Reviews for Primary Care - Fall 2007 - (Page 55) GERD Symptoms on Antisecretory Therapy grades C and D erosive esophagitis. Many will respond to increasing the dose, changing dose timing, or switching the PPI; however, some patients will not respond to any of these maneuvers. Despite twice-daily (or greater) dosing of a PPI, GERD symptoms may persist, other symptoms may occur or become prominent, and erosive esophagitis may persist. These symptom complex; however, he is mostly concerned about continued nighttime heartburn and its potential implications. Two of his children have heartburn and his brother has Barrett’s esophagus. In light of his rare dysphagia, but mostly due to his concern of long-term complications, you elect to perform endoscopy, which reveals a single, 5-mm erosion in the distal Despite twice-daily (or greater) dosing of a proton pump inhibitor, gastroesophageal reflux disease symptoms may persist, other symptoms may occur or become prominent, and erosive esophagitis may persist. patients represent a small subset that requires more aggressive antisecretory therapy, endoscopic or surgical therapy for GERD (perhaps for non–acid reflux), and a large proportion who have other causes for their symptoms. This overall group of patients presents a major challenge for the gastroenterologist asked to evaluate and manage them. The approach to evaluation and management of the “refractory or difficult GERD patient” is the subject of this state-of-the-art review. esophagus, a 2 cm length of a columnar lined esophagus, and a 2-cm hiatal hernia. You elect to increase his PPI therapy to twice daily. On follow-up 12 weeks later, he has major improvement in his symptoms to where he is controlled in the daytime but is still complaining of rare regurgitation and nocturnal heartburn. Case in Context This 65-year-old gentleman with classic GERD (heartburn and regurgitation) presents with incomplete symptom relief on once-daily PPIs. He has endoscopic findings of erosive esophagitis and Barrett’s (biopsy confirmed). Although the increase in PPI dose results in complete daytime symptom relief, some residual nighttime symptoms remain. The approach to the patient at this point is not nearly as straightforward. However, before moving to addressing the approach to the patient with incomplete symptom relief on twice-daily PPIs, a brief review of the key features of this case is useful in order to place it in the context of the typical GERD patient and disease work-up. Case Study A 65-year-old white male with 11 years of classic daily heartburn presents for evaluation. He has heartburn at least 3 times a week, both postprandial and nighttime, occasionally awakening him from sleep. He complains of intermittent regurgitation, very rare (less than once per month) dysphagia to liquids and solids, and occasional trouble sleeping. He has self-managed, usually with over-the-counter (OTC) agents or as-needed use of medication from family members and friends. While taking a once-daily OTC PPI given empirically, he visits you (a gastroenterologist) for evaluation of failure of the drug to adequately relieve his symptoms. On closer questioning, he reports a 50% improvement in his overall Discussion We have come to “expect” that most patients who present with heartburn will have effective symptom relief on once-daily PPIs. Although this is true in the vast majority of patients, a careful review of the literature suggests that a clinically important number will fail to have complete symptom relief even after 8 weeks of therapy.1-5 A meta-analysis published in 1997 found that PPIs given once daily resulted in 77.4% ( 10.4%) of patients with erosive esophagitis being heartburn-free after 8 weeks of therapy.6 In a study specifically evaluating daytime and nighttime heartburn separately after 8 weeks of therapy, patients taking omeprazole 20 mg/day reported experiencing heartburn on 11.8% of days and 8% of nights compared to patients taking 30 mg/day of lansoprazole experiencing heartburn 8.6% of days and 6.5% of nights.7 Using variations in efficacy measures from relief to complete relief to complete resolution, somewhere between 60% and 85% of patients with erosive esophagitis at baseline reach the measured endpoint at between 4 and 8 weeks.8,9 In the more heterogeneous group of patients with nonerosive reflux (heartburn with a normal endoscopy), complete absence of heartburn is reported in lower frequency (46%-57%).10,11 In this patient population, another efficacy measure is the number of heartburn-free days, which in a single study using esomeprazole was approximately 66% of the days.12 The latter patients may be a better representation of the universe of patients who receive empirical therapy. Regardless of efficacy measure or initial endoscopic appearance, these results suggest that a sizable number of patients will have incomplete relief even of classic GERD symptoms. Our patient is therefore not uncommon. Few would argue that in this setting of a classic presentation of GERD and partial symptom relief (even in the absence of erosive disease) increasing VOL. 1 NO. 1 2007 REVIEWS FOR PRIMARY CARE 55
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