Medical Treatment for Reflux

"Reflux" usually refers to the regurgitation of stomach contents into the esophagus. This causes heartburn and can even cause a laryngitis-like sensation. Patients with esophageal reflux are at increased risk of developing Barrett's esophagus and esophageal cancer.

The goals of medical treatments are to:

  • Decrease gastroesophageal reflux
  • Improve esophageal clearance
  • Protect the esophageal lining

These goals can be achieved by certain general measures and specific drug treatments. Treatment controls symptoms and reflux esophagitis but does not result in regression of Barrett's esophagus. There is still a small risk of developing esophageal cancer. Therefore, patients need to be monitored closely and followed up with periodic endoscopic biopsies for the development of dysplasia and early adenocarcinomas.

Traditional advice to patients with uncomplicated cases has been to elevate the head of the bed by using blocks or a foam wedge. This simple procedure can help reduce the reflux that may occur while sleeping. Patients are also advised to lose weight, avoid eating within 3 hours of bedtime, and cut back on large or high-fat meals. Chocolate, nicotine, peppermint, raw onions, caffeine, and alcohol may aggravate reflux and are best avoided.

In mild cases of gastroesophageal reflux, the use of certain over-the-counter and prescription medicines can be indicated. These include histamine H2 receptor blocking agents such as cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), and nizatidine (Axid), as well as proton pump inhibitors (discussed in the next section). Tums, Rolaids, or other quick-acting reflux medications can also be considered.

Prokinetic agents, or drugs that help move food through the gastrointestinal tract more quickly, offer an attractive alternative either alone or in combination with acid inhibition. For example, metoclopramide can be taken 30 minutes before meals and at bedtime to hasten gastric emptying and improve esophageal clearance.

Proton pump inhibitors

Proton Pump Inhibitors

Proton pump inhibitors (PPIs), including Prilosec (omeprazole is available over the counter) and Prevacid, have been shown to be effective in treating GERD. PPIs are more potent suppressors of gastric acid secretion compared to histamine H2 receptor blocking agents. However, some patients report that when the use of a PPI is discontinued, symptoms recur within days. Thus, patients often need to continue the PPI on a long-term basis. Reflux esophagitis requires prolonged therapy for 3 to 6 months or longer if the disease recurs quickly. As noted above, treatment with PPIs and other medications controls symptoms and reflux esophagitis but does not result in regression of Barrett's esophagus. Therefore, the risk of cancer is not eliminated and endoscopic surveillance is necessary.

Surgery for Reflux

Laparoscopic fundoplication illustration

Fundoplication

For some patients with severe reflux disease, an operation is an alternative option to long-term use of medication. This applies especially to patients with resistant (at least 6 to 12 months) or complicated reflux esophagitis (with strictures) that does not respond fully to medical therapy or to patients in whom long-term medical therapy is not desirable.

Usually a laparoscopic fundoplication (in which the gastric fundus is wrapped around the esophagus so as to mimic a normal lower esophageal sphincter and prevent reflux) is performed. The laparoscopic approach has substantially reduced postoperative discomfort in comparison with open thoracotomy or laparotomy (opening the abdomen). Johns Hopkins also offers transoral incisionless fundoplication (TIF).