Medical therapy of gastroesophageal reflux and management of esophageal strictures

Esophagitis and esophageal strictures

Esophagitis and esophageal strictures are important causes of esophageal disease in dogs and cats. Clinical suspicion is created when the clinician recognizes the clinical signs suggestive of esophageal disease and accounts for historical information and physical examination findings. Once suspected, the diagnosis of esophagitis and esophageal strictures is a fairly simple one in most cases. Although the benefit of diminishing secretion of gastric acid in patients with esophagitis is unquestioned, other questions regarding adjunctive medical treatments, such as sucralfate and glucocorticoids for dogs and cats with esophagitis, have not been answered through appropriate clinical studies. Esophageal strictures are readily treated with balloon dilation or esophageal bougienage, and clients can expect most patients to become functional, although dietary change may be necessary.

Surgical and endoscopic treatment of gastroesophageal reflux disease

There is no evidence to advocate medical or surgical therapy as the best therapy for GERD. The decision to have antireflux surgery must be individualized. All patients taking long-term medications for GERD should receive advice on the safety and wisdom of staying on that therapy and information on antireflux surgery. Fundoplication should be considered in three circumstances [4]: 1. Patients who are intolerant of PPI therapy because of side effects should be considered for surgery. This situation will be less common now with five PPIs, however. 2. Patients who are poorly responsive to PPI therapy should be considered for surgery. This situation is probably not common, given the effectiveness of the currently available PPIs. It is more common in patients with atypical GERD. The gastroenterologist should be as certain as possible that the patient not only has GERD, but also that the patient's symptoms are reflux related. 3. Surgery should be considered when patients desire a permanent solution to free them of the need to take medications. These patients must be warned about the potential suboptimal results, including the frequent need for medication within a few years of having the procedure and the small but real possibility of becoming worse after the operation. Even in experienced hands, 1% to 2% of patients are worse after the procedure. A careful preoperative evaluation to ensure that the patient's symptoms are reflux related and that the right operative procedure is performed offers the patient the best opportunity for success. Widespread use of endoscopic therapy for GERD is probably still several years away. The best endoscopic therapy is yet to be determined, but it will need to be safe, effective, and easy to use.

Special review: game theory to analyse management options in gastro-oesophageal reflux disease

This study aims to demonstrate the applicability of linear programming to threshold analysis, using, as an example, patients with new onset of gastro-oesophageal reflux disease (GERD). The choice amongst competing management options is modelled as a decision tree, using threshold analysis, as well as an m x n matrix on an Excel spreadsheet. The different options of medical management correspond to the m rows, whilst the different disease states correspond to the n columns of the matrix. Each number at the intersection of a row and a column represents the outcome associated with that particular combination of management and disease state. The threshold values are calculated by the built-in functions for linear programming of Excel using its Solver tool. Varying the cost estimates in the sensitivity analysis translates into solving a set of different matrices. Threshold analysis provides a formalism to phrase problems of medical decision analysis in a concise fashion.

Cost effectiveness of competing strategies to prevent or treat GORD-related dysphagia

OBJECTIVES

The variety of influences that contribute to the occurrence of dysphagia in gastro-oesophageal reflux disease (GORD) provide the physician with many options to intervene in the pathophysiology of the disease process. The aims of the present analysis were to compare the relationships between the costs and effectiveness of competing therapeutic interventions in preventing dysphagia.

METHODS

Dysphagia was modelled as the focal point of multiple influences leading to its development. The costs associated with different forms of drug therapy were based on the average wholesale prices listed in the Red Book of 1998. Procedural costs were estimated from Medicare reimbursements. Different treatment options were assessed by their incremental cost-effectiveness ratio.

RESULTS

Lifestyle modifications, treatment with prokinetic agents or antacids reduce the occurrence of dysphagia by 22, 21 or 25%, respectively. Acid inhibition results in a 57 to 89% reduction of dysphagia, depending on treatment with histamine-2-receptor antagonists (H2RAs) or proton pump inhibitors (PPIs). Oesophageal dilation results in a reduction ranging between 54 and 81%. The incremental ratio of cost effectiveness associated with prokinetic agents or H2RAs is much higher than that of PPIs. Based on the concept of extended dominance, therefore, prokinetic drugs and H2RAs do not constitute cost-effective means to prevent dysphagia and should be excluded in favour of treatment with PPIs.

CONCLUSIONS

An economic analysis of various treatment strategies to reduce the risk of GORD-related dysphagia indicates that PPIs are the most cost-effective means to prevent its occurrence.

Effectiveness of single dilation with Maloney dilator versus endoscopic rupture of Schatzki's ring using biopsy forceps

Current recommendations for treatment of patients with symptomatic Schatzki's ring are based on anecdotal experience or uncontrolled studies. Maloney dilation is the gold standard. We performed a randomized controlled trial to compare the use of a single 52-Fr Maloney dilation versus four quadrant biopsy of Schatzki's ring for relief of dysphagia. The subjects answered standardized dysphagia-related questions on a scale of 0-5 (0 = no dysphagia; 5 = cannot handle secretions). To account for modifications in diet and eating habits, subjects answered 11 question to arrive at a eating/diet score. Patients with Schatzki's ring were randomized into one of the two protocols. Group 1 underwent endoscopic biopsies of the ring, one biopsy in each quadrant. In group 2, the endoscope was taken out, and a single 52-Fr Maloney dilation was performed. Twenty-six patients participated in the study and were followed for up to 15 months. There was no significant difference in age, sex, race, smoking, alcohol abuse, or medication intake between the two groups. Dysphagia score improved by 91% in both groups at three months and 84% and 85% at 12 months in groups 1 and 2, respectively. The eating/diet habit score improved by 78% in both groups. There was one failure in each group, and one recurrence at six months in the dilation group. Fifty-five percent of dilation group and 100% of biopsy group described the procedure as easy. There was no difference in the amount of sedatives used during the procedure or the acid blockers after the procedure. In patients undergoing endoscopy, the superior cost/safety profile of endoscopic biopsy makes it a preferred choice for treatment of Schatzki's ring over bougienage.

Postfundoplication complications. Prevention and management

Management of post-fundoplication problems begins by preventing complications from occurring. The prevention of complications after antireflux surgery can be divided into three important areas: (1) patient selection, (2) selection of the surgery, and (3) selection of the surgeon. After addressing prevention techniques, the author discusses the management of new postoperative symptoms such as Dysphagia, gas-bloat syndrome, and nausea and vomiting.

Anatomy and physiology of the esophagus

Modern diagnosis and treatment of esophageal disease is a result of progress in assessing the anatomy and physiology of the esophagus, as well as refinements in anesthetic and surgical techniques. Esophageal carcinoma spreads rapidly and metastasizes easily. The tendency for early spread and the absence of symptoms result in late diagnosis that reduces treatment options and cure rates. Lifestyle (i.e., use of alcohol and tobacco), nutritional deficiencies, ingestion of nitrosamines, and mutagen-inducing fungi are blamed for cancer of the esophagus. Other pathologic conditions (e.g., achalasia, Barrett's epithelium, gastric reflux, hiatal hernia) are potential contributors to the development of carcinoma. Nurses are in key positions to identify the existence of factors contributing to premalignant or malignant lesions and to educate patients and make the appropriate referrals.