Diagnosing and treating patients with GERD is complicated. 30% of patients still have chronic GERD symptoms despite taking médications. PPI treatment, when taken long-term have been shown to have significant side effects and may interfere with other medication. The diagnostic methods in GERD are not completely ideal. That is why I would like to know your opinion about what is the real need in care of patients with GERD.
I think GERD is different enough from physiological GER and we do need more accurate and safer drugs , specially for toddlers and geriatric patients
Everything is important, but I think actually we have good diagnostic tools such as endoscopy and 24 h. pH-metry and for treatment we are very confident with continuous PPIs treatment in low dose
Dear Cristians,
Esophageal mucosal hypersensitivity, large volume of refluxate are among the putative mechanisms. Impedance-pH-metry is now considered the most sensitive test for reflux detection and to have a critical role in establishing the relevance of non-acid in reflux-symptoms.
So I agree with the Dr. Luis Rodrigo.
Sincerely,
Dzmitry
In my opinion, one should rely mainly on clinical method, mostly questionning for diagnosis and adjusting the treatment. It is important to determine whether pain is, or not, acido-dependent, by taking a liquid alkaline as a test. If negative, responsibility of reflux must be questionned. Then, if positive, do erosions persist? If yes, increase treatment power. If not, it is an hyper-sensitivity. Then, look for depression, main cause of hypersensitivity everywhere (and sometimes of reflux itself). If present (sleep, appetite or various nero-vegetative troubles, more frequent and specific than mood troubles), test various anti-depressants.
In case of respiratory troubles, remember searching for lipid-loaded macrophages in sputum.
Don't over-estimate risks of well used PPIs.
I almost never use pH-metry. If double dose PPI fail to lead to symptoms disappearance (except respiratory), reflux, even present, isn't the cause of persisting symptoms.
Finally, for treatment, don't forget hygienic actions (alcohol, tobacco, obesity, blocks under headboard).
Is need to used strategy step up or step down, because PPI in long treatment have many side effects. But, is need for attention is actuell acidic or biliar refluxif and here is very import pH impedance, especially when is refractory GERD.
In cases when not have efect with PPI and other medications, is need to detected factors for refractory GERD.
pH impedance is gold standard for GERD diagnosis.
Finally, antireflux surgery give better results also PPI treatment.
Indications for long term treatment of GERD are its complications.
I think with GERD resistent PPI need to assess the factor that make the GERD happen. Also the gold standard is pH imdepdance because in Asia the mayority is NERD (Non-erosive GERD)
Everything is relevant on this subject but I think the bet treatment is PPI continuous use at a low dose
By patients with large hiatal hernia, especially over 5 cm, is need to working laparoscopic fundoplication, and show to be better than PPI treatment.
Diagnosing asymptomatic GERD from symptomatic GERD is important to avoid a myriad of side effects related to inappropriate PPI therapy by judicious use of available diagnostic methods. Equally important is to rule out complications of GERD such as asthma, sinusitis, and early diagnosis of Barett's esophagus, as well as metaplasia-induced carcinoma of the esophagus.
PPI use and important to reverse modifiable risk factirs for reflux eg obesity, stress, caffeine, smoking, alcohol etc. once these have been addressed then i agree the lowest possible dose of ppi to control symtpoms or even trying to come off medication. For larger hiatus hernias, volume reflux, intolerance of PPI and (possibly) Barrett’s oesophagus are all reasons to consider surgical options.