How to Treatment Gastric Reflux

How to Treatment Gastric Reflux - Patients with GERD (Gastroesophageal Reflux Disease) may display symptoms described as (a) typical, (b) atypical, or (c) alarm. Table 34–2 summarizes each of these clinical presentations of GERD. The severity of the symptoms of gastroesophageal reflux does not always correlate with the degree of esophagitis, but it does correlate with the duration of reflux. Patients with nonerosive disease may have symptoms as severe as those with endoscopic findings. It is important to distinguish GERD symptoms from those of other diseases, especially when chest pain or pulmonary symptoms are present. Interestingly, close to half of patients presenting with chest pain who have a normal electrocardiogram have GERD. Similarly, approximately half of patients with asthma have GERD.


Patients presenting with asthma (especially nocturnal asthma) that is poorly responsive to standard medical therapies should be evaluated to determine if GERD contributes to their symptoms. Pulmonary symptoms result from either direct irritation of the vagus nerve when refluxed acid comes in contact with the esophageal mucosa, causing bronchospasm (the reflex theory) or, less commonly, from aspiration of the refluxate into the lungs, causing chemical irritation that manifests as pneumonia or pulmonary fibrosis (the reflux theory). As previously mentioned, patients who are inadequately treated for GERD may go on to develop complications from long-term acid exposure.

Long-term, recurrent reflux symptoms that are not ade quately treated may lead to the development of Barrett’s esophagus and may be an independent risk factor for the development of esophageal adenocarcinoma. Esophageal strictures may be present in patients presenting with dysphagia. However, these symptoms may occur in other esophageal disorders such as esophageal diverticulum, achalasia, obstruction, esophageal spasm, esophageal infections, scleroderma, and malignancy. The presence of alarm symptoms should be further investigated to differentiate other diseases as the cause.

The most useful tool in the diagnosis of gastroesophageal reflux is the clinical history, including both presenting symptoms and associated risk factors. Patients presenting with mild, typical symptoms of reflux (heartburn and regurgitation) do not usually require invasive esophageal evaluation. These patients generally benefit from an initial empiric trial of acid-suppression therapy. A clinical diagnosis of GERD can be assumed in patients who respond to appropriate therapy.1 Further diagnostic evaluation should be performed in those patients do not respond to therapy, for those who present with alarm symptoms (e.g., dysphagia, weight loss), and in those with long-standing GERD symptoms. Alarm symptoms may indicate more complicated disease and long-standing GERD symptoms increase the risk for Barrett’s esophagus.

Useful tests in diagnosing GERD include endoscopy, ambulatory reflux monitoring, and manometry. Endoscopy is the preferred technique for assessing the mucosa for esophagitis, identifying Barrett’s esophagus and diagnosing complications. It enables visualization and biopsy of the esophageal mucosa. Although endoscopy is a highly specific test, it is not extremely sensitive. In mild cases of GERD, the esophageal mucosa may appear relatively normal. In addition, noninflammatory GERD and major motor disorders may be missed by endoscopy. A camera-containing capsule swallowed by the patient offers the newest technology for visualizing the esophageal mucosa. The PillCam ESO is less invasive and takes less than 15 minutes to perform in the clinician’s office. Images of the esophagus are downloaded through sensors placed on the patient’s chest that are connected to a data collector. The camera-containing capsule is passed in the stool.

Although less expensive than endoscopy, barium radiography lacks the sensitivity and specificity needed to accurately determine the presence of mucosal injury or to distinguish between Barrett’s esophagus and esophagitis. For these reasons, barium radiography has limited use in the routine diagnosis of GERD. Unfortunately, the presence or absence of mucosal damage does not prove the patient’s symptoms are reflux related; for that, ambulatory reflux monitoring is useful.

Ambulatory pH testing identifies patients with excessive esophageal acid exposure and helps determine if symptoms, both typical and atypical, are acid related. However, pH monitoring may be less reliable in confirming laryngopharyngeal reflux. Interestingly, patients may have severe symptoms, including esophagitis, even when total acid exposure is considered normal.1 Ambulatory pH testing may also be useful in patients who are on what is considered adequate therapy, but whose symptoms are not improving. However, GERD that is truly refractory to medical therapy is uncommon. Ambulatory pH testing can be performed by passing a small pH probe transnasally and placing it approximately 5 cm above the LES. Patients are asked to keep a diary of symptoms that later are correlated with the pH measurement corresponding to the time the symptom was reported. 

In addition to correlating symptoms to abnormal esophageal acid exposure, ambulatory pH testing also documents the percentage of time the intraesophageal pH is below 4 and determines the frequency and severity of reflux. Two recent developments related to ambulatory reflux monitoring include (a) the use of combined impedance and acid testing and (b) the use of a tubeless method of acid monitoring. Whereas ambulatory pH testing only measures acid reflux, combined impedance and acid testing measures both acid and nonacid reflux. This may be useful when evaluating patients on acid suppression therapy.

The second method involves the attachment of a radiotelemetry capsule to the esophageal mucosa. The advantages of this method are that a longer period of monitoring is possible (48 hours) and it is more comfortable for the patient because a nasogastric tube is unnecessary. The empiric use of standard- or even double-dose proton pump inhibitor (specifically omeprazole) as a therapeutic trial for diagnosing the presence of GERD may be useful in patients with atypical symptoms. This approach is less expensive, more convenient, and more readily available than ambulatory reflux monitoring. Problems with using a proton pump inhibitor as a diagnostic tool include lack of a standardized dosing regimen and duration of the diagnostic trial.

Esophageal manometry may be used to ensure the proper placement of esophageal pH probes and to evaluate esophageal peristalsis and motility prior to antireflux surgery. To perform manometry, a multilumen pressure sensing tube is passed into the stomach and the pressures are measured as the tube is pulled back across the lower esophageal sphincter, esophagus, and pharynx. The recent advancement of the tubeless pH monitoring system using endoscopic landmarks for placement may negate the need for manometry
for ensuring proper placement of esophageal pH probes.

General Approach to Treatment

The treatment of GERD is categorized into one of the following modalities: (a) lifestyle modifications and patient-directed therapy with antacids, nonprescription H2-receptor antagonists, and/or nonprescription proton pump inhibitors; (b) pharmacologic intervention with prescription-strength acid suppression therapy; (c) and interventional therapies (antireflux surgery or endoscopic therapies; Table 34–3). The initial therapeutic modality used is in part dependent on the patient’s condition (frequency of symptoms, degree of esophagitis, and presence of complications).



Historically, a step-up approach was used, starting with  noninvasive lifestyle modifications and patient-directed therapy, and progressing to pharmacologic management or interventional approaches (Table 34–4). A step-down approach, starting with a proton pump inhibitor given once or twice daily instead of an H2-receptor antagonist, and then stepping down to the lowest degree of acid suppression needed to control symptoms, is also effective. Neither the “step-up” nor the “step-down” approach has superior efficacy over the other.



The clinician should determine the most appropriate approach for the individual patient. Every attempt should be made to aggressively control symptoms and to prevent relapses early in the course of the patient’s disease in order to prevent the complications that are seen with long-standing symptomatic GERD. In patients with moderate to severe GERD, especially those with erosive disease, starting with a proton pump inhibitor as initial therapy is advocated because of its superior efficacy over H2-receptor antagonists. 

Dietary and lifestyle modifications with education about factors that may worsen GERD symptoms is reasonable to discuss with the patient even though they are unlikely to control the patient’s symptoms in most cases. Table 34–5 lists many of the lifestyle modifications that can be recommended. Although most patients do not respond to lifestyle changes alone, education about their potential benefits should be stressed on a routine basis. Patients with mild or infrequent symptoms may see improvement with the inexpensive nonprescription H2- receptor antagonists, proton pump inhibitors, antacids, or alginic acid.

Patients who do not respond to lifestyle modifications and patientdirected therapy after 2 weeks should seek medical attention and are generally started on empiric therapy consisting of an acid-suppression agent. Acid-suppression therapy with proton pump inhibitors or H2- receptor antagonists is the mainstay of GERD treatment. Patients presenting with moderate to severe symptoms (with or without esophageal erosions) should be started on a proton pump inhibitor as initial therapy because it provides the most rapid symptomatic relief and healing in the highest percentage of patients. H2-receptor antagonists in divided doses are effective in patients with mild GERD. Standard H2-receptor antagonist doses may be increased to 2 to 4 times the normal dose in patients who do not respond to standard doses. However, if this is necessary, it is more cost-effective to switch to a proton pump inhibitor.

Promotility agents are not as effective as acid-suppression agents. Combining promotility agents with acid-suppression drugs offers only modest improvements in symptoms over standard doses of H2- receptor antagonists and should not be routinely recommended. In addition, the availability of a promotility agent that has an acceptable adverse effect profile is lacking. Mucosal protectants, such as sucralfate, have a very limited role in the treatment of GERD. Maintenance therapy is generally necessary to control symptoms and to prevent complications. In patients with more severe symptoms (with or without esophageal erosions), or in patients with other complications, maintenance therapy with a proton pump inhibitor is most effective.

Routine use of combination therapy has no role in maintenance therapy of GERD. GERD that is refractory to adequate acid suppression is rare. In these cases, the diagnosis should be confirmed through further diagnostic tests before longterm, high-dose therapy or interventional approaches (antireflux surgery or endoscopic therapies) are considered.

Salam

by Umaee
Source: Pharmacotherapy 7th
image: realresultswsl.com
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1 comments:

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