Gastroesophageal reflux disease. (Women's Health Adviser).
In its most serious form, affecting about 10% of gastroesophageal reflux disease (GERD) patients, the constant reflux of acid can cause Barrett's esophagus, a metaplastic change of the esophageal lining that is associated with the development of esophageal cancer.
Diagnosis. GERD is a constellation of symptoms that compose a chronic, lifelong condition. The etiology is unknown, but the symptoms--caused by gastric contents entering the esophagus through the lower esophageal valve--are usually associated with large or high-fat meals eaten quickly.
Highly specific symptoms include heartburn or regurgitation, or both, more than twice a week and usually occurring after meals, especially large or fatty ones. The symptoms are often aggravated by postural changes such as bending or lying down, and can be relieved by antacids.
When patients present with these symptoms, it's usually reasonable to assume that GERD is present. Offer them a trial of empirical therapy, including dietary and lifestyle modifications. But the following warning signs suggest complicated GERD and should prompt additional diagnostic testing: dysphagia, bleeding, weight loss, choking (acid causing coughing, shortness of breath, or hoarseness), and chest pain.
Ambulatory pH testing, in which a nasoesophageal catheter records the amount of acid entering the esophagus, has a sensitivity and specificity of 90%95% for abnormal acid exposure and is the best method for determining the amount of acid reflux. Endoscopy can identify areas of esophagitis caused by acid reflux.
Treatment. Lifestyle modifications should be considered. Patients should be advised to elevate the head of their bed, so that gravity can help reduce the amount of acid entering the esophagus, and to sleep on their left side. They also should decrease fat intake, eat smaller meals, stop smoking, and avoid lying down for 2-3 hours after eating. Some foods, including chocolate, caffeine, peppermint, and foods high in acid, can aggravate symptoms.
Over-the-counter antacids and histamine type-2 receptor antagonists like famotidine are useful, especially when taken before an activity that may promote symptoms, such as a heavy meal or exercise. Antacids work quickly, but gastric pH begins to rise again less than 30 minutes post dose.
Histamine receptor antagonists are available over the counter in half the strength of their prescription doses. They don't work as quickly as antacids, but their effects are longer lasting. Antacids based on magnesium or aluminum shouldn't be taken with these drugs, as the antacids can decrease absorption of histamine receptor agonists.
Most patients have already tried these measures before they seek physician advice for their heartburn; only about 25% of GERD patients will be able to control symptoms this way Many patients will need treatment with a proton pump inhibitor (PPI) or a histamine type-2 receptor antagonist in prescription strength.
PPIs control symptoms and heal esophagitis in more patients than do histamine receptor antagonists. They also work faster; most people experience relief in days or a few weeks, compared with a month or more with the histamine receptor antagonists. However, the proton pump drugs are more expensive, so where cost is a concern, a histamine receptor antagonist may be appropriate. These drugs control symptoms in 50%-60% of patients.
Promotility drugs, which work by emptying the stomach faster or increasing lower esophageal valve pressure to keep acid out, are prescribed only for those with severe symptoms and are associated with cardiac arrhythmias.
Maintenance therapy. Whatever drug successfully controls the patient's symptoms should be utilized during maintenance therapy. PPIs are safe for long-term therapy; Patients whose symptoms have been well controlled on PPIs, but who want a less expensive drug, also may try a course of a histamine receptor antagonist.
Sources: Dr. Ken DeVault of the Mayo Clinic, Jacksonville, Fla.; and Dr. Philip O. Katz, chief of gastroenterology, Graduate Hospital, Philadelphia; American College of Gastroenterology.
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|Author:||Sullivan, Michele G.|
|Publication:||OB GYN News|
|Date:||Jul 1, 2003|
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