Sports Medicine: Just the Facts

CHAPTER 35 • GASTROENTEROLOGY 207

therapy fails, it is important not only to consult gas-

troenterology, but also the specialty that would evaluate

for extraintestinal complications. In the face of a clas-

sic history and normal physical examination, it is rea-

sonable to institute empiric therapy in a stepwise

fashion (Fig. 35-2).

• Persistent symptoms despite behavioral interventions
  warrant medical therapy. Episodic complaints are
  treated with over-the-counter(OTC) antacids or an
  H-2 receptor antagonist(H2RA) as needed. This can
  beadvanced to prescription-strength H2RA therapy if
  control is insufficient. Should symptoms continue
  after 6 weeks of H2RA therapy, neither continuing
  therapy nor increasing the dose are likely to achieve
  control (Kahrilas, Fenerty, and Joelsson, 1999). At
  this point, it was previously common practice to con-
  sider add-on therapy with a prokinetic agent to
  improve LES tone, gastric emptying, and peristalsis.
  These agents all have side effects that make them
  undesirable for use in athletes. Bethanechol has gen-
  eralized cholinergic effects. Metoclopramide has a
  high incidence of fatigue, restlessness, tremor, and
  tardive dyskinesia, making it a poor choice for any-
  thing more than sporadic use. Cisapride, formerly the
  prokinetic agent of choice, was found to be associated

with arrhythmia development, especially with con-

comitant use of macrolides, imidazoles, or protease

inhibitors (Wysowski and Bacsanyi, 1996). This dis-

covery led to severe prescribing restrictions in the

United States.

• In individuals who fail to respond to H2RAs, standard-
  dose proton pump inhibitors (PPI) are the treatment of
  choice. PPIs provide more rapid relief of symptoms
  (Bardhan et al, 1999) and are more likely than H2RAs
  to heal and prevent recurrence of erosive esophagitis
  (Chilba et al, 1997). The agents in this class are equally
  efficacious in controlling heartburn and have similar
  healing and relapse rates (Caro, Salas, and Ward,
  2001). Because reported differences in initial bioavail-
  ability and antisecretory potency are not clinically sig-
  nificant with long-standing use, one PPI cannot be
  recommended over another (Williams et al, 1998). If
  the response to episodic treatment is generally favor-
  able but symptoms are occurring on a more chronic
  basis, maintenance therapy is beneficial. Because their
  efficacy is dose-dependent, PPI therapy can be stepped-
  up to control symptoms. Failure to respond to high dose
  PPI therapy requires gastroenterologist evaluation to
  rule out complications of GERD. In the absence of find-
  ings consistent with reflux disease, further GI testing

FIG. 35-2 Therapeutic Pyramid
for Exercise-Related Gastroeso-
phageal Reflux Disease.