Symptoms consistent with gastroesop...

Symptoms consistent with gastroesophageal ebb disease (GERD) are extraordinarily everyday and treatment of GERD is an important aspect of primary care medicine. Therapeutic options range from patient-driven lifestyle changes and as-needed use of over-the-counter (OTC) agents, between the walls of therapy with powerful prescription mix with drugss up to new endoscopic and surgical treatments. In this issue of American Family Physician, Heidelbaugh and associates (1) provide a well-written, comprehensive review of the treatment of GERD However, a not many additional comments are appropriate.

on the time of the initial visit, most numerous patients with GERD symptoms have tried antacids, and many have used OTC histamine-[H.sub.2] receptor antagonists (H2RAs). Sophisticated patients also may have researched the bring under rule of GERD and attempted lifestyle changes. The family physician is then left to make couple major decisions: (1) Should the patient have endoscopy to direction out complications of GERD? (2) Which prescription medication should the patient receive? Heidelbaugh and colleagues (1) appropriately husband endoscopy for patients who have "warning" symptoms or who are at risk for Barrett's esophagus.

If splendor were not a factor, once-daily proton cross-examine inhibitor (PPI) therapy would be the initial treatment of choice, because it is clearly superior to twice-daily H2RA therapy. (2) Reasons for using H2RAs are related primarily to lower expense and, occasionally, intolerance of PPIs (most many times because of headache or diarrhea). With the introduction of generic and OTC PPIs, initial PPI therapy would assume to be an even stronger preferr treatment choice.

PPI therapy should superintend symptoms and mucosal damage in more than 80 percent of patients with GERD This leaves sum of two units groups of patients in whom consideration of alternative therapies would present the appearance reasonable: those whose symptoms are not well controll on medical therapy and those who would rather not remain forward medical therapy because of side forces cost, or personal preference.

Antireflux surgery now is being furnished to more patients, primarily because recuperation is quicker with the newer, laparoscopic approach. further patient selection for surgery remains problematic. a certain data suggest that the best surgical consequence is in patients whose symptoms rejoined completely to PPI therapy. (3) Patients with atypical and refractory symptoms are les likely to have a favorable surgical issue than are those with heartburn and regurgitation, which are well controll by dint of medical therapy. (4)

An important, obvious, on the contrary often over-looked aspect of patient selection for surgery is to be absolutely confident that the patient has GERD Acceptable evidence includes endoscopically documented esophagitis (mucosal breaks, not redness) or an abnormal ambulatory pH proof The presence of typical symptoms and a rejoinder to medical therapy are not sufficient to support the use of surgery In this situation, patients should bear endoscopy and, if the examination is normal, have ambulatory pH testing performed while they are on the farther side medications to make sure that they have pathologic amounts of acid exposure

Contraindications to surgery are related primarily to intolerance of anesthesia. However, antireflux surgery may not be possible in a certain quantity of patients who have had previous upper abdominal surgery and may be les effective in extremely obese patients. (5)

Well-selected patients should have symptoms and esophagitis that are at least as well controll with surgery as with medications. (6) However, surgical therapy does have a certain quantity of downsides. Increasing information suggests that many, if not greatest in number surgically treated patients end up taking ebb medications at some point. For example, long-term follow-up in a form into groups of patients randomized to receive medication or surgery construct that after 10 years, 92 percent of the patients randomized to medical therapy were still taking medication, and 62 percent of the patients initially treated with surgery were again taking antireflux medications. (7)

Furthermore, postoperative symptoms are frequent and include dysphagia, (8) difficulty with belching, increased flatulence, and diarrhea. (9) Although mortality from antireflux surgery is subdued death can occur in approximately united of 1,000 patients. (10,11) Safety and efficacy appear to be greater when antireflux surgery is performed according to a surgeon who has done the operation 50 or more times. (10) When counseling patients, I recount them that even when antireflux surgery is performed from an experienced surgeon, new, annoying symptoms may befall in 10 to 20 percent of patients, significant, life-altering symptoms may unfold in 1 to 2 percent of patients, and death may present itself in 0.1 percent of patients. (6-9)

The introduction of endoscopic techniques for controlling ebb generated a great deal of excitement. Radiofrequency application (Stretta procedure) is designed to increase the ebb barrier of the lower esophageal sphincter. At one-year follow-up in the greatest degree patients in the first cohort treated with this technique reported improvement of symptoms, nevertheless 34 percent were again taking PPIs, and an additional 38 percent were regularly taking antacids. (12)