Archive October 2017 XVIII, No. 10

Your Best Treatment Options for GERD

Several possible interventions are available. Here are some factors to consider.

Ronnie Fass

Ronnie Fass, MD


Dr. Fass and his staff GERD WATCHING Dr. Fass and his staff examine a high-resolution esophageal manometry image to determine whether there are abnormalities in a patient's upper esophageal sphincter.

The number of treatment options available to the estimated 50 million Americans suffering with gastroesophageal reflux disease (GERD) is growing. There are now 3 FDA-approved endoscopic therapies and 2 minimally invasive surgical procedures. At least one other new procedure is in the pipeline, awaiting FDA approval. But it's important to note that as promising and potentially effective as some or all of these treatments may end up being, for most patients they shouldn't be the first choice. Instead, they should be considered when medication isn't the most viable option. Still, that leaves a significant subset of patients who may be good candidates for surgery or endoscopic therapy. Which treatment makes the most sense? The answers aren't always black and white, but there are some factors to consider.

Which patients?
The first consideration, of course, is pinpointing which patients we're talking about. Some patients simply aren't interested in medical therapy, which is usually administered in the form of proton pump inhibitors (PPIs). Those patients may not want to deal with having to take pills on a daily basis, or they might not trust themselves to be compliant. There are also a growing number of patients who are concerned about the potential side effects of PPIs. Taken, together, these make up one subset of patients who may be good candidates for endoscopic or surgical therapy.

Some patients have side effects from medical therapy and thus can't take the appropriate medication. For others, PPIs aren't enough to fully control their symptoms, and they have a poor quality of life as a result. Or they may be symptomatic because they also have large hiatal hernias, a condition that definitely requires surgery.

Patients whose predominant symptom is regurgitation or who continue to have an abnormal pH test despite being on the maximum PPI dosage (and who are assessed to be fully compliant) are also candidates for surgical or endoscopic interventions. And patients who have symptoms that correlate with what's called non-acid reflux, despite taking maximum PPI doses, may also benefit from interventions. (The term non-acid reflux is common, but it's really a misnomer. These are the patients who have weakly acidic reflux [pH between 4 and 7], neutral reflux [7] or alkaline reflux [above 7]).

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