Current management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a chronic condition that is very common, and may result in considerable morbidity as well as mortality (from complications). I present data on the therapy of patients with GERD and offer a practical approach to their management. The goals of management of GERD are relief of symptoms, healing of esophagitis, prevention of complications, and maintenance of remission. Simple lifestyle changes may control GERD in up to 20% of patients. Promotility therapy addresses the pathophysiology of this disorder, but the best results are only 50 to 60% control using cisapride, whereas the older agents (metoclopramide and bethanechol) are limited by side effects. Acid suppression using histamine receptor antagonists controls GERD in 50 to 60% of patients, whereas proton pump inhibitors offer the most effective control (80-100%). A surgical approach (especially using newer laparoscopic techniques) will provide effective therapy of GERD in a high percentage of patients, but further careful comparisons are needed to define the long-term efficacy and cost issues associated with both surgical and chronic medical therapy of GERD. Despite this lack of long-term data, we know that GERD is a chronic, often lifelong illness, and maintenance therapy should be offered to most patients. This therapy may include aggressive medical therapy (up to and including chronic proton pump inhibitor therapy) or antireflux surgery in selected patients.