittent, with chiefly episodes occurring within 60 minutes of eating, during exercise, and while lying down. Drinking water or taking an antacid may relieve the symptoms, unless heartburn generally occurs frequently. Kahrilas reviewed the management of refractory heartburn.

Proton cross-question inhibitor (PPI) therapy is useful as a therapeutic trial because it many times successfully reduces acid-related disorders, including GERD However, answer to treatment cannot make or control out a diagnosis. Inadequate answer to treatment can be explained through inadequate treatment, esophagitis of nonreflux etiology, nonacid ebb or functional heartburn. After a failed PPI therapeutic trial, options include increasing the strength of GERD therapy with medication, endoscopic treatment, or surgery; endoscopy and monitoring pH; and empiric treatment for functional heartburn with low-dosage tricyclic antidepressants. Because increased dosages of PPIs are not likely to work better than the initial dosage and because functional heartburn is generally a diagnosis of exclusion, the best choice is upper endoscopy, with pH monitoring to tread close upon if no clear pathology is originate on visualization of the gastroesophageal region. Patients should discontinue PPI therapy for five to seven days before starting pH monitoring.

Endoscopy and pH monitoring should clarify the relationship between symptoms and actual acid ebb If they are not significantly associated, functional heartburn can be diagnosed, and the patient can be treated with a tricyclic antidepressant given in a depressed dosage at nighttime. Patients with functional heartburn have symptoms that are typical of esophageal disease on the other hand that have no physical explanation. Heartburn symptoms usually are more usual during times of stress.

The author judges that because PPIs are in the way that effective in treating symptoms of esophagitis, refractory, endoscopy-negative heartburn probably has other etiologies. The latter can include esophagitis where disease is at hand but not detected; absence of abnormality of esophageal epithelium further evidence of reflux etiology; and heartburn not attributable to gastroesophageal ebb but more likely caused from psychosocial factors. Determining the appropriate category for patients with refractory heartburn will lead to appropriate therapeutic intervention with a greater likelihood of success

Kahrilas PJ Refractory heartburn. Gastroenterology June 2003;124:1941-5

COPYRIGHT 2004 American Academy of Family Physicians

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