Long-term strategy for the treatment of gastro-oesophageal reflux disease

Surprisingly little is known about the natural history of gastro-oesophageal reflux disease (GORD). There is no clear relationship between symptoms and the amount of GORD or oesophagitis. The substantial majority of GORD patients have mild disease and are free of oesophagitis. Little is known about the natural history of patients with mild reflux disease whose symptoms wax and wane. More is known about the natural history of patients with oesophagitis. After healing oesophagitis with H₂-receptor antagonists or omeprazole, the relapse rate after abrupt discontinuation has been disappointingly high. The aims of long-term treatment of reflux oesophagitis are prevention of symptoms, prevention of relapse, and prevention of complications. Lifestyle changes are said to be the cornerstone of a good anti-reflux regimen. Elevating the head of the bed on either blocks or a wedge improves acid clearance times. Recent reviews of the literature suggest that healing rates will rarely exceed 60% after up to 12 weeks of treatment, even when higher than standard doses are used. Healing differs considerably and depends mostly on the degree of oesophagitis before therapy. Superior results are obtained with omeprazole. It is readily apparent that mild to moderate acid suppression is inadequate in preventing relapse of reflux oesophagitis. Cisapride has recently been shown to be more effective than placebo in preventing relapse of oesophagitis. Also, the use of omeprazole seems promising in preventing relapse. The indication for surgical therapy today depends upon whether the patient becomes free of symptoms under conservative treatment or not regardless of the severity of the disease, or if GORD repeatedly recurs after initial successful medical therapy. The standard current approach is a 'floppy' Nissen fundoplication. The long-term results of operation are acceptable. Operation-related mortality today is well below of 0.5% and postoperative morbidity does not exceed 7-10%. The majority of the so-called 'post-fundoplication syndrome' sequelae are avoidable since they are due to surgical failures. Oesophageal columnar metaplasia (OCM) may occur after extensive reflux-induced destruction of the squalous epithelium. Columnar metaplasia is generally considered to be precancerous lesion. Not uncommonly, carcinoma may be multifocal. In the columnar epithelium surrounding the tumour, severe dysplasia is present in 90-100% of cases. As the majority of patients present with an advanced tumour, the prognosis is poor. Estimates of incidence differ considerably from one case per 52 to 441 patient years of follow-up.