Prävalenz und natürlicher Verlauf der gastroösophagealen Refluxkrankheit

[Conservative Therapy of Reflux Disease and its Limits]

Gastrooesophageal reflux disease (GORD) is common. Proton pump inhibitors (PPI) are regarded as first line therapy for all clinical manifestations. However, their efficacy is inadequate for at least 30% of patients and they are occasionally poorly tolerated. Moreover, some patients would prefer an alternative therapy. Alginate cause mechanical reflux inhibition by forming a gelatinous layer in the so-called acid pocket, an acid reservoir that forms on the surface of the chyme in the gastric corpus immediately after food intake. They may be used an alternative to treat the symptoms of uncomplicated GORD and as an add-on to PPIs if these do not improve symptoms adequately. If the reflux symptoms persist or if reflux oesophagitis does not heal, differentiated diagnostic testing must be performed, using endoscopy and functional analysis. Extraoesophageal manifestations of GORD include cough, compulsive clearing of the throat, problems with the voice and globus sensation. These often do not respond to antireflux therapy. Recent data indicate that these are complex hypersensitivity syndromes and that reflux is only one of several possible triggers.

[Gastro-oesophageal reflux disease-update 2021]

Gastro-oesophageal reflux disease (GORD), a highly prevalent disease, is defined by troublesome symptoms and/or oesophageal lesions caused by reflux of gastric content. A diagnostic gold standard does not exist. A reliable diagnosis may be difficult in individual cases. Patients' history, endoscopic findings and pH-impedance monitoring contribute to the evaluation of gastro-oesophageal reflux and its consequences. High-resolution manometry may add important information on the pathophysiology of the disease and may help to rule out motility disorders as the leading cause of the symptoms. Proton pump inhibitors (PPI) are the drugs of first choice. In patients with insufficient PPI response, optimization of PPI therapy and/or combination with drugs having another mechanism of action are the available options. If PPIs are not sufficiently effective, not tolerated, or not wished antireflux procedures may be offered in specialized centers taking pathophysiological data into account.

[Gastroenterological diseases as triggers of chest pain]

BACKGROUND

Non-cardiac chest pain is very common and gastroenterological diseases are one of the most important causes. The frequency distribution of the underlying causes depends on the sector of the healthcare system in which it is ascertained. In individual cases it must always be taken into consideration that detection of coronary heart disease, for example, does not exclude another origin of chest pain.

OBJECTIVE

This article provides a systematic review of gastroenterological diseases that can cause chest pain. Furthermore, a management algorithm was developed.

MATERIAL AND METHODS

This article is based on a selective search of the literature.

RESULTS AND DISCUSSION

The most frequent cause is gastroesophageal reflux disease, which is also known as reflux-chest pain syndrome. If there are no clinical alarm signals, treatment is carried out with a proton pump inhibitor either as a diagnostic test or as a probatory therapy. If this initial management does not lead to satisfactory symptom control, extended diagnostics are indicated. In individual cases this concerns the detection or exclusion of a reflux disease, of motility disorders and structural damage to the esophagus as well as diseases of the upper abdominal organs, which can evoke chest pain. After exclusion of these morphologically and/or functionally defined diseases, a so-called functional chest pain is present. The essential mechanisms are altered pain processing, esophageal hypersensitivity and mental comorbidities. The treatment of functional chest pain often proves to be difficult.

[Barrett's esophagus]

Barrett's esophagus is an endoscopically visible metaplasia of the columnar epithelium in the esophagus with histological detection of a specialized intestinal metaplasia. The circumferential and longitudinal extent are described endoscopically using the Prague classification. Barrett's esophagus mostly occurs as the result of gastroesophageal reflux disease. The risk of developing esophageal adenocarcinoma is increased but the absolute risk is low with 0.10-0.15 % per year. According to guideline recommendations, screening for Barrett's esophagus as well as endoscopic and biopsy surveillance should be limited to high risk groups. On detection of intraepithelial neoplasia (IEN) endoscopic therapy is indicated, whereby a second opinion must be obtained from a specialized pathologist for low-grade IEN. The influence of proton pump inhibitors on the progression to carcinoma is controversially discussed and a preventive anti-reflux operation is not indicated.

[Insufficient symptom control under long-term treatment with PPI in GERD - fact or fiction?]

BACKGROUND

Randomized controlled trials show that patients with gastroesophageal reflux disease (GERD) and treatment with proton pump inhibitors (PPI) in about 30% of the cases complain about persisting reflux symptoms (heartburn, regurgitation). The aim of the study was to evaluate the efficacy of PPI long-term treatment in patients with GERD in the family doctor's office.

METHOD

Patients with GERD and a PPI therapy of at least one year participated in a prospective, multicenter observational study. The patients obtained a questionnaire together with a further prescription of PPI. They were asked about the intensity and frequency of heartburn, regurgitation and sleep disorders due to reflux symptoms, satisfaction with PPI therapy, diagnostics performed up to now (endoscopy, pH monitoring, manometry) and surgical consultation. The questionnaire included a validated instrument for the diagnosis of GERD (GerdQ). Patients with the diagnosis "GERD " according to the questionnaire who were very dissatisfied with their current PPI therapy (score 1 or 2 on a 5-point Likert scale) were defined as "lost patients " (LOPA).

RESULTS

39% of the patients still suffered from heartburn at least two days a week, 30% of regurgitation. In 22% of the patients, reflux symptoms led to sleep disorder at least two days a week. 20% of the patients were very dissatisfied with the current PPI therapy. 70% of them (= 14% of the total patient population) were "lost patients " according to the definition. An endoscopy was performed in 86% of the patients and function diagnosis (pH monitoring ± manometry) in 8%. A surgeon was consulted in 8% of the patients, a third of which had received function diagnosis before.

CONCLUSIONS

A poor symptom control can often be found in GERD patients with PPI long-term therapy, but does not stand out in the daily routine. So diagnosis will not continue and treatment alternatives will not be searched for. In the future quality of treatment should be verified e. g. by questionnaires.