Gastroesophageal ebb disease (GERD)...

Gastroesophageal ebb disease (GERD) is a usual chronic, relapsing condition that is associated with a risk of significant morbidity and the possibility of mortality from complications. An estimated 44 percent of the U adult population (61 million Americans) have heartburn, the hallmark of acid regurgitation, at least one time a month. (1) Approximately 14 percent of Americans have gastroesophageal symptoms weekly, and 7 percent have symptoms daily. (12)

Many patients self-diagnose and self-treat, and do not solicit medical attention for their symptoms, while others have more stiff disease, including erosive esophagitis. (3) Patients who have GERD generally report decreased quality of life, reduc productivity, and decreased well-being. In many of these patients, reported quality of life is lower than in patients who have untreated angina pectoris or chronic heart failure. (4) This article summarizes an evidence-based approach to the cost-effective management of patients with GERD (5)

Diagnosis

A careful history is essential to establish the diagnosis of GERD If a patient has classic symptoms of heartburn and acid regurgitation, the diagnosis can be made with high specificity, notwithstanding the sensitivity remains low. (67) GERD can be missed in patients with heartburn, and an patients with Barrett's esophagus or adenocarcinoma of the esophagus do not complain of heartburn. merely 2 to 3 percent of acid ebb events reach the conscious of the same height and are perceived by patients with GERD (8) Furthermore, many patients with GERD not past nor future with atypical symptoms (6,7) (Table 1) (9) although the mien of such symptoms is not required for clinical diagnosis.

There is no gold standard for diagnosing GERD although 24-hour pH monitoring (pH probe) is the accepted standard for establishing or excluding its demeanor In patients with nonerosive ebb disease or symptomatic reflux esophagitis, 24-hour pH monitoring has a sensitivity and specificity of 70 to 96 percent nevertheless false-positive or false-negative results are possible. (10) While endoscopy lacks sensitivity for identifying pathologic ebb it is the gold standard for assessing esophageal complications of GERD (11) Barium radiology is seldom useful for diagnosing GERD (12)

In practice, the initial diagnosis of GERD is based onward the history. Empiric acid suppression therapy for four to eight weeks should be tried in patients who have typical GERD symptoms without atypical manifestations and without warning signs or symptoms suggestive of complicated disease (1314) (Table 2) (14) [Reference 13-evidence even A, meta-analysis of randomized controll trials (RCTs)]

For the empiric trial, treatment may be initiated with a standard dosage of a histamine [H.sub.2]-receptor antagonist (H2RA) taken twice daily forward demand or a standard dosage of a proton cross-question inhibitor (PPI) taken 30 to 60 minutes before the first meal of the day. The preferr empiric approach is step-up or step-down therapy. Step-up therapy begins with an eight-week trial of an H2RA and progresse to use of a PPI if symptoms of heartburn and regurgitation are not relieved. Step-down therapy starts with a PPI for eight weeks; treatment is then "downgraded" to the lowest effective dosage and stamp of medication that provide symptom relief. (15)

unsalable article selection should be based upon the frequency or severity of symptoms at presentation, with a treatment goal of finished cost-effective symptom relief (13,14) (Figure 1 (14) and Table 3 (5)) Diagnostic testing should be reserv for patients who current with warning signs and symptoms, have not corresponded to PPI therapy, or have disease duration of five to 10 years.

[FIGURE 1 OMITTED]

Treatment

LIFESTYLE MODIFICATIONS

Based onward expert opinion, lifestyle modifications should be initiated and continued from first to last the course of therapy in patients with a history that is typical of uncomplicated GERD (Table 4) (14) Although there is little supporting evidence, it is considered reasonable to educate patients about various factors that may precipitate ebb (16)

ANTACIDS

Over-the-counter acid suppressants and antacids are considered appropriate initial therapy for GERD Almost the same third of patients with heartburn-related symptoms use the same of these agents at least twice weekly, for an annual expenditure of more than $1 billion. (1718) Antacids (eg Tum Rolaids, Maalox) and combined antacid--alginic acid preparations have been shown to be more effective than placebo in relieving GERD symptoms, based forward measures such as lower global symptom scores, les acid regurgitation, and fewer days and nights with heartburn. (1920)

Sucralfate (Carafate), a prescription put drugs into increases the barrier to acid penetration in the esophagus. However, clinical studies have shown limited or no clinical efficacy for this agent in patients with GERD (14)

HISTAMINE [H.sub.2]-RECEPTOR ANTAGONISTS

A number of RCT have shown that H2RAs, given in standard dosages, are more effective than placebo for relieving heartburn in patients with GERD; within a scarcely any weeks of initiating treatment, up to 70 percent of patients reported symptomatic relief. (1314) No RCT or systematic reviews have compared the having recourse rates of esophagitis symptoms in patients treated with H2RAs or placebo.