Reviews for Primary Care - Fall 2007 - (Page 61) GERD Symptoms on Antisecretory Therapy Patients With Positive Symptom Index (%) 100 90 80 70 60 50 40 30 20 10 0 72 35 32 16 22 14 10 ENT symptoms 21 Others 37 Regurgitation 18 Heartburn 20 Cough 22 Chest pain 25 Abdominal symptoms 7 Figure 7. Patients with positive symptom index for each symptom recorded. Many patients report more than 1 symptom during a 24-hour period. ENT, ear, nose and throat. this is the group most likely to have non–acid reflux. Patients with infrequent symptoms (less than daily) and Barrett’s patients are routinely evaluated with the Bravo capsule. The former benefit from the additional day of monitoring for symptom association purposes and the latter because I am most interested in esophageal acid control over more than 1 day, and the vast majority are not symptomatic. More often I am evaluating patients on current therapy to assess symptom association and perhaps efficacy of antisecretory therapy in control of pH and subsequently performing pH monitoring OFF therapy to determine if reflux was present at baseline. This is increasingly necessary in patients with ear, nose, and throat (ENT)–related complaints. These patients are given a diagnosis of laryngopharyngeal reflux and treated primarily based on ENT signs and symptoms. They are often on high doses of antisecretory therapy, have normal esophagoscopy, and have not had a diagnosis of gastroesophageal reflux disease confirmed. In these cases we use the 48-hour Bravo capsule for testing. A thorough evaluation may require impedance/pH monitoring on therapy and 48-hour Bravo off therapy to satisfy the patient and referring physician as to the diagnosis. Summary Patients with symptoms suspected due to GERD who are refractory to antisecretory therapy fall into the following categories: (1) GERD is the correct diagnosis and the patient is sub-optimally treated for acid reflux. In this case, antisecretory therapy can be optimized in the short or long term and/or the patient offered endoscopic or antireflux surgery; (2) the patient has non–acid reflux. Early impedance/pH studies suggest that this is seen in a small but important minority, most often with typical symptoms of regurgitation and heartburn. What is not clear is whether the symptoms are produced by abnormal Main Points • Despite twice-daily (or greater) dosing of a proton pump inhibitor (PPI), gastroesophageal reflux disease (GERD) symptoms may persist. These patients represent a small subset that require 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. • A careful review of the literature suggests that a clinically important number of patients will fail to have complete symptom relief even after 8 weeks of PPI therapy. • It may be prudent to consider earlier endoscopy to look for continued erosive esophagitis and/or Barrett’s esophagus in the elderly and in those with frequent symptoms. • Healing of erosive esophagitis is perhaps the most objective way to assess therapeutic efficacy of PPIs. VOL. 1 NO. 1 2007 REVIEWS FOR PRIMARY CARE 61
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