Internal Medicine

0521779407-08 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:47

612 Gastroesophageal Reflux Disease

differential diagnosis

■Esophageal motor disorders, angina pectoris, asthma, dyspepsia,

peptic ulcer disease, cholelithiasis

management

What to Do First

■Stepwise approach to GERD: lifestyle modification, antacids and

OTC H2 antagonists; proton pump inhibitors; surgery

General Measures

■Lifestyle modifications: diet changes, elevation of the head of the

bed, avoidance of early recumbency after meals, discontinuation of

smoking, alcohol and irritant medications

specific therapy

Indications for Treatment

■Goals of therapy: relieve symptoms, heal esophageal mucosa, pre-

vent and manage complications, maintain remission

Treatment Options

■Antacids: beneficial in patients with mild reflux without erosive

esophagitis who do not require daily medication; ineffective in heal-

ing esophagitis

■Promotility drugs (metoclopramide): enhance esophageal peri-

staltic clearance and gastric emptying; potent antiemetic; does not

heal esophagitis

■H2 receptor antagonists (cimetidine, ranitidine, famotidine, and

nizatidine): equally effective when used at the proper doses: cime-

tidine, 400 mg bid; ranitidine and nizatidine 150 mg bid and famo-

tidine, 20 mg bid; therapy for 6–12 wk relieves symptoms in 50%,

heals esophagitis in 50% and maintains remission in 25%; efficacy

in severe esophagitis

■Proton pump inhibitors (omeprazole, lansoprazole, rabeprazole,

and pantoprazole): faster symptom relief; rapid and complete

mucosal healing; more effective than H2 receptor antagonists;

achieve healing rates of 80–100% within 8 wk; also improves dys-

phagia and decreases the need for dilation of strictures

■New endoscopic therapies (radiofrequency therapy, endoscopic

ligation): recently become available; they both achieve symptom

control in 70% of cases

■Antireflux surgery: used for severe, intractable GERD and its

complications; laparoscopic Nissen fundoplication most frequently