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There are several available diagnostic options to evaluate patients with suspected gastroesophageal reflux, whether acid, weakly acid, or nonacid. The appropriate application of these technologies is the subject of much discussion among experts. Thoughtful use of reflux monitoring is of great benefit in the evaluation of patients with endoscopy-negative disease reflux symptoms that are resistant, recurrent, or refractory to standard or double-dose antisecretory therapy; patients with distinct, atypical symptoms such as cough, laryngitis, chest pain, globus, or regurgitation in whom heartburn is infrequent or absent; patients who are seeking surgical or endoscopic corrective procedures to treat their symptoms; and those with recurrence of symptoms after undergoing surgical procedures. Reflux monitoring may be useful in avoiding an incorrect diagnosis of gastroesophageal reflux disease (GERD) and in management of patients with Barrett's esophagus. This article will review the current clinical applications of reflux monitoring in patients with GERD. more...

Although the balance of epidemiologic data supports a relationship between obesity and gastroesophageal reflux disease (GERD), it is difficult to establish true cause and effect. However, results of several studies show that the frequency and severity of GERD symptoms and complications may be higher in obese patients, including an increase in the presence of hiatal hernia. Additionally, findings of a recent meta-analysis demonstrate a statistically significant increase in the risk for GERD symptoms, erosive esophagitis, and esophageal adenocarcinoma in obese patients. No definitive study is available, however, to suggest deviating from standard GERD screening or treatment guidelines for the obese patient. Physicians should approach obese patients with GERD as they do those with reflux disease and ideal body weight. The recommendation of weight loss for the obese patient with GERD is reasonable to improve GERD physiology and symptoms. Lifestyle modifications and medical therapy with a proton pump inhibitor (PPI) once daily before breakfast for 4 to 8 weeks should be initiated. Antireflux surgery is always an option for patients with GERD who have a symptomatic response to PPIs. Prospective studies directed at the obese patient are needed to determine if different approaches are required. more...

The consequences of nocturnal gastroesophageal reflux disease (GERD) may be greater than daytime GERD in terms of clinical complications such as increased risk of esophageal lesions and respiratory conditions, as well as issues of health-related quality of life, sleep, work productivity, and economics. Proton pump inhibitors (PPIs) are the most effective therapy for patients with GERD; however, treatment success is greater in the improvement of daytime symptoms and acid control. Acid suppression of most PPIs, which are administered once daily before breakfast, wanes during the nighttime hours. Although nighttime heartburn improves with once-daily PPI treatment, PPIs are unable to eliminate nighttime heartburn completely. Increasing the dose of a PPI provides longer acid suppression, but the benefits have not been shown to be consistently greater than standard once-daily dosing. Twice-daily dosing, with a dose given before bedtime, would extend the duration of acid suppression into the nighttime hours; however, nocturnal acid breakthrough remains an issue. As a result, improved PPIs that will more reliably control nighttime symptoms and provide on-demand relief have been developed and studied. These newer PPI formulations offer significant hope for the advancement of treatment opportunities. more...

Maximizing therapy for the patient with symptomatic gastroesophageal reflux disease (GERD) and optimizing efficacy of available agents in the difficult or refractory patient requires an understanding of antisecretory pharmacology and pharmacodynamics. Recent studies raise issues related to potential side effects of proton pump inhibitors (PPIs). Non-acid reflux and its potential association with symptoms must be considered in the management of refractory patients. Medical therapy of GERD is discussed, emphasizing optimizing antisecretory therapy, reviewing recent studies addressing potential side effects of PPIs and options for treatment of non-acid reflux. more...

A clinically important subset of patients with erosive esophagitis will not attain adequate symptom relief and healing on once-a-day proton pump inhibitor therapy. This is especially true in patients with frequent and nocturnal heartburn and in those with Los Angeles Grades C and D erosive esophagitis. The approach to evaluation and management of cases of refractory or difficult gastroesophageal reflux disease is the subject of this state-of-the-art review. more...

Although heartburn and regurgitation are the most common symptoms of gastroesophageal disease (GERD), several laryngeal, pharyngeal, and pulmonary symptoms, collectively known as laryngopharyngeal reflux, have also been associated with this disease. However, the case that GERD is the cause of these symptoms is difficult to make because neither endoscopy nor prolonged reflux monitoring has shown consistent evidence of either esophageal injury or abnormal reflux frequency. To date, there have been few controlled trials of antireflux therapy, and the data that are available are conflicting. Nevertheless, gastroenterologists are often confronted with difficult-to-manage patients with extraesophageal symptoms that are considered to be the result of GERD. This article reviews the current literature on this topic and discusses the author's approach to treating these patients. more...

The patient with extraesophageal manifestations of gastroesophageal reflux disease presents a clinical challenge. Symptom presentation overlaps with other otolaryngologic and pulmonary disease, and heartburn might be infrequent or absent. Endoscopy and pH monitoring are insensitive and therefore not useful in many patients as diagnostic modalities. Thus, antisecretory therapy is used as both a diagnostic trial and as therapy in the majority. Attention to optimizing therapy and judicious use of endoscopy and reflux monitoring are needed to minimize cost and maximize success. more...

The primary controversy regarding Barrett's esophagus (BE) relates to what form of therapy is "best" and, more importantly, whether any therapy results in the regression of abnormal epithelium or reduces the rate of progression to dysplasia and/or adenocarcinoma. The current standard of practice suggests that patients with BE should be treated in a similar fashion as patients with typical gastroesophageal reflux disease, that is, with antisecretory agents as needed to provide complete symptom relief. The most recent guidelines from the American College of Gastroenterology point out that there are no prospective studies that support any alternative approach to treatment (ie, neither high-dose acid suppression nor antireflux surgery has demonstrated reduced risk of dysplasia or esophageal adenocarcinoma). However, accumulating evidence suggests that simply controlling symptoms is inadequate. more...

As a drug class, proton pump inhibitors are excellent pharmacologic agents for the treatment of gastroesophageal reflux disease. All 5 of the agents discussed here are exceptionally effective, so much so that cost has often superseded other outcome measures as a primary reason for the choice of agent. This article reviews other important outcome measures including control of intragastric pH, healing, symptom relief, improvement in quality of life, sleep, and increase in work productivity in an effort to "move beyond cost" in decision-making related to patient care. more...

Potential interventions for gastroesophageal reflux disease include lifestyle modifications, antacids, mucosal protectants, prokinetic (promotility) agents, H2 receptor antagonists (H2RAs) and, the agents of choice in 2003, proton pump inhibitors (PPIs). This article reviews the current state of the art in use of these agents. Lifestyle changes, though sound in their intent and in many cases based on solid laboratory research, can today be considered only adjuncts to pharmacologic therapy. The mainstay of pharmacologic therapy in 2003 is antisecretory therapy. Both H2RAs and PPIs inhibit acid secretion and raise intragastric pH. H2RAs only block one receptor, have limited effect on acid reduction, and are relatively weak inhibitors of meal-stimulated acid secretion. PPIs provide superior control of intragastric pH over a 24-hour period compared with H2RAs and effect greater symptom relief and healing. more...

Intragastric pH monitoring has become an important tool, used in the clinical laboratory to assess pharmacodynamic profiles of antisecretory agents. The technique is standardized, reproducible, and reliable. We have been able to compare antisecretory agents head-to-head, develop an understanding of interindividual variability in pH control with proton pump inhibitors, evaluate the role of H. pylori and its effect on intragastric pH, and gain insight into the potential role of genetic variation in cytochrome p450 status and its effect on pH control. These laboratory experiences can be used in clinical practice to aid in management of patients with gastroesophageal reflux disease. more...

The primary therapeutic endpoint for patients with gastroesophageal reflux disease is complete relief of symptoms and improvement in quality of life. The withdrawal of cisapride has created a vacuum in the prokinetic market, with few promising drugs in the pipeline. Reflux inhibitors are being considered for clinical trials, but as of yet are unavailable. Proton pump inhibitors (PPIs) continue to be the backbone of therapy for acid suppression, providing excellent relief of symptoms and healing of erosive esophagitis. Isomeric technology with esomeprazole as the prototype represents an advance in PPI pharmacology. Antireflux surgery is now more patient-friendly, with shorter hospitalization and less major morbidity compared to open fundoplication, but surgery is at best equal to medical therapy when optimal doses of antisecretory therapy are used. Two endoscopic procedures were recently approved by the U.S. Food and Drug Administration for treatment of gastroesophageal reflux disease: radiofrequency energy delivery to the gastroesophageal junction, and transoral flexible endoscopic suturing. These techniques should be used selectively until we have more data and until results are compared to the safe and highly effective medical therapies. more...

Gastroesophageal reflux disease (GERD) is defined as chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus; heartburn, its most common manifestation, occurs in 7% to 10% of the U.S. population on a daily basis. In addition, many so-called extraesophageal or atypical symptoms, including chronic cough, laryngitis and other otolaryngologic conditions, asthma, and unexplained chest pain, can be associated with GERD, but these patients appear to have a decreased frequency of heartburn, making the diagnosis of GERD difficult. All patients can be successfully managed with appropriate, titrated use of pharmacologic therapy. Antireflux surgery should thus be considered as an option only for patients who cannot afford or choose not to continue long-term medical therapy and for the rare patient with side effects or resistance to proton pump inhibitors. Endoscopic therapy for reflex should be considered as an experimental technology needing continuing evaluation. more...