Fortnightly review: Treatment of gastro-oesophageal reflux disease in adults

Abstract

Gastro-oesophageal reflux disease is caused by retrograde flow of gastric contents through an incompetent gastro-oesophageal junction. The disease encompasses a broad spectrum of clinical disorders from heartburn without oesophagitis to severe complications such as strictures, deep ulcers, and intestinal metaplasia (Barrett's oesophagus).1 The prevalence of heartburn, the most typical symptom of gastro-oesophageal reflux disease, is extremely high,2 but most people with reflux do not seek medical help for this condition and treat themselves with over the counter preparations. Oesophagitis (defined by mucosal breaks) is less frequent, occurring in less than half of patients undergoing endoscopy for reflux symptoms. Symptoms and severity of oesophagitis are poorly correlated. Although reflux may remain silent in patients with Barrett's oesophagus, heartburn can severely affect the quality of life of patients with negative endoscopy results. The natural course of the disease also varies considerably.2 Patients with gastro-oesophageal reflux disease seen by gastroenterologists usually have a chronic condition with frequent relapses, whereas those who rely on general practitioners' help usually have less severe disease, consisting of intermittent attacks with prolonged periods of remission. #### Summary points Most patients with dominant heartburn have no signs of oesophagitis at endoscopy. However, chronic relapsing gastro-oesophageal reflux disease can severely affect quality of life In primary care many patients can be successfully treated by intermittent courses of drugs on demand Alginate-antacids and H2 receptor antagonists are useful in patients with mild disease Cisapride is as effective as H2 receptor antagonists in short term treatment and can prevent relapse in mild oesophagitis Proton pump inhibitors relieve symptoms and heal oesophagitis more completely and faster than other drugs. They are effective throughout the disease spectrum, and maintenance therapy prevents recurrences The principles of laparoscopic and open antireflux surgery are the same. In skilled hands, similarly good results have been reported …