Treatment Options for Gastroesophageal Reflux Disease (GERD)
Gastroesophageal reflux is the passage of gastric contents into the esophagus, which can cause symptoms or other complications, such as damage to the lining of the esophagus. Symptoms of GERD include heartburn, regurgitation, coughing, throat clearing, hoarseness, belching, difficulty with or painful swallowing, chest pain or globus sensation in the back of the throat. While lifestyle modifications alone may result in resolution of symptoms in 25 percent of people, most patients will require long-term medical therapy to treat GERD. In order to remain symptom-free, the goal is to decrease the amount of acidic reflux back into the esophagus.
Medical therapy to treat GERD include medications which neutralize acids or suppress secretion of acid in the stomach. The cornerstone of GERD treatment is acid suppression, especially if there is damage or inflammation of the lining of the esophagus from reflux. The amount of relief is directly related to the degree of acid suppression by these medications.
Antacids, such as Tums, are used for as-needed symptom control. They do not prevent acid reflux from occurring. However, these medications neutralize the acidity of gastric juices, decreasing the acidity of contents that pass back up into the esophagus. This protects the lower esophagus from exposure to very acidic contents. They typically provide relieve of symptoms within five minutes and last 30 to 60 minutes.
Histamine blockers, or H-2 blockers, such as ranitidine or famotidine, decrease acid secretion of acid-producing cells of the stomach by blocking the histamine-2 receptor. A decrease in acid secretion reduces the potential damage that can occur in the lower esophagus, improves symptoms, and allows for healing of inflammation caused by reflux. H-2 blockers have a slower onset than antacids, peaking at 2.5 hours, but can last from four to 10 hours.
Proton pump inhibitors (PPIs) are the most potent of the gastric acid inhibitors, even more potent than H-2 blockers. Examples of these types of medications include omeprazole, lansoprazole, or pantoprazole. They inhibit the Hydrogen-Potassium (H-K) ATPase pump of acid cells in the stomach. Consequently, these cells need to form new pumps, which may take several hours. It is important that these medications be taken 30 minutes before a meal in order to work properly and be effective. PPIs are used for the prevention of acid reflux and should not be used for as-needed therapy. These have been shown to provide more effective relief than H-2 blockers of GERD symptoms. However, H-2 blockers are often added to PPI therapy at bedtime to block breakthrough symptoms at night during sleep.
Surgery and Endoscopy
While medications work to reduce acid secretion or neutralize acid, surgical and endoscopic interventions focus on the mechanical and functional abnormalities of the anti-reflux barrier, or lower esophageal sphincter (LES). Currently, surgery for GERD, called a Nissen fundoplication, is completed laparoscopically with special scopes. In this procedure, part of the stomach is wrapped around the lower esophagus forming a tight barrier to reflux. Prior to surgery, several tests are required to confirm symptoms are due to true reflux, including a 24-hr pH testing off of all therapy and esophageal manometry to ensure there are no motility abnormalities of the esophagus. People who require high doses of PPI and H-2 blockers to control symptoms should be considered for surgery, especially in younger patients. In patients who fail maximal medical therapy, surgery remains controversial, as oftentimes, patients still require medications after surgery. Those who do not respond at all to PPI therapy should not be considered for surgery.
Success rate for surgery is 80 to 90 percent. However, symptoms that may occur after surgery include gas bloat (where gas builds up in the stomach but cannot be relieved with belching due to tightness of the wrap), diarrhea, and stomach discomfort. Up to one-third of patients will eventually require PPI therapy again after surgery for persistent or recurrent symptoms.
There are several endoscopic procedures to treat GERD in development. Such methods include altering the shape or tightening the LES with insertion of sutures or devices to form a barrier against passage of contents from the stomach into the esophagus. Some of these methods have been used, however, they are not widespread and long-term efficacy remains unknown at this time.
Many medical therapies for GERD are now offered over the counter, however, before starting any medication, it is important to talk to your doctor about your symptoms to ensure they are not from something other than GERD. Based on your level of symptom control, you can then tailor your regimen with your physician's guidance.