Reviews for Primary Care - Fall 2007 - (Page 58) GERD Symptoms on Antisecretory Therapy continued sions on an upper GI endoscopy in this type of patient. Rarely discussed are patients with esophageal stricture (a small and perhaps vanishing minority) and patients with Barrett’s, the group with the greatest esophageal acid exposure and arguably the most difficult to control disease. The prevalence of Barrett’s esophagus (columnar-lined esophagus with intestinal metaplasia on biopsy) in patients with heartburn greater than 3 times a week undergoing endoscopy is 10% to 17%.23,24 It is also known that the prevalence of erosive esophagitis (especially Los Angeles Grades C and D) and Barrett’s esophagus increases in frequency in the elderly population. A study that investigated the relationship between age and GERD severity found that the prevalence of erosive esophagitis and Barrett’s esophagus increased substantially in patients older than the age of 60. In this highly selected group of patients, the prevalence of erosive esophagitis and Barrett’s esophagus was significantly higher in the older age groups (81%) compared to the younger groups (47%, 50 45 40 35 30 25 20 15 10 5 0 21 21–30 31–40 41–50 Age (years) P N 11,945 .0001 for each vs age Patients (%) Erosive esophagitis C and D Severe heartburn 51-60 61–70 70 Figure 4. Graph showing an increase in frequency of erosive esophagitis with increasing age. Severity of heartburn does not necessarily increase. Reprinted from Johnson DA and Fennerty MB,26 with permission from the American Gastroenterological Association. pared to “nonerosive” (more women). This may be related to differences in symptom thresholds, healthcare-seeking behavior,27 or a statistical quirk, but still reflects variation in potential for optimal symptom relief, and may change the threshold for endoscopy in men. Thus there are ample data to suggest, despite superlative results with once-daily PPI in patients with typi- The prevalence of Barrett’s esophagus (columnar-lined esophagus with intestinal metaplasia on biopsy) in patients with heartburn greater than 3 times a week undergoing endoscopy is 10% to 17%. P .001).25 Symptom severity did not differ significantly among age groups. In a more recent study reviewing a large endoscopic database, the authors found a greater prevalence of Grades C and D erosive esophagitis in patients older than the age of 50; however, they found no significant difference in self-rated heartburn severity in that age group compared to those younger than 50 (Figure 4).26 There appears to be a subtle difference in gender ratios in erosive esophagitis trials (more men) comcal heartburn as the primary presentation, that these patients will still present for evaluation with continued symptoms. Add to that number those empirically treated, and many will likely still need careful evaluation. All of this puts into perspective the dilemma regarding the timing of endoscopy in patients with “refractory or difficult-to-manage GERD.” It may be prudent, therefore, to consider earlier endoscopy to look for continued erosive esophagitis and/or Barrett’s esophagus (both diagnostic of GERD) in the elderly and in those with frequent symptoms, as is the case with this patient. There are few data on the incidence or prevalence of continued symptoms in patients treated with higher doses of PPIs either given once or twice daily. Therefore, in developing an approach to these patients, one must use indirect data from pH monitoring studies performed in patients (subjects) on PPIs either once or twice daily. These studies have made us well aware of the prevalence of what has been termed nocturnal gastric acid breakthrough,28 a pharmacodynamic phenomenon in which 70% to 80% of patients taking PPIs twice daily will have periods of intragastric pH falling to below 4 for greater than 60 minutes in the overnight period.28 What is less frequently discussed is the prevalence of continued esophageal acid exposure in this patient population. One study documented the presence of some esophageal acid exposure in 15% of patients with GERD (without Barrett’s esophagus) studied with combined intraesophageal and intragastric pH monitoring on twice-daily PPI.29 One large study found that almost 10% of patients on twice-daily 58 VOL. 1 NO. 1 2007 REVIEWS FOR PRIMARY CARE
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