Gastroesophageal reflux disease. When antacids aren't enough

Gastroesophageal reflux disease is a very common condition that is usually manifested by heartburn or regurgitation. Reflux esophagitis, caused by mucosal exposure to the backflow of caustic gastric contents, is primarily a result of lower esophageal sphincter dysfunction. Diagnostic workup varies but commonly includes esophagoscopy, 24-hour esophageal pH monitoring, and radiography of the upper gastrointestinal tract. Treatment, which progresses from simple life-style changes and antacids to histamine2 receptor antagonists to omeprazole (Prilosec) or surgery, is tailored to individual needs and is generally successful.

[Barrett's esophagus does not revert after medical or surgical therapy for gastroesophageal reflux]

An evaluation was made of 34 patients having Barrett's oesophagus. Medical therapy consisted of antacids, H2 blockers, orthopramides, and postural measures (20 cases, mean follow-up 2.9 years). A Nissen fundoplication was done in 14 cases (mean follow-up 2.5 years). Clinical, endoscopic and histologic evaluation was done in all patients and pH measurements also done in all operated cases. Clinical results have been excellent in 70% of medically treated patients and in 100% of surgically treated ones, pH measurements were between normal limits in all operated patients. However, recovery of the normal epithelium did not occur in any case, except for some partial improvement in one patient treated surgically.

[Endoscopic control of balloon dilatation of the pylorus]

After resection of a cardia carcinoma a gastric obstruction was observed. Because of a severe esophagitis the planned operation could not be performed. In the following a method of palliative treatment of pyloric dysfunction is described. Under fluoroscopic control a stiff balloon catheter was introduced into the stomach. Under endoscopic control a guide wire fitting the central lumen of the balloon catheter was passed into the pylorus by use of a biopsy forceps. Under endoscopic and fluoroscopic control the guide wire was positioned in the duodenum. Than the balloon catheter was passed through the pylorus both, under endoscopic and fluoroscopic control and inflated. No complication was observed. After dilatation of pylorus the patient was able to take food as usual. In the following weeks the esophagitis was treated and the pyloroplasty was performed successfully.

[Characteristics of the clinical course, diagnosis and treatment of reflux esophagitis in pregnancy]

Evaluation and treatment of 55 pregnant women with reflux esophagitis have shown that the disease is common in patients with gastrointestinal diseases, but it may occur in normal women. Exacerbations in most patients were seen with advancing gestational age. Early identification of reflux esophagitis and preventive care will help normal delivery.

[Gastroesophageal reflux and peptic esophagitis]

This review focuses on the advances made in the pathophysiology, diagnosis and treatment of gastroesophageal reflux disease. During the last five years, the factors responsible for the disease have been extensively investigated and are now relatively well understood. Little progress, however, has been made with regard to diagnostic techniques, but the roles of endoluminal pH-monitoring and esophageal manometry have greatly increased. Finally, the therapy of the disease has substantially been improved, particularly by the availability of new antisecretory and prokinetic compounds such as omeprazole and cisapride.

[Does Barrett's esophagus regress after effective treatment of gastro-esophageal reflux?]

Regression and disappearance of Barrett's esophagus are a rare event of which there are only three well documented cases in the literature. Two cases are described in this study.

Treatment approaches to reflux oesophagitis

The management of oesophageal reflux disease can and should be highly individualised, depending on the severity of the disease. Mild occasional symptoms of heartburn can often be controlled with conservative measures or changes in diet and antacids. For patients with erosive or ulcerative oesophageal disease, it is becoming clear that acid plays a crucial role in injury and that suppression of acid enhances healing. Antipeptic dosages of histamine receptor antagonists achieve good relief of symptoms but may not always heal erosive oesophagitis. Healing rates are improved with the use of new hydrogen-potassium adenosine triphosphatase (ATPase) pump inhibitors which suppress virtually all acid production. The recurrence of disease is common after acid suppression therapy is discontinued, suggesting the need for some form of long term maintenance therapy. Promotility drugs, which improve oesophageal motility, have inconsistent results in clinical trials and have been associated with a higher rate of adverse drug effects in comparison with acid-suppressive therapies. Surgical treatment should still be considered for patients with chronic recurrent disease who do not respond well to pharmacological therapies.

[Diagnosis and endoscopic treatment of reflux esophagitis]

The article analyses the use of endoscopic selective drug denervation of the stomach (ESDDS) in 58 patients with reflux esophagitis. Complex appraisal of the efficacy of the treatment showed the result to be good and satisfactory in one month in 96.4% of cases and 6 month after ESDDS in 89.1% of cases; the respective values in the same terms after nonoperative treatment were 66.7% and 54.5%. The pathogenetic substantiation of the use of ESDDS is the arrest of the flow of pathological vegetative impulses due to its action, which promotes restoration of regulation of the main functions of the gastroesophageal system which become almost natural, and normalizes processes of autocleansing of the esophagus. The method may be recommended for treating active manifestations of reflux esophagitis and preventing recurrences, including cases of its combination with duodenal ulcer.

[Role of conservative therapy and surgical treatment in disease caused by gastroesophageal reflux]

A series of 82 subjects affected with reflux esophagitis is presented. Gastroesophageal reflux and peptic esophagitis were discovered and staged by contrast meal and endoscopy with biopsy. All patients underwent medical therapy based on drugs affecting gastroesophageal motility and acidity of gastric content: this therapy was administered for three months, then was performed a control endoscopic examination. Endoscopic recovery of esophagitis allowed a long term maintenance therapy, endoscopically controlled every year. When esophagitis persisted, cycles of medical attack therapy, were repeated. surgical operation was performed in 15 cases in which either three cycles of medical therapy failed to improve esophageal lesions, or when endoscopy showed worsening esophagitis.

[Physiopathology and diagnostic methods in esophagitis due to reflux]

Several sensitive and specific methods are now available for the investigation of gastro-oesophageal reflux and oesophagitis. Nevertheless, judicious medical or surgical management requires a good understanding of the pathophysiological aspects of these conditions and of the significance of the investigation results.

[Gastroesophageal reflux: diagnostic and therapeutic approach in tropical regions. Apropos of 33 case reports]

The authors report on 33 cases of which two were operated by 270 degrees fundoplication. Then they clinically study reflux gastroesophagitis and underline the great interest of Trendelenburg maneuver in X Ray case-finding of this syndrome. Finally, some modern methods of exploration are detailed, such as manometry, pH metry, scanning, their respective advantages and their usages in a tropical environment. They draw conclusion that symptomatology and X Ray ease a correct approach of reflux gastroesophagitis, in absence of any organic lesion. The only problem remaining, because of the lack of exploratory means, is how to evaluate, during the post-operative period, the surgical technics applied.

Healing, relapse rates and prophylaxis of reflux esophagitis

Gastroesophageal reflux is a daily occurrence in the general population. Reflux esophagitis is less common but still a considerable clinical problem. The results of medical therapy are generally clearly inferior to those seen in peptic ulcer disease. After healing relapse is rapid and maintenance has not been proved superior to placebo. The promising results with omeprazole (inducing pronounced acid inhibition) and surgery (strengthening anti-reflux mechanisms) indicate that a more aggressive approach may be needed in future treatment. Additional studies also using combinations of drugs both in the healing stage and during maintenance is needed. These should be compared to the long-term results of surgery.