GERD pathophysiology: the importance of acid control.

The optimal acute therapy for reflux disease is estimated and initiated on the basis of the patient's history. Endoscopy is initially warranted if there is significant doubt regarding the diagnosis of GERD or if the patient relays alarm symptoms suggesting more ominous diagnoses (dysphagia, bleeding, weight loss, odynophagia). Depending on the initial therapy rendered, medical therapy is then adjusted in a step up or step down fashion to ascertain the least potent effective regimen according to the scale of potency in table 1. Once identified, the optimal acute therapy should be maintained for at least 8 weeks. If even the most potent medical therapy still results in a poor response, further evaluation should be undertaken as indicated. On the other hand, if acute medical therapy alleviates symptoms, the patient should then be given a trial off of medication. The need for maintenance medical therapy is determined by the rapidity of recurrence; recurrent symptoms in less than 3 months suggest disease best managed with continuous therapy while remissions in excess of 3 months can be adequately managed by repeated courses of acute therapy as necessary. The 3 month figure is derived from observations of patients randomized to placebo in maintenance trials of proton pump inhibitors; if recurrence was going to occur within a year, it invariably occurred within the first 3 months. It is this author's opinion that patients who requires continuous maintenance therapy should have an endoscopy to rule out Barrett's metaplasia and, in particular, dysplasia. Patients on effective maintenance therapy may opt to have elective antireflux surgery after a thorough discussion of the associated risks and benefits.