Introduction

Gastroesophageal reflux disease (GERD) is extremely common, although physicians may not see too many patients with this complaint. That's because OTC medication is fairly effective in dealing with the symptoms, and is also relatively cheap. A recent review in the Journal of Family Practice has covered present views on the diagnosis, work-up, and treatment options for the family practitioner.

Prevalence

The nature of the disease is such that most people don't have symptoms every day, making true estimates of prevalence problematical. It's been estimated that symptoms occur in between 21% and 51% of the population in a given year. More helpful is a breakdown according to extremes of frequency:

Rates of GERD Symptoms

	Daily Symptoms	One or More Symptoms a Month
General Adult Population	9%	21%
Obstetric Patients	25%	52%
Men Over 65	8%	54%
Women Over 65	15%	66%

Only 1 patient in 5 who has weekly symptoms goes to the doctor.

Etiology

The principal cause of GERD is lower-than-normal esophageal sphincter pressures, allowing gastric content to reflux into the lower part of the esophagus. The resultant esophagitis causes reduction of normal motility. Helicobacter pylori, though obviously associated with peptic ulceration, seems to have a protective effect against the development of GERD. Sometimes erosions in the epithelium lining the lower esophagus can occur, leading to erosive esophagitis.

A hiatal hernia is obviously a precipitating factor for GERD. Obesity, pregnancy, tight clothing, smoking, fatty food, alcohol, caffeine, chocolate, onions, peppermint -- all may be indicted as triggers for GERD attacks. In some of these, the likely mechanism is fairly clear; with others, it's obscure.

Diagnosis

The simplest way to make the diagnosis is a therapeutic trial of the protein-pump inhibitor, omeprazole. If this drug (40 mg orally each morning and 20 mg each evening, given for 4 weeks) results in symptomatic improvement, there is a high likelihood that the patient has GERD.

Individual symptoms (heartburn, regurgitation, belching, dyspepsia) are not, in themselves, very useful. However, the physician's overall impression is much more reliable. If this impression points towards GERD, a therapeutic trial is indicated.

More invasive tests should be reserved for those patients who don't respond to omeprazole, unless there are what Dr Flynn calls 'red flags' -- signs ands symptoms of obstruction, bleeding, or perforation, and people over 50 who are at a higher risk of cancer.

Twenty-four-hour pH monitoring is preferred over endoscopy, as being more accurate. And the small esophageal tube kept in place for 24 hours is less unpleasant than upper endoscopy. However, endoscopy is indicated for patients with more serious signs -- dysphagia, weight loss, bleeding -- to exclude other pathology.

None of the other tests sometimes recommended (manometry, scintography, esophogram) is superior to pH monitoring or endoscopy as a diagnostic instrument.

Other conditions may be associated with GERD -- e.g. asthma, chronic cough, laryngitis, non-cardiac chest pain -- and treatment of the esophageal reflux can improve or cure them.

Medical treatment

Lifestyle modifications aimed at reducing the impact of precipitating factors are worthwhile. Raising the head of the bed and avoiding postprandial recumbency will lessen the likelihood of lower esophageal acidity. Certain foods and alcohol may be associated with increased reflux in different individuals. Trial and error is often the best approach. Successful treatment of obesity reduces the mechanical grounds for reflux.

Medical treatments include drugs to increase motility (and hence clear acid from the esophagus), acid neutralization, and suppression of acid formation.

The promotility agents include metoclopramide, bethanecol, and cisapride. Today they have been replaced by other, more effective, drugs. Over-the-counter antacids and alginates have been successful, and are still widely used.

The histamine-2 blockers (e.g. cimetidine, rantitidine) have been shown in numerous controlled clinical studies to be effective in healing esophagitis and relieving symptoms. For every 5 GERD patients treated with histamine-2 blockers instead of placebo, one patient benefits; i.e. the 'number-needed-to-treat' (NNT) is 5.

However, the proton-pump inhibitors have the best results in suppressing acid secretion. Their NNT is 2 for short-term treatment, and 3 for long-term treatment of GERD.

Both histamine-2 blockers and proton pump inhibitors appear equally safe. Moreover, there is little to choose between representatives of the same class. Meta-analyses of clinical trials that compare histamine-2 blockers with proton pump inhibitors invariably favor the latter -- improvement rates are 25% vs. 75%. High-risk patients may expect to benefit more from proton pump inhibitors, avoiding possible complications such as esophageal stricture. These results are offset by price differentials -- in general, proton pump inhibitors are, today, about ten times the price of generic histamine-2 blockers.

Surgery

If medical therapy fails, open Nissen fundoplication offers 10-year success rates in 80% to 93% of patients. Laparoscopic surgery is equally successful in the short-term, but long-term results are not yet available.

The prognosis

With today's drugs -- the proton pump inhibitors -- symptoms of GERD are suppressed in over 75% of patients at 1 year. However, sometimes the condition becomes chronic, requiring intermittent medication for flares.

Rarely, GERD leads to esophageal strictures, which may require treatment by appropriate dietary changes and possibly dilatation. Sometimes a condition known as Barrett's esophagus occurs, in which there is metaplasia of the squamous cells lining the lower esophagus into columnar epithelial cells; these can undergo transformation to adenocarcinoma. The actual risk of Barrett's esophagus developing in a patient with chronic GERD is about 3% to 4%, and only about 4% of these cases go on to develop esophageal cancer. Overall, there is a 7- to 10-fold increase in the risk of esophageal adenocarcinoma in people with chronic GERD.