What are the best treatment options for GERD?

Malcolm Robinson MD: Gastroesophageal reflux disease is an increasingly common problem, particularly in Western civilization. We think that as many as 20% of the population has very frequent reflux-related symptoms, and perhaps even 40% of the population could be defined as having reflux to an extent that is in some way pathological, so it's very common.

We understand that the pathophysiology of reflux disease is related to transient lower esophageal sphincter relaxations, but also to other processes, including impaired gastric emptying, impaired salivation, impaired esophageal peristalsis, and even in a few cases to the hypersecretion of gastric acid. Our therapeutic options for reflux disease begin with lifestyle modifications. Unfortunately, these are underutilized by many physicians and by most patients. Also, antacids are extremely effective in the short-term treatment of reflux symptoms. They are rapid in their onset. They last a surprisingly long time, and I think a lot of health professionals do not look upon these as a sufficiently high-tech medication to be recommended.

However, I personally recommend that antacids be tried in patients with reflux disease and intermittent symptoms very early along and be added to regimens in patients who are in breakthrough symptoms for whatever reason.

Beyond antacids, we have a variety of pharmacological approaches to reflux disease. H2 receptor antagonists remain highly effective for the intermittent therapy of heartburn, but are probably not too effective for chronic use because of the development of tachyphylaxis or tolerance.

Beyond the H2 receptor antagonists are the proton pump inhibitors. We know that proton pump inhibitor therapy will heal erosive esophagitis effectively, even in patients who have failed to respond to adequate doses of H2 receptor antagonists. We know that proton pump inhibitors, unlike H2 receptor antagonists, will maintain patients in a symptom-free state week after week, month after month, and even year after year. And this has become extremely advantageous in the modern therapy of reflux disease. We do have some more aggressive, invasive techniques for the treatment of reflux disease. We have surgery. We have a number of new endoscopic procedures that are used for reflux disease. Surgery clearly has a role, but it's a very tertiary role in very few patients, because most patients will respond to medical therapy and because, unlike medical therapy, surgery has very significant associated morbidity and even some mortality.

The new endoscopic procedures for reflux disease are all fascinating, but none are ready for prime time because all of these procedures are understood only on an acute basis, and this, of course, is a chronic disease.