Get answers to your GERD/LERD questions.
Acid suppression continues to be the mainstay for treating GERD. The aim of drug therapy is to reduce the amount of acid and improve any abnormalities in muscle function of the lower esophageal sphincter, esophagus, or stomach.
Most cases of gastroesophageal reflux are mild and can be managed with lifestyle changes, over-the-counter medications, and antacids.
Patients with moderate-to-severe symptoms that do not respond to lifestyle changes, or who are diagnosed at a late stage may be started on medications of varying strength, depending on their complications at diagnosis. Experts argue, however, about the best way to start drug treatment for GERD in most of these patients. The two major treatment options are known as the step-up and step-down approaches:
If neither approach relieves symptoms, the physician should look for other conditions. Endoscopy and other tests might be used to confirm GERD and rule out other disorders, as well as evaluate when treatment is not working. In some cases, bile, not acid, may be responsible for symptoms, so acid-reducing or blocking agents would not be helpful. (Bile is a fluid that is present in the small intestine and gallbladder.)
To date, no treatments can reverse the cellular damage after Barrett's esophagus has developed, although some procedures are showing promise.
Medications. If a patient is diagnosed with Barrett's esophagus, the doctor will prescribe PPIs to suppress acid. Using these medications may help slow the progression of abnormal changes in the esophagus.
Surgery. Surgical treatment of Barrett's esophagus may be considered when patients develop high-grade dysplasia of the cells lining the esophagus. See "Surgery" section.
Here are some tips on managing GERD in infants:
Managing GERD in Children. The same drugs used in adults may be tried in children with chronic GERD. While some drugs are available over the counter, do not give them to children without physician supervision.
Surgical fundoplication involves wrapping the upper curve of the stomach (fundus) around the esophagus. The goal of this surgical technique is to strengthen the LES. Until recently, surgery was the primary treatment for children with severe complications from GERD because older drug therapies had severe side effects, were ineffective, or had not been designed for children. However, with the introduction of PPIs, some children may be able to avoid surgery.
Surgical fundoplication can be performed laparoscopically through small incisions. Weakening of the LES over the long-term occurs with children as well as adults.
Surgery may be needed in certain circumstances:
Some physicians are recommending surgery as the treatment of choice for many more patients with chronic GERD, particularly because minimally invasive surgical procedures are becoming more widely available, and only surgery improves regurgitation. Furthermore, persistent GERD appears to be much more serious than was previously believed, and the long-term safety of using medication for acid suppression is still uncertain.
Nevertheless, anti-GERD procedures have many complications and high failure rates. As with medications, current surgical procedures cannot cure GERD. About 15% of patients still require anti-GERD medications after surgery. Furthermore, about 40% of surgical patients are at risk for new symptoms after surgery (such as gas, bloating, and trouble swallowing), with most side effects occurring more than a year after surgery. Finally, evidence now suggests that surgery does not reduce the risk for esophageal cancer in high-risk patients, such as those with Barrett's esophagus. New procedures may improve current results, but at this time patients should consider surgical options very carefully with both a surgeon and their primary doctor.
Procedures to Remove the Mucus Lining. Various techniques or devices have been developed to remove the mucus lining of the esophagus. The intention is to remove early cancerous or precancerous tissue (high-grade dysplasia, or severe abnormalities in the cells) and allow regrowth of new and hopefully healthy tissue in the esophagus. Such techniques include photodynamic therapy (PDT), surgical removal of the abnormal lining, or ablation techniques, such as the use of laser, to destroy the abnormal lining.
Studies on ablation techniques combined with the aggressive use of proton-pump inhibitors or surgical treatments are very encouraging. For example, using high-intensity radio waves to remove precancerous esophageal tissue (dysplasia) seems to slow progression of Barrett's esophagus, and it may reduce the risk of esophageal cancer. Some of these techniques may eventually offer cures. At this time, they can be very effective at removing harmful tissue, although the benefits do not last in all patients. These procedures also carry potential complications, such as swallowing problems, which patients should discuss with their physician.
Esophagectomy. Esophagectomy is the surgical removal of all or part of the esophagus. Patients with Barrett's esophagus who are otherwise healthy are candidates for this procedure if biopsies show they have high-grade dysplasia or cancer. After the esophagus is removed, a new conduit for foods and fluids must be created to replace the esophagus. Alternatives include the stomach, colon, and a part of the small intestine called the jejunum. The stomach is the optimal choice.
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