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Gastroesophageal Reflux Disease

Barium esophagrams are not useful in reflux. They are good at dysphagia and I will challenge a radiologist to do a lot better than flipping a coin for the majority of reflux patients. Now if you have a carcinoma, they are pretty sensitive; if you have severe esophagitis they are okay; if you have moderate esophagitis they are a little bit worse. The vast majority of patients have low-grade esophagitis, so barium esophagram.

Can it detect Barrett's? The answer is no. The reticular changes in the distal esophagus were suggested as a radiographic sign of Barrett's and when these were assessed, they looked at several large cohorts of patients and combined them and only found that this reticular pattern had a sensitivity of about 26 and a specificity of about 50%. Barium radiography is therefore not that useful for Barrett's and is not that useful for the majority of cases of reflux.

The other thing we don't know when we are dealing with who to scope is what is the instance of Barrett's esophagus. I think we know a lot from Rick's presentation, but when we look at specific endoscopic findings.

Does it matter whether or not you have esophagitis on how well you are going to do on medical therapy? I think not. This is a study that looked at quality of life and illness behavior of patients with reflux, either with or without esophagitis. They had 66 patients who had esophagitis or strictures; they had 53 patients who didn't. When they looked at the quality of life alterations using both general wellness surveys and using disease-specific gastrointestinal surveys, people with esophagitis had no difference in illness behavior or alteration in quality of life compared to those without. Both of these were low, less than the norm, actually less than most illnesses except for severe chronic heart disease and psychiatric in-patients. A lot of reflux patients are measurable to have an altered quality of life, but endoscopy does not predict that. Also, the natural history of reflux disease without esophagitis gives us some questions of using endoscopy as a predictive factor on how people are going to do. There was a small study of only 33 patients, followed for three to six months after a negative EGD and a positive pH test, so they had reflux; they had nonerosive reflux disease, or NERD, as I am beginning to call it. They were treated with a modest regimen of either a prokinetic or antacids; this was a study that was published a few years ago. Nineteen of these 33 were still symptomatic at follow up, which I think was about one year, but 5 had developed esophagitis, so out of the 33, 5 had gone on to develop esophagitis essentially on something not a lot better than a placebo. However, 14 of these 33 were now asymptomatic, so it is really hard to say that esophageal endoscopy itself really guides your therapy. I think the role for endoscopy is the diagnosis of Barrett's and that is just in the application of therapy to strictures.

What about treatment? Acid suppression is the mainstay of treatment. We made some changes in our statement, one by moving proton pump inhibitors above H2 blockers. I believe that they provide the most rapid symptom relief in the highest percentage of patients. H2 blockers still work in a lot of patients and they are effective in patients with less severe reflux disease.

H2 blockers work in a lot of people - 40 to 60%. Interestingly enough, placebo is effective in probably about 25%; this is probably due to lifestyle changes, getting to know your drug coordinator well and wanting to please your doctor in these studies more than anything else, but placebo does work in some patients. This is an important concept. I think that when you are walking all factors would indicate this to be a cost effective approach.

Combination therapy is very expensive. We see a lot of patients who come to us on a combination of H2 blockers and a promotility agent. This is quite expensive therapy; it runs for an eight-week course at well more than $100 a month and it is not as effective as once daily proton pump inhibitors. I really don't believe in combination therapy for reflux except for the bloated, dyspeptic patient who may benefit somewhat from a protmotility agent and somewhat from an acid blocker. If you double up the proton pump inhibitor therapy, you go way over 90%, and the cost obviously goes up. The combination of a proton pump and a promotility agent is actually even more expensive and the efficacy does not quite reach that of b.i.d. proton pump inhibitors. The PPI's are the way to go in most patients. Whether you step up or step down therapy remains poorly understood, even from the cost effective standpoint.

The next guideline I would like to briefly touch on is maintenance therapy. That is the key thing, because we have heard that reflux is a chronic disease. I tell my patients that this is like hypertension and diabetes; it is something that you are going to deal with. It is a chronic condition and continuous therapy is required.

Surgical therapy for reflux. There is now comparison between proton pump inhibitors and surgery. These patients were put into remission on proton pump inhibitor therapy. Three hundred patients were randomized to surgery or omeprazole. At the end of three years, the surgical group maintained a consistent, statistically significant high percentage of people, 80 versus about 70, in symptomatic remission compared to once daily PPI. If you are allowed to increase the PPI dose to two or three times daily, these slides become unified. If you increase the dose, you can really control people as well on PPI. From the financial standpoint, in four Scandinavian countries, it all depended on whether it was a country where drugs were expensive, in which case surgery looked cheaper. If it was a country where surgery was expensive, drugs looked cheaper. It takes probably somewhere between 5 and 10 years to recoup the cost of surgery. However, this is the first comparison, and hopefully we will see it in manuscript form soon.

Two final points and then I will finish. Refractory GERD to therapy is extraordinarily rare. If you see a patient who does not respond to high-dose proton pump inhibitor therapy, reconsider the diagnosis before you send them off for surgery. These patients do poorly with surgery. The patient who does well with surgery is the one who is well controlled and you decide to use it as a maintenance.

Finally, just one word on extraesophageal manifestations of reflux; they are common and Rick has already talked about it. I think that when you get past cardiac disease, it is the most common cause of noncardiac chest pain. Cough, hoarseness and asthma are more difficult.