High doses of ranitidine in patients with reflux oesophagitis

Medical therapy. Management of the refractory patient

Although relatively rare, GERD patients refractory to medical therapy remain a challenge for the clinician. Refractoriness can be diagnosed only if the patient is properly studied on medication and if what should be adequate medical therapy has been given a sufficient therapeutic trial. Use of 24-hour intragastric and intraesophageal pH-metry has improved the ability to manage patients who appear to be nonresponders. Simple advice and minor adjustments to medical therapy are usually all that is needed for most patients, but in some, management requires knowledge of the principles outlined in this article. If followed, only a small group of patients should be medically refractory.

Review article: drug therapy for reflux oesophagitis

Gastro-oesophageal reflux disease is a common disorder and symptoms can be mild to severe. Management of the disease should be individualized. Life-style changes are important for all patients. Drug therapy is often necessary but only very few patients with severe disease need surgical treatment. The purpose of this article is to focus on drug therapy and to review the clinical trials of all the drugs used for gastro-oesophageal reflux disease. Thereafter, judged solely on the data derived from these trials, a practical approach to the management of gastro-oesophageal reflux disease is suggested.

A prospective study of effects of Belsey MK IV antireflux surgery on endoscopic esophagitis, lower esophageal sphincter pressure, and 24-hr pH measurements. Relation to symptom improvement

A prospective study on the effect of the Belsey MK IV operation on esophagitis, lower esophageal sphincter pressure (LESP), and acid reflux as monitored on 24-hr pH recording was conducted to investigate the association between objective changes and the effect of operation on reflux-associated symptoms. Thirty-one patients were included. The effect of surgery on symptoms was recorded in all patients, and 22 patients agreed to undergo endoscopy, manometry, and 24-hr pH recording. Follow-up ranged from three to nine years (mean five years); 87% reported long-lasting improvement (50% free of symptoms, 37% major improvement, no medication needed). The combination of symptomatic improvement and absence of esophagitis was found in 70%. LESP significantly increased [8 +/- 6 mm Hg preoperatively, 14 +/- 5 mm Hg postoperatively (P < 0.001)] to a level above 5 mm Hg in 96% of the patients. No endoscopic esophagitis was found in 17 of 20 patients (85%; P < 0.05) (two patients refused endoscopy). The 24-hr pH monitoring normalized in 11 of the 20 patients (55%) (one registration failed). The operation-induced rise in LESP correlated with improvement on endoscopy (r = 0.51; P < 0.002) and with reduction of reflux parameters (number of episodes with pH < 4: r = 0.64; P < 0.05, percentage of total time pH < 4: r = 0.42; P = 0.07). A rise in LESP must be an important aim of antireflux surgery. The Belsey MK IV does not induce a rise to a level that causes severe dysphagia or bloating, but the trade-off is less control of acid reflux.(ABSTRACT TRUNCATED AT 250 WORDS)

Basal acid output and gastric acid hypersecretion in gastroesophageal reflux disease. Correlation with ranitidine therapy

The purpose of this study was to evaluate possible differences in basal gastric acid secretion with regard to severity of gastroesophageal reflux disease. Basal acid output was determined by nasogastric suction in 228 patients with gastroesophageal reflux disease who received upper gastrointestinal endoscopy and were diagnosed with either pyrosis alone (N = 98), erosive esophagitis with or without pyrosis (N = 87), or Barrett's esophagus (N = 43). Mean basal acid output for the 228 patients with gastroesophageal reflux disease was 6.5 +/- 5.6 meq/hr, which was significantly different from 65 normal subjects with a mean basal acid output of 3.0 +/- 2.7 meq/hr (P < 0.0001). Compared to normal subjects, mean basal acid outputs significantly differed for patients with pyrosis (P < 0.05), esophagitis (P < 0.01), and Barrett's esophagus (P < 0.01). There was also a significant difference in mean basal acid output between the patients with pyrosis and Barrett's esophagus (P < 0.01). Nineteen of the 98 patients with pyrosis (19%), 24 of the 87 patients with esophagitis (28%), and 15 of the 43 patients with Barrett's esophagus (35%) had gastric acid hypersecretion (basal acid output greater than 10.0 meq/hr). One hundred forty-six patients with gastroesophageal reflux disease were treated with ranitidine in doses that resulted in complete healing of esophagitis and disappearance of pyrosis. Ninety-three patients responded to ranitidine 300 mg/day; however, 53 patients required increased dose of ranitidine (mean 1205 mg/day, range 600-3000 mg/day).(ABSTRACT TRUNCATED AT 250 WORDS)