Gastroesophageal reflux disease (GERD) is a common medical condition affecting about 10- 40% of the adult population in the Western world. The principal symptoms are heartburn and regurgitation due to back flow of acid and food from the stomach tot the oesophagus.
Once a patient is diagnosed as having GERD the mainstay of treatment is medical. Simple measures and lifestyle modifications can also help to reduce symptoms in mildly symptomatic patients.
Simple measures like avoiding alcohol, smoking and use of antacids might reduce mild symptoms. Avoiding food which may precipitate reflux is also important. Raising the head end of the bed and avoiding tight filling clothes may also contribute to symptom control.
Though medical management by drugs controls the symptoms of GERD, this will not correct the underlying problem of reflux. Drugs will reduce the acidity of the stomach and bring the PH value to a higher state. Thus the refluxing fluid will be less acidic and less irritative to the oesophagus.
Surgical management is indicated when
- Symptoms are severe and distressing
- Symptoms cannot be controlled with maximal medical treatment
- Patient does not like to take lifelong medication
Drugs used to treat GERD are
- H2 Receptor Antagonists
- Proton pump Inhibitors
Antacids act locally to neutralise the acidity in the stomach. They are less effective in controlling moderate to severe symptoms. Antacids can be combined with mucosal anaesthetic agents such as oxetacaine to relieve the burning sensation. It is important not to take other medication with antacids, since they can reduce the absorption of other drugs.
H2– (Histamine) receptor antagonists are a group of drugs which can reduce the acid production in the stomach. They were introduced in 1970s and were effective in treating peptic ulcers. They failed to show a great efficacy in treating GERD. Commonly used agents include cimetidine, famotidine and ranitidine. With the introduction of proton pump inhibitors they are no longer used as a first line agent.
Proton pump inhibitors are the mainstay of medical management in GERD nowadays. Commonly used agents include esomeprazole, omeprazole, pantoprazole and rabeprazole. They were introduced in late 1980s and revolutionized the management of peptic ulcers and GERD. They are much more effective in suppressing acidity of the stomach.
These drugs are generally safe for long term use. Side effects of proton pump inhibitors include abdominal pain, nausea and constipation. Less frequent side effects include fatigue, joint pains, muscle pain and numbness. Manufactures advised to use them with caution especially in pregnancy and breastfeeding.
Treatment failures may result due to poor compliance and under dosing.
Prokinetics are a group of drugs which stimulate emptying of the stomach. They try to reduce acid expose of the oesophagus by rapidly emptying the stomach. Commonly used drugs include domperidone and mosapride.
Overall the medical management is highly effective in symptom control in GERD. Failure in spite of maximal medical therapy has to be reviewed cautiously since this may be an indication to consider the surgical option.
Dr Udaya Samarajeewa MBBS, MD- Surgery, MRCS (Eng.)
Consultant General Surgeon