Updates in management of Gastro-esophageal Reflux disease

Abstract

Gastro-esophageal reflux disease (GERD) is the most common disease encountered by the gastroenterologist. This increasingly prevalent disease has been shown to have adverse effect on quality of life and work productivity and interference with daily living. The disease encompasses a broad spectrum of clinical symptoms and disorders from simple heartburn without esophagitis to erosive esophagitis with severe complications, such as esophageal strictures and intestinal metaplasia. The high-pressure zone at the esophago-gastric junction is generated by the lower esophageal sphincter (LES) and the crural diaphragm. Transient LES relaxations are prolonged relaxations of the LES and are the main mechanism underlying gastro-esophageal reflux. Risk factors for GERD include obesity, poor diet, lack of leisure physical activity, consumption of tobacco and alcohol, and respiratory disease. It is often diagnosed based on typical symptoms of heartburn and regurgitation. In addition to these, GERD is increasingly associated with extra-esophageal symptoms, including chronic cough, asthma, laryngitis, dental erosions and sleep disturbances. Due to the poor sensitivity of endoscopy and pH monitoring, and the poor specificity of laryngoscopy, empiric therapy with proton pump inhibitors (PPIs) is now considered the initial diagnostic step in patients. Those who improve with PPIs, GERD is the presumed etiology, but for those who remain unresponsive to such therapy, further diagnostic testing with impedance/pH monitoring may be necessary in order to exclude refractory acid or weakly acid reflux. The first test that patients should have is an upper endoscopy. The exception is the patient with dysphagia. An esophagram first may alert the physician to conditions that may make the endoscopy more complicated. Endoscopy is the mainstay diagnostic and therapeutic tool in the management of GERD. Newer imaging techniques include narrow band imaging, chromoendoscopy, capsule endoscopy, and ultra-thin, unsedated transnasal endoscopy. Multi-channel intraluminal impedance combined with pH monitoring is a promising new technique that can detect both acid and nonacid reflux. Lifestyle changes and empiric medical therapy with a PPI is recommended in mild cases. Medical treatment with PPIs has an excellent efficacy in reversing the symptoms of GERD, but they should be taken for life, and long-term side effects do exist. However, patients who desire a permanent cure and have severe complications or cannot tolerate long-term treatment with PPIs are candidates for surgical treatment. Laparoscopic antireflux surgery achieves a significant symptom control, increased patient satisfaction, and complete withdrawal of antireflux medications, in the majority of patients. Several devices have been developed to create an antireflux barrier endoscopically for the treatment of gastro-esophageal reflux disease (e.g. Radiofrequency Ablation :The Stretta system, Endoluminal Fundoplication: The EsophyX device). Some have failed to provide long-term symptom relief, were associated with clinically important complications, or were otherwise removed from the market. A new device, the Esophyx (Endogastric Solutions, Redmond, WA), provides the closest approximation experimentally to a standard fundoplication. Endoscopic fundoplication seems to be best suited for patients with small hiatal hernias and mild-to-moderate typical symptoms.