How is GERD with or without Barrett's esophagus treated?
Medical (non-surgical) therapy
The medical treatments for the symptoms of Barrett's esophagus are the same as those for GERD.
The suppression of acid is the backbone of treatment for GERD. For mild reflux symptoms, over-the-counter medications are commonly used, ranging from antacids to low doses of drugs called H-2 receptor antagonists or H2 blockers. Examples of over-the-counter H2 blockers are cimetidine (Tagamet) and famotidine (Pepcid, Zantac 360). For more persistent symptoms, higher (prescription-strength) doses of the H-2 receptor antagonist drugs may be used, for example:
However, for persistent symptoms requiring maintenance (ongoing) therapy or for complicated GERD with strictures or bleeding, proton pump inhibitors (PPIs) are used. Examples of PPIs are:
Some patients need to take only one pill daily, while others need two pills (a double dose) to control the symptoms. The double dose can be taken as one pill twice daily or 2 pills once daily.
PPIs are potent inhibitors of acid secretion from the stomach. They are effective in relieving heartburn and healing esophageal inflammation (esophagitis) and esophageal ulcers that are induced by acid reflux. The PPIs are well tolerated with few side effects. After stopping these medications, symptoms of acid reflux usually recur, sometimes with increased intensity. This increase in symptoms occurs, in part, because of a rebound secretion of acid (acid hypersecretion), which is a response prompted by recovery from the inhibition of secretion of acid by the PPI.
The long-term safety of the PPIs is an important consideration. Although certain stomach tumors (carcinoids) were reported in experiments with older female rats, similar tumors have not been observed in people after more than 15 years of PPI use. In some people on long-term PPI therapy, small benign polyps (fundic gland polyps) may develop in the upper half of the stomach. However, these polyps do not require follow-up or biopsy because they remain benign (do not become malignant) and cause no problems. Long-term use also is associated with a slightly increased risk of hip fractures in people older than 50 years, and poor absorption of vitamin B12.
The main point to remember about PPIs is that patients should never abruptly stop them. When PPIs are discontinued, the dose should be gradually decreased (tapered). Tapering the dose minimizes the rebound hypersecretion that can occur when PPIs are stopped. If a patient is hospitalized and cannot eat (or take pills), intravenous acid-suppressing drugs at higher doses should be given. Gradual lowering (tapering) of the dose of PPIs should be done when these drugs are to be discontinued after fundoplication (anti-reflux surgery) operations for GERD.
In addition to drug therapy, certain lifestyle maneuvers are very important. These include:
- Losing weight, if overweight.
- Change the diet, by reducing fat, chocolate, caffeine, and acid food and fluids (for example, citrus).
- Stop smoking.
- Avoid excessive alcohol.
- Avoid food and fluids for 90 to 120 minutes before going to bed.
- Elevate the upper body when lying in bed by (for example, putting blocks under the head of the bed).
A number of drugs, including tricyclic antidepressants and calcium channel blockers, may promote gastroesophageal reflux. Therefore, if an alternative medication can be substituted for these drugs, this may help in the management of reflux. Patients with GERD should consult their physicians regarding medications that can promote reflux, and if alternatives are available.
Adjunctive (supplementary) drug therapy has been used in the past for patients whose symptoms are not easily controlled with double daily dose of a PPI. The supplementary drugs commonly used are called prokinetics. These drugs work by accelerating gastric emptying so that there is less food and fluid in the stomach for reflux. Cisapride (Propulsid) was the most commonly used drug in this class, but it was taken off the market because of adverse cardiac effects. Metoclopramide (Reglan) is another prokinetic agent, but it is approved only for short term use and can cause drowsiness, restlessness and more important neurological complications. Although other prokinetic drugs are available, none have had the kind of scrutiny in GERD as did cisapride. One drug that has similar actions as cisapride is domperidone (Motilium). It is available in many countries, but has not been approved by the Food and Drug Administration (FDA) in the U.S.
Surgical treatment of GERD, with or without Barrett's esophagus
GERD, with or without the presence of Barrett's esophagus, sometimes is treated by anti-reflux surgery. This operation, called fundoplication, is done to stop the reflux of acid. Fundoplication is not done for Barrett's esophagus itself. The operation involves wrapping the upper stomach (the fundus) around the lower end of the esophagus. The purpose of the wrap is to tighten the lower esophageal sphincter (LES) in order to prevent the reflux of stomach contents into the esophagus. There is no evidence that anti-reflux surgery, or for that matter, acid suppression therapy with drugs, decreases the risk of esophageal cancer among patients with Barrett's. This doesn't mean that the possibility is not affected, but it would take long-term studies to prove that either medical or surgical treatment decreases the risk of cancer, and such studies are not likely to be done.
Candidates for the fundoplication operation are patients with GERD who:
- Have serious complications, such as recurring strictures; or
- Require high doses of acid-suppressing medications, and want to stop taking these medications.
Today, this surgery is usually done laparoscopically without the need for a large incision. Therefore, patients have a much shorter recovery time and can be discharged home within a few days. In some patients, for technical reasons, laparoscopic surgery cannot be done, and the conventional open operation is necessary.
A number of new endoscopic approaches are being evaluated to replace surgery (fundoplication) for the treatment of GERD. The idea is to endoscopically tighten up the junction between the stomach and esophagus to prevent reflux. The tightening is done during upper GI endoscopy by, for example, internally sewing (suturing) or clipping the region of the lower esophageal sphincter. As more data has become available showing that these techniques are as effective as fundoplication, they are increasingly being used as an option for managing these patients.