The patient’s unmet needs (PUNs)
A 62-year-old man presents with the classic symptoms of gastro-oesophageal reflux disease – heartburn and an acidic taste in his mouth that is worse when bending over. He has had similar symptoms in the past very occasionally, but has never sought medical help. He has attended today because the symptoms have been much worse and persistent for the last four months or so. On two or three occasions he has felt food stick slightly, with associated discomfort, but this is very intermittent, not progressive and there is no regurgitation or vomiting. His lifestyle is poor – he smokes, drinks excessively and his weight is on the increase. ‘Don’t send me for one of those camera-down-the-throat jobs’ he protests as I explain the problem. ‘Can’t you just give me some medication?’
The doctor’s educational needs (DENs)
Is an OGD always necessary in the context of a classic case of GORD in older patients? If not, when would it be required?
Yes, current guidelines recommend that patients over 55 years with new onset uncomplicated dyspepsia should be investigated using early upper GI endoscopy.1 This is to exclude serious underlying conditions and to confirm the diagnosis. It is usually recommended that this is done before starting medications for acid reduction.
Many patients with GORD complain of occasional episodes of dysphagia – how significant is this? Guidelines tend not to distinguish between painless and painful dysphagia – does the distinction alter management?
Dysphagia and odynophagia are common symptoms in GORD but either may be a manifestation of underlying malignancy. Endoscopy - and possible biopsy - is indicated whenever there is difficulty swallowing.
How effective are lifestyle measures in GORD? Which should be the priority?
Lifestyle issues are not usually the cause of GORD but can make it worse. Although patients often identify dietary precipitants, the evidence for dietary modification other than weight loss is poor. Tobacco and alcohol cessation is not associated with improvement in oesophageal pH profiles or symptoms, but head of the bed elevation and left lateral decubitus position improves the overall time that the oesophageal pH is less than 4.0. Unfortunately many patients find it difficult to comply and even with strict adherence symptom reduction is often incomplete such that medication is usually required.
PPIs tend to be prescribed routinely in GORD these days. Is this the best approach? When should other treatments be considered?
The superiority of PPIs over other drugs (antacids, prokinetics and H2 receptor antagonists) is well established and they are the mainstay of medical antireflux therapy. Maintenance or on-demand therapy should be tailored to the patient’s clinical course. PPI therapy, when initially effective, usually remains effective, although dose escalation may be required in up to 25% of patients.
The addition of other drugs such as H2 receptor antagonists is often unhelpful due to its relatively weak acid reduction compared to PPIs, and the addition of prokinetics is also disappointing. Patients may continue to take antacids/alginates for symptom breakthrough.
Although dramatically effective in most patients with typical GORD, a significant minority fail to respond to PPI therapy. These patients comprise a heterogeneous mix with ongoing reflux-related symptoms and those with reflux-unrelated problems such as functional heartburn and dyspepsia or occasionally eosinophilic oesophagitis – a build-up of eosinophils that causes inflammation of the oesophagus. If encouraging compliance and dose escalation fail to bring an improvement then endoscopy with biopsy and detailed physiological studies may be required. The best symptom indicators of persistent true reflux are retrosternal burning and acid taste in the mouth.
Fortunately, PPIs are extremely well tolerated. Diarrhoea is the most frequent adverse event, occasionally related to enteric infection. Headaches and nausea may occur. Pneumonia incidence may be slightly increased and an increase in bone fracture has been questioned.
In which patients should we consider surgery?
The decision on the value of a surgical procedure is a balance of effectiveness with the risk of an operation. Patients who are fit, not likely to have complications with anaesthetics and relatively young with a suitably long life expectancy are good candidates to consider surgical intervention.
The motivation for surgery is usually persistent typical reflux symptoms - acid regurgitation, heartburn and swallow discomfort - which have partially responded to PPI therapy. A complete lack of response should raise the question about the accuracy of the diagnosis.
Sometimes the side effects of PPI are the reason for seeking a physical cure to reflux. The presence of a hiatus hernia at endoscopy supports a decision for surgery, but the finding of eosinophilic oesophagitis on a biopsy suggests the symptoms may not be reflux related and an alternative medical therapy needed.
In 90% of patients with typical symptoms the majority of reflux symptoms can be expected to resolve in the long term, so that medication is no longer required. The remaining 10% may have swallow discomforts, recurrent reflux or require further interventions.
The symptom of cough, hoarseness and breathing difficulties are not clear reasons for anti-reflux surgery and less than 50% of such patients get symptom improvement. If they also have typical GORD symptoms they are usually happy with the outcome, but for many patients with just respiratory or throat symptoms the outcome of surgery is often not helpful and surgeons are usually slow to advise intervention for these symptoms alone.
Currently trials are underway with assess new endoscopic therapies - like transoral Incisionless fundoplication (Esophyx) - and less invasive operations by laparoscopy such as electrical stimulation or magnetic bracelet around the lower oesophagus.
Although commonly seen on the internet, none of these research techniques are NICE approved and further research is essential before they are recommended.
- Endoscopy is useful to exclude alternative diagnosis to GORD and to assess severity of injury
- Treatment includes a combination of lifestyle adjustment and medication with PPI
- Although very effective, medication may fail to control symptoms in a significant minority of patients
- Operative interventions should be considered on a balance of the potential benefit, with the drawbacks of the outcome and the risk of complications
- For newer technologies, good clinical research needs to be performed and published before taken into general use.
Mr Stephen Attwood is a consultant general surgeon at Northumbria NHS Trust and Spire Washington Hospital.
Dr Stuart Riley is a consultant gastroenterologist at Sheffield Teaching Hospitals NHS Foundation Trust.
This article was produced in collaboration with the British Society of Gastroenterology (BSG), a professional organisation focused on the promotion of standards in gastroenterology and hepatology within the UK. The BSG has produced guidance designed to aid emerging CCGs to commission an effective gastrointestinal and liver disease service. For more information and to download the guidance, go to: http://www.bsg.org.uk/clinical/general/commissioning-report.html
1 SIGN. Guideline 68: Dyspepsia (2013)
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3 Kaltenbach T, Crockett S, Gerson LB,. (2006) Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Archives of Internal Medicine, 166(9), 965-71
4 Galmiche JP, Hatlebakk J, Attwood S, Ell C, Fiocca R, Eklund S, Langstrom G, Lind T, Lundell L,. (2011) Laparoscopic Antireflux Surgery vs Esomeprazole Treatment for Chronic GERD. The LOTUS Randomized Clinical Trial. JAMA. 305 (9); 1969-1977
5 Zerbib F, Sifrim D, Tutuian R, Attwood S, Lundell L,. (2013) Modern medical and surgical management of difficult-to-treat GORD. United European Gastroenterology, 1 (1) 21-31
6 Fiocca R, Mastracci L, Engstrom C, Attwood S, Ell C, Galmiche JP, Hatlebakk J, Junghard O, Lind T, Lundell L,. (2010) Long-term outcome of microscopic esophagitis in chronic GERD patients treated with esomeprazole or laparoscopic antireflux surgery in the LOTUS trial. The American Journal of Gastroenterology. 105 (5) 1015-1023