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High-grade dysplasia best indicator for progression to esophageal adenocarcinoma
The management of gastroesophageal reflux disease (GERD) has changed greatly over the last few years and it continues to evolve as advances are made in the areas of diagnosis and therapy. At the recent Canadian Consensus Conference on the management of GERD in adults (Update 2004), there was agreement that GERD is the most prevalent acid-related disorder and that it imposes a significant burden of illness, both for individuals and for the health care system. In addition, there was virtual unanimity that the term 'GERD' applies to individuals with reflux of gastric contents into the esophagus causing: (a) symptoms sufficient to reduce quality of life and/or (b) esophageal injury. However, this definition deliberately did not identify specific symptoms or lesions as being pathognomonic of GERD; the importance of this decision is highlighted by Dr. Reza Shaker's commentary (see page 3)on the association between gastroesophageal reflux and respiratory tract abnormalities including cough, wheezing, asthma, laryngitis and pharyngitis. Although heartburn and regurgitation are considered to be the archetypal symptoms of GERD, there is a number of other symptoms, both esophageal and extra-esophageal, that have been associated with the reflux of acidic and of non-acidic gastric contents. Dr. Shaker and Dr. Vakil (see page 1) have both highlighted, firstly, the role of acid reflux in causing symptoms and, secondly, the fact that investigations have a limited role in determining management for many patients. Dr. Vakil pointed out that acid reflux is important in a high proportion of patients with presumed non-erosive reflux disease (NERD) or endoscopy negative reflux disease (ENRD). However, although these patients have, by definition, a normal endoscopy, many will still respond well to effective acid suppression therapy. The low sensitivity of endoscopy for the diagnosis of GERD was recognized by participants in the CAG GERD Consensus Conference and this led them to state that heartburn and acid regurgitation 'can be treated empirically, without further investigation, provided that there are no alarm features. This is consistent with Dr. Shaker's comment that it is difficult to ascertain the role of acid in producing extra-esophageal symptoms without putting the patient on proton pump inhibitor (PPI) therapy. There is a proportion of patients whose symptoms do not respond to effective acid suppression therapy, despite the fact that they appear to be reflux related. The symptomatic response to an initial course of antisecretory therapy should be assessed at four to eight weeks and, if there has been no response, consideration should be given to a trial of double-dose (twice daily) PPI therapy or investigations, such as pH-monitoring or esophageal impedance monitoring, to determine whether the symptoms are truly related to acid reflux. PPIs are still the mainstay of therapy for patients with anything more than mild symptoms and for those with evidence of esophageal injury. The effectiveness of PPIs and H2-RAs for the healing of esophagitis is proportional to their ability to reduce intragastric acidity and, in time, the more potent PPIs are able to achieve healing rates of 85 to 95% after eight weeks of therapy. However, GERD is a chronic condition in many individuals and there is often, therefore, a need for long-term maintenance therapy. Understandably, many individuals would prefer not to have to take medication regularly for many years and there has been, therefore, a wealth of new techniques developed with the aim of preventing gastroesophageal reflux. Endoscopic anti-reflux procedures have provoked particular interest and excitement among gastroenterologists but Dr. Lehman's view (see page 4) appears to be that none of the new procedures is ready for prime time. Endoscopic anti-reflux procedures are most likely to be effective for patients with mild GERD and, like surgical anti-reflux procedures, they probably work best in patients who have already responded to PPI therapy. As a result, they are unlikely to be effective in patients who have been refractory to medical therapy. Thus, despite the ingenuity of the developers and the excitement generated by these new endoscopic techniques, the Canadian GERD Consensus part-icipants stated that the "role of endoscopic anti-reflux therapy procedures for the management of GERD in clinical practice has not been adequately defined" with fair evidence that these procedures should not be used outside the context of controlled clinical trials. Overall, these three commentaries emphasise that, although the management of GERD has progressed significantly in recent years, there remains much to learn about the etiology, symptomatology, diagnosis and management of this, the most common acid-related disorder. Reference |
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