New strategies in the management of GERD and dyspepsia
- Author:
Espallardo Noel L.
;
Daez Ma Lourdes
- Publication Type:Journal Article
- MeSH:
DYSPEPSIA;
INDIGESTION
- From:
The Filipino Family Physician
2011;49(1):1-7
- CountryPhilippines
- Language:English
-
Abstract:
The internationally accepted definition of dyspepsia is "chronic or recurrent pain or discomfort centered on the upper abdomen."Gastro-esophageal reflux disease on the other hand is defined as the presence of risks of physical complications of gastroesophageal reflux, or the experience of clinically significant impairment of health-related well being (quality of life) due to reflux related symptoms. Several theories have been proposed regarding the etiology of these disorders, including acid exposure, visceral hypersensitivity, impaired fundal accommodation, delayed gastric emptying, and H. pylori infection. There seems to be a significant overlap of pathophysiological disorders between dyspepsia and GERD. The diagnosis of dyspepsia is challenging. The use of self administered questionnaires in routine clinical care has been questioned by other authors as studies showed that the rate of recognition of heartburn differed between questionnaires. Endoscopy is the preferred procedure to detect lesions in the upper gastrointestinal tract. However, experts suggest empiric treatment over prompt endoscopy because of cost and limited availability of endoscope facilities.
After a diagnosis of dyspepsia or GERD, the primary care physician can choose between the following strategies: symptom-guided empirical treatment, direct referral for endoscopy, non-invasive testing for H pylori and subjecting the H pylori positive patients to endoscopy ("test-and-scope"), and. non-invasive testing for H pylori and treatment of the infection in H pylori positive patients ("test-and-treat"). While the role of H pylori in peptic ulcer has been clearly established, its role in dyspepsia is still being debated. A recent meta-analysis suggested that there is a small benefit of about 10% over placebo.
Considering the pathophysiology as acid reflux and dysfunctional motility as being the main problem, the combination of a prokinetic like domperidone and a PPI like pantoprazole may offer improved response to empiric treatment. Starting the patient on high potency drugs or combination treatment (step-down approach) is therefore a new strategy that has potential impact to improve response. Potential advantages of the step-down approach include faster healing, maximum symptom relief and a more rapid improvement in the patient's quality of life.
Adherence to treatment is also an issue for a chronic and relapsing illness like dyspepsia and GERD. Adherence to prescribed self-administered medication is low in patients with chronic conditions. It is estimated to average only 50%. Fixed dose and sustained release formulations are designed to decrease the number of pills to be taken and the frequency of dosing Le. simplifying the treatment regimen thereby improving adherence.
Dyspepsia is a multi-factorial syndrome. Abnormalities include disturbances of GI motor and sensory function as well as specific psychological disorders including depression and anxiety. An intensive medical treatment targeting GI abnormalities with psychological interventions will result to better long-term improvement of symptoms.
