TREATMENT OF ACID REFLUX COMPLICATIONS

TREATMENT OF ACID REFLUX COMPLICATIONS
Strictures
Mildly symptomatic esophageal strictures can be handled by careful attention to dietary intake, and use of medical therapy, primarily proton-pump inhibitors. Short, simple strictures can be dilated with weighted rubber or Teflon dilators (e.g., Hurst-Maloney). Tortuous or angulated strictures are more easily approached over a previously placed guidewire passed through an endoscope or under radiographic control (Savary dilators). Graded-steel olives (Eder-Puestow olive dilators), a dilator with graded increases of size (Celestin dilator), or a balloon with a fixed maximal diameter (Cooke balloon) can be passed over the previously placed wire. Alternatively, a balloon of fixed maximal diameter can be passed through the large channel of an endoscope during diagnostic endoscopy and dilated under direct vision (through-the-scope [TTS] dilation). Once the lumen is restored to a diameter of 13 to 15 mm, most patients swallow without difficulty. If the stricture is stable and requires dilation only every 4 to 6 months, no other therapy is necessary.
High-dose H2 -antagonists or, preferably, proton-pump inhibitors and dilation of the stricture can lead to healing of the mucosa and less need for repeated stricture dilation. Patients who do not tolerate dilation or require vigorous dilation every 3 to 4 weeks need a definitive antireflux operation, following which the stricture may regress. If strictures persist after antireflux surgery, esophageal replacement by colon, jejunum, or stomach is a surgical maneuver of last resort associated with a relatively high morbidity and mortality. Patients afflicted by strictures may have significant lung and cardiovascular disease that makes them unsuitable operative candidates.
Ulcers
Esophageal ulcers also represent a major therapeutic problem. They usually require treatment with a proton-pump inhibitor.
Barrett's Esophagus
Barrett's (columnar) epithelium may be premalignant and can be removed only by esophageal resection. Adequate antireflux therapy with high-dose H2 -antagonists or with a proton-pump inhibitor causes regression of columnar epithelium in some patients.
Patients with Barrett's epithelium should be followed up with periodic endoscopic biopsies every 1 to 3 years to look for dysplasia and early changes of adenocarcinoma. The persistence of confirmed high-grade dysplasia is an indication for esophagectomy, because high-grade dysplasia may progress to carcinoma and because coexistent carcinoma may be undetected on biopsy. If low-grade dysplasia is present, the patient is treated medically with proton-pump inhibitors and undergoes biopsy every 6 to 12 months. Experimental endoscopic ablation therapies using photodynamic therapy, laser, or multipolar electrocoagulation are being tried to remove the columnar epithelium with the hope of subsequent growth of the normal squamous epithelium, primarily in patients with low-grade dysplasia or in patients with high-grade dysplasia who are not surgical candidates. Following these new ablation techniques, either long-term gastric acid suppression or laparoscopic Nissen fundoplication is needed to control the reflux and prevent recurrence of Barrett's epithelium.
Pulmonary Complications
Treatment of the pulmonary complications of reflux in adults relies on improved night posture, gastric acid suppressants, and prokinetic agents. Caution is advised before recommending esophageal surgery in patients with reflux and predominant pulmonary problems, because the cause-and-effect relationship may be uncertain in individual patients.