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.

Barrett's esophagus Treatment: Photodynamic therapy

Photodynamic therapy may effectively treat superficial esophageal cancer and Barrett's esophagus. The treatment begins with an injection of a light sensitive medication. Your normal body cells can get rid of this medication, but precancerous and cancerous cells in your esophagus cannot, so it accumulates in these tissues and makes them sensitive to light. Two days after the injection, your doctor inserts an endoscope — a long, flexible instrument — into the diseased area of your esophagus. The light from a laser on the endoscope activates the medication, killing the light sensitive cancerous cells.

This medication will make all the cells in your body light sensitive, so talk to your doctor about how you can avoid sunlight for up to 6 weeks after the treatment.

Heartburn Relief : Acid Reflux Treatment

The management of frequent heartburn entails certain measures to confirm the diagnosis of GERD. Following these diagnostic procedures, treatment of acid reflux disease should be considered.
Acid Reflux Treatment
The aim of treatment are to reduce refluxing, render the refluxate harmless, improve esophageal clearance, and protect the esophageal mucosa. The management of non-complicated cases generally includes weight reduction, sleeping with the head of the bed elevated by about 4 to 6 in. with blocks, and elimination of factors that increase abdominal pressure. Patients should not smoke and should avoid consuming fatty foods, coffee, chocolate, alcohol, mint, orange juice, and certain medications (such as anticholinergic drugs, calcium channel blockers, and other smooth-muscle relaxants). They should also avoid ingesting large quantities of fluids with meals. In mild cases, life-style changes and over-the-counter antisecretory agents may be adequate. In moderate cases, H2receptor blocking agents (cimetidine, 300 mg; ranitidine, 150 mg bid; famotidine, 20 mg bid; nizatidine 150 mg bid) for 6 to 12 weeks are effective in symptom relief. Higher doses are necessary for healing erosive esophagitis, but proton pump inhibitors (PPIs) are more effective in this setting.

In cases resistant to H2receptor blockers and severe cases, rigorous acid suppression with aPPI is recommended. The PPIs are comparably effective: omeprazole (40 mg/d), lansoprazole (30 mg/d), pantoprazole (40 mg/d), and rabeprazole (20 mg/d) for 8 weeks can heal erosive esophagitis in up to 90% of patients. Reflux esophagitis requires prolonged therapy, for 3 to 6 months or longer if the disease recurs quickly. After initial therapy, a lower maintenance dose of PPI is used. Side effects are minimal. Aggressive acid suppression causes hypergastrinemia but does not increase the risk for carcinoid tumors or gastrinomas. Vitamin B12 absorption is compromised by the treatment. Patients with reflux esophagitis who have complications, such as Barrett's esophagus with concomitant esophagitis, should be treated vigorously. Patients who have an associated peptic stricture are treated with dilators to relieve dysphagia as well as provided with vigorous treatment for reflux.

Antireflux surgery, in which the gastric fundus is wrapped around the esophagus (fundoplication), increases theLESpressure and should be considered for patients with resistant and complicated reflux esophagitis that does not respond fully to medical therapy or for patients for whom long-term medical therapy is not desirable. Laparoscopic fundoplication is the surgery of choice. Ideal candidates for fundoplication are those in whom motility studies show persistently inadequate LES pressure but normal peristaltic contractions in the esophageal body.

Patients with alkaline esophagitis are treated with general antireflux measures and neutralization of bile salts with cholestyramine, aluminum hydroxide, or sucralfate. Sucralfate is particularly useful in these cases, as it also serves as a mucosal protector.

Acid Reflux Relief : Combination Therapy

Most patients treated with PPIs in conventional dosages do not exhibit complete suppression of stomach acid secretion. Approximately 70% of individuals who take a PPI twice a day experience nocturnal stomach acid breakthrough (defined as a stomach pH lesser than 4 for more than 1 hour at night). Brief episodes of acid reflux occur frequently during these breakthrough periods in patients with GERD. For some patients taking a PPI twice daily, nocturnal acid breakthrough can be abolished by adding a histamine H2-receptor blocker at bedtime. It is not clear that this approach is desirable, however. Complete elimination of acid reflux usually is not necessary to effect the healing of reflux esophagitis. Indeed, most patients who are treated with a PPI in conventional dosage exhibit complete healing of their symptoms and signs of GERD. No clear clinical benefit yet has been demonstrated for the practice of adding a histamine H2-receptor blocker at bedtime to PPI therapy.

A few older investigations have explored the value of combination drug therapy for the healing of GERD. The great efficacy of the PPIs used as single agents in this condition has discouraged investigators from undertaking new studies on combination therapy. Drug combinations that have been studied have included an H2 blocker plus either sucralfate or a prokinetic agent. Cimetidine (1200 mg/d) combined with sucralfate (5 g/d) was found to be superior to cimetidine alone for relieving daytime heartburn and for improving the endoscopic signs of esophagitis. For patients unresponsive to treatment with cimetidine alone, the addition of metoclopramide resulted in symptomatic improvement significantly more often than the addition of placebo, but side effects of metoclopramide were frequent. A combination of ranitidine (300 mg/d) plus metoclopramide (40 mg/d) was not found to be as effective as omeprazole alone (20 mg/d) in healing the signs and symptoms of esophagitis. Some studies explored combination therapy with the prokinetic agent cisapride, but these studies are of historical interest only because cisapride has been withdrawn from general use due to serious side effects (lethal arryhythmias). For patients with moderately severe reflux esophagitis, the use of combination therapy may eliminate the need for treatment with a PPI. However, the addition of a second medication increases the cost of therapy and the potential for side effects. Furthermore, the long-term benefit of combination therapy has not been demonstrated. For patients who are refractory to single-agent therapy (with an H2 blocker, sucralfate, or a prokinetic), a change to a PPI generally is more likely to effect healing than the addition of a second drug.