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DIAGNOSIS AND MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE

DIAGNOSIS AND MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE ABCDDV/1011 ABCD Arq Bras Cir Dig Review Article 2014;27(3):210-215 DIAGNOSIS AND MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE Diagnóstico e tratamento da doença do refluxo gastroesofágico Maria Aparecida Coelho de Arruda HENRY From the Department of Surgery and ABSTRACT - Introduction: Gastroesophageal reflux disease (GERD) is probably one of the Orthopedy, School of Medicine, São Paulo most prevalent diseases in the world that also compromises the quality of life of the affected State University (UNESP), Botucatu, SP, Brazil significantly. Its incidence in Brazil is 12%, corresponding to 20 million individuals. Objective: To update the GERD management and the new trends on diagnosis and treatment, reviewing the international and Brazilian experience on it. Method: The literature review was based on papers published on Medline/Pubmed, SciELO, Lilacs, Embase and Cochrane crossing the following headings: gastroesophageal reflux disease, diagnosis, clinical treatment, surgery, fundoplication. Results: Various factors are involved on GERD physiopathology, the most important being the transient lower esophageal sphincter relaxation. Clinical manifestations are heartburn, regurgitation (typical symptoms), cough, chest pain, asthma, hoarseness and throat clearing (atypical symptoms), which may be followed or not by typical symptoms. GERD patients may present complications such as peptic stenosis, hemorrhage, and Barrett’s esophagus, which is the most important predisposing factor to adenocarcinoma. The GERD diagnosis must be based on the anamnesis and the symptoms must be evaluated in terms of duration, intensity, frequency, triggering and relief factors, pattern of evolution and impact on the patient’s quality of life. The diagnosis requires confirmation with different exams. The goal of the clinical treatment is to relieve the symptoms and surgical treatment is indicated for patients who require continued drug use, with intolerance to prolonged clinical treatment and with GERD complications. Conclusion: GERD is a major digestive health problem and affect 12% of Brazilian people. The anamnesis is fundamental for the diagnosis of GERD, with special analysis of the typical and atypical symptoms (duration, intensity, frequency, triggering and relief factors, evolution and impact on the life quality). High digestive endoscopy and esophageal pHmetry are the most sensitive diagnosctic HEADINGS - Gastroesophageal reflux. methods. The clinical treatment is useful in controlling the symptoms; however, the great problem Diagnosis. Therapeutics. Fundoplication. is keeping the patients asymptomatic over time. Surgical treatment is indicated for patients who Surgery. required continued drug use, intolerant to the drugs and with complicated forms of GERD. Correspondence: RESUMO - Introdução: A doença do refluxo gastroesofágico (DRGE) é, provavelmente, uma das Maria Aparecida Coelho de Arruda Henry doenças mais prevalentes no mundo que compromete significativamente a qualidade de vida. e-mail: rhenry@ibb.unesp.br Sua incidência no Brasil é de 12%, o que corresponde a 20 milhões de indivíduos. Objetivo: Atualizar o manuseio da DRGE e as novas tendências no diagnóstico e tratamento, revendo as Financial source: none experiências internacional e brasileira sobre o tema. Método: Foi realizada revisão da literatura Conflicts of interest: none baseada em artigos publicados no Medline/Pubmed, SciELO, Lilacs, Embase e Cochrane cruzando os seguintes descritores: doença do refluxo gastroesofágico, diagnóstico, tratamento Received for publication: 06/12/2013 clínico, cirurgia, fundoplicatura. Resultados: Vários fatores estão envolvidos na fisiopatologia Accepted for publication: 08/05/2014 da DRGE, sendo o mais importante o relaxamento transitório do esfíncter inferior do esôfago. As manifestações clínicas são azia, regurgitação (sintomas típicos), tosse, dor torácica, asma, rouquidão e pigarro (sintomas atípicos), que podem ser seguidos ou não de sintomas típicos. Pacientes com DRGE podem apresentar complicações como estenose péptica, hemorragia e esôfago de Barrett, que é o fator predisponente mais importante para adenocarcinoma. O diagnóstico deve ser baseado na anamnese e os sintomas devem ser avaliados em termos de duração, intensidade, frequência, fatores precipitantes e relevância, padrão de evolução e impacto na qualidade de vida do paciente. O diagnóstico exige confirmação com exames diferentes. O objetivo do tratamento clínico é aliviar os sintomas e o tratamento cirúrgico é indicado para os que necessitam de uso contínuo de drogas, com intolerância ao tratamento clínico prolongado e com complicações. Conclusão: A anamnese é fundamental para o diagnóstico de DRGE, com análise especial dos sintomas típicos e atípicos. Endoscopia digestiva alta e pHmetria esofágica são os métodos diagnósticos mais sensíveis. O tratamento clínico é útil no controle dos sintomas; DESCRITORES - Refluxo Gastroesofágico. no entanto, o grande problema é manter os pacientes assintomáticos ao longo do tempo. O Diagnóstico. Terapêutica. Fundoplicatura. tratamento cirúrgico é indicado para pacientes que necessitaram o uso contínuo de drogas, Cirurgia. intolerantes às drogas e com formas complicadas da DRGE. INTRODUCTION astroesophageal reflux disease (GERD) is a major digestive health problem due to its ever high and increasing incidence and because it is the cause Gof serious complications. It is defined as a condition that involves gastric content reflux with ensuing symptoms or complications . It is one of the most frequent causes of gastroenterological consultations in out-patients and compromises the quality of life of the patients significantly . The objective of this review was to update the GERD management and the new ABCD Arq Bras Cir Dig 2014;27(3):210-215 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercia License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. DIAGNOSIS AND MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE trends on diagnosis and treatment, reviewing the international thorax pain, respiratory manifestations (cough and bronchial and Brazilian experience on it. asthma), otorhinolaryngologic disorders (dysphonia, throat clearing and pharyngeal globus sensation), and oral disorders 1,14,15,22,37 (dental erosion, aphtha and halitosis) (Table 1). METHOD TABLE 1 - Typical and atypical GERD manifestations Symptoms Atypical manifestations A population study was conducted in 22 cities from Typical Othorhyno- different regions of Brazil involving 13,959 adults older than manifestations Pulmonary Orals laringological 16 years of age. The participants replied a questionnaire on Chronic cough heartburn complaints and frequency. Heartburn occurrence Pharyngitis over once a week was reported by 12% of the participants, Heartburn Hoarseness Dental erosion Throat clearing Acid Otitis Halitosis which corresponds to 20 million Brazilians who are affected Pneumonia Regurgitation Sinusitis Aphtha by GERD . Bronchiectasia In a similar study, Oliveira et al. (2005) surveyed 3,934 Asthma individuals from Pelotas, Rio Grande do Sul state regarding heartburn symptoms and/or bitter taste. They reported that Patients with atypical manifestations may not present 31.3% of the investigated population presented symptoms at the typical GERD symptoms. The screening criteria for the least once a week. Association with women, aging and stress investigation of GERD in patients with chronic cough were was reported in population studies . not smoking patients and absence of environmental irritants, Similar and sometimes higher values have been non-asthmatic, retronasal secretion, normal thorax and reported in other Western countries. Lower incidence rates sinus radiographs . Patients with otorhinolaryngological in Eastern countries (India – 7.5%, Malaysia – 3.0%, China – manifestations initially visited an area specialist and 0.8%) suggest that environment, alimentary habits and even performing laryngoscopy, which may reveal GERD-specific race contribute with factors on GERD . lesions, such as edema, erythema, vocal cord nodules, The most relevant contributing factor to GERD is the granulomas . transient lower esophageal sphincter relaxation. It may last from 5 to 35 s and is not related to swallowing; it occurs when Diagnosis methods 5,31 the gastric fundus is distended by food or gas . More frequently the patients had a mean age of 54 In addition to transient lower esophageal sphincter years, presented heartburn and acid regurgitation and GERD relaxation, other factors participate in the physiology of GERD, test sensitivity of 67% and specificity of 77% . Thus, the GERD such as lower esophageal sphincter hypotonia, alteration in diagnosis confirmation required further exams. the gastroesophageal anti-reflux barrier as a result of slipping hiatus hernia, inadequate esophageal peristalsis, lesion of High digestive endoscopy the esophageal mucosa, obesity, pregnancy and the use of This is the exam of choice in the evaluation of patients 5,17,24 estrogens . with GERD symptoms and it is indicated in chronic cases GERD patients, especially with chronic disease, may in patients over 40 years old and with alarm symptoms, present complications such as Barrett’s esophagus (BE), such as dysphagia, odynophagia, weight loss, digestive peptic stenosis, and hemorrhage. BE is a most relevant hemorrhage, nausea, vomits, and family history of cancer. complication due to the susceptibility of evolution to It allows the diagnosis of other disorders as well, such as adenocarcinoma. It involves the substitution of the peptic ulcer, esophageal moniliasis, gastric cancer and esophageal squamous epithelium, usually in the distal eosinophilic esophagitis, which also present dyspepsia portion of the esophagus, with glandular columnar symptoms. It also allows the obser vation of erosions (limited epithelium with calciform cells and affects from 10-15% dissolution of mucosa continuity with at least 3 mm, fibrin of chronic GERD patients. Another major complication deposition and neutrophilic epithelial permeation, which is is peptic stenosis, more frequent in patients with severe characteristic of esophagitis), ulcers (dissolution of mucosa esophagitis associated with dysphagia resulting in continuity reaching at least the mucosa muscle layer), esophageal obstruction. Hemorrhage from esophageal Barrett’s esophageal peptic stenosis . Other lesions that do ulcers is the least frequent complication. not allow GERD diagnosis due to their subjectivity may also be observed, such as edema, erythema and friability. Diagnosis Various classifications have been proposed to The main resource in GERD diagnosis is the clinical characterize the intensity of reflux esophagitis. The most history. The anamnesis must identify the characteristic commonly used is the Los Angeles Classification (Table 2). It is symptoms, their duration, intensity, frequency, triggering worth pointing out that esophagitis is diagnosed in only 40% and relief factors, evolution over time and the impact on the of GERD patients and that its severity does not correlate with quality of life . Typical symptoms reported by most 20 38 the intensity of the symptoms . Nasi et al. (2001) disagree patients are heartburn and acid regurgitation. Heartburn and reported to have observed intense heartburn in 37.5% of is a retrosternal burning sensation that irradiates from the the patients with erosive esophagitis and in 10.3% of patients manubrium of the sternum to the base of the neck or throat. without erosion (p<0.01). It generally occurs 30-60 min after eating, especially a large meal or a meal rich in fat or acid foods. It may be relieved by TABLE 2 - Los Angeles endoscopic classification taking antacid or even water . Acid regurgitation is the reflux of the acid content into the oral cavity. Degree Finding If the patients present these symptoms at least twice A One or more erosions smaller than 5 mm a week in a period of four to eight weeks or more, GERD One or more erosions greater than 5 mm in its greater diagnosis must be considered. However, one must bear in extension, non-continual between esophageal fold apices Contiguous (or convergent) erosions between at least mind that other diseases, such as peptic ulcer, gastritis and C esophageal fold apices, commitment of less than 75% of gastric cancer, have similar symptoms. the esophagus GERD may present other clinical manifestations as well. D Erosion of at least 75% of the esophagus circumference The most frequent atypical manifestations are non-coronary ABCD Arq Bras Cir Dig 2014;27(3):210-215 REVIEW ARTICLE The complementation of the endoscopic exam with receptor attached to the patient’s belt for computer analysis. biopsy must not be a routine procedure and must be reserved It is spontaneously released and is eliminated through the for special situations, such as stenosis, ulcer and BE. digestive tract. The use of this method is rather limited in Brazil due to the high cost of the capsule . After a comparative Radiological examination of the esophagus study of the conventional and the wireless esophageal pH- This examination has low sensitivity and specificity metry methods, Azzar et al. (2012) concluded that both are in the diagnoses of GERD. It must be ordered when the able to diagnose pathological gastroesophageal reflux. patient reports dysphagia and/or odynophagia, since it allows the morphological evaluation of the esophagus and Bernstein test demonstrates the occurrence of stenosis and conditions that This is a provocative test in which the esophageal favor gastroesophageal reflux, such as slipping hiatus hernia mucosa is perfused with a diluted hydrochloric acid solution. and abnormal gastroesophageal angle . The appearance of symptoms during perfusion is associated with sensitivity and specificity of around 80%. However, the Computerized esophageal manometry results are only qualitative and do not allow the quantification Esophageal manometry is not used for diagnosis of gastroesophageal reflux. It has nearly ceased to be used purposes; however, it provides very useful information for the after the development of 24-h esophageal pH-metry . evaluation of the pressure tonus of the esophageal sphincters and the motor activity of the body of the esophagus. It Esophageal impedanciometry has a predictive value in the assessment of the evolution This is a new method that demonstrates the antegrade of GERD. Thus, the diagnosis of severe lower esophageal and retrograde movements of the refluxate. In association sphincter hypotonia (lower than 10 mm Hg) indicates clinical with pH-metry (esophageal impedance-pH-metry), it also maintenance treatment or even surgical fundoplication. evaluates the physical (liquid, gaseous, mixed) and chemical Andreollo et al. (2010) observed its hypotonia in 29.5% of (acid, non-acid, mildly acid) nature of the refluxate. Therefore, the patients submitted to laparoscopic fundoplication. this exam provides the characterization of liquid, gaseous or Other indications for esophageal manometry are: mixed refluxate and whether it is acid or non-acid. In patients a) localization of the esophageal sphincters, essential irresponsive to PPI, non-acid reflux diagnosis is indicative of information for the correct positioning of pH-metry sensors; surgical treatment, as the fundoplication surgery eliminates b) diagnosis of specific motor disorders, such as achalasia, these two types of reflux . collagen disease, aperistalsis and severe hypocontractility; c) motor activity analysis previous to fundoplication to Therapeutic testing ensure that the esophagus has conditions to adapt to a In patients under 40 years old with typical GERD 19,37 gastroesophageal anti-reflux valve . complaints and without alarm manifestations, PPI full doses may be administered for four weeks associated with Esophageal scintigraphy behavioral measures (Table 3). The test is considered positive This exam exhibits the gastroesophageal reflux after when the symptoms disappear, with a strong indication of 99 5 the ingestion on technetium -marked contrast. This is a non- GERD diagnosis . invasive technique that can be used in the diagnosis of GERD in children. However, this exam is expensive and available in TABLE 3 - Behavioral measures proposed by the 3rd Brazilian few advanced centers . GERD Consensus 1. Elevation of the bed head (15 cm) Prolonged esophageal pH-metry Moderation in the ingestion of the following foods (based on This is a specific and sensitive method for the diagnosis 2. symptom correlation): fatty foods, citrus, coffee, alcoholic and/ of gastroesophageal reflux that has a high correlation with its or carbonated beverages, mint, peppermint, tomato, chocolate symptoms (symptom index). In addition to the diagnosis and Special care with “at risk” medicines: anticholinergics, evaluation of the intensity of GERD, this exam characterizes its theophylline, calcium-channel blockers, alendronate pattern, that is, if it is orthostatic, supine or bipositional . This 4. Avoidance of lying down in the 2 h following meals exam is recommended in the following situations: a) GERD 5. Avoidance of large meals diagnosis in normal upper endoscopy; b) characterization of 6. Quitting of smoking the gastroesophageal reflux pattern; c) contribution of acid 7. Reduction of body weight, if overweight reflux to atypical GERD manifestations with examination with a catheter with at least two sensors is advisable - one Treatment positioned at the distal esophagus, and the second at the There are two therapeutic approaches to GERD, upper esophageal sphincter or above -, for the diagnosis of clinical and surgical, the choice of which depends on the gastroesophageal and laryngopharyngeal reflux, respectively; patient’s characteristics (age, treatment adherence, personal d) study of symptom recurrence after surgery; e) evaluation of preference, existence of comorbidity) and on factors such the efficacy of the clinical treatment . as treatment response, existence of esophageal mucosa In patients with normal pH values and with response erosions, atypical symptoms and complications . favorable to proton pump inhibition (PPI), the diagnosis of non-erosive reflux disease is advisable. Another relatively Clinical treatment common situation is the patient who presents normal pH The goal of the clinical treatment is symptom relief, values, a negative symptom index, and is irresponsive to PPI, healing the esophageal mucosa lesions and prevention of the which is suggestive of functional heartburn diagnosis. development of complications. It is based on pharmacological and non-pharmacological measures. Wireless prolonged esophageal pH-metry (Bravo capsule) This method has the advantages of providing a greater Non-pharmacological treatment comfort to the patient, longer esophageal pH recording (up The non-pharmacological treatment involves behavioral to 96 h), and the added advantage of non-displacement measures (Table 3). In the last years, these recommendations of the catheter, which may occur in the conventional pH- have been questioned by some authors based on their lack metry. A capsule temporarily fixed by suction onto the distal of scientific foundation in addition to their deleterious effects esophageal mucosa telemetrically transmits signals to a 30 12 to the patients’ quality of life . Castro et al. (2000) reported ABCD Arq Bras Cir Dig 2014;27(3):210-215 DIAGNOSIS AND MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE that these measures do not benefit the great majority of or weakly acid reflux patients is gamma-aminobutyric acid GERD patients. Nevertheless, these recommendations are type B . time honored and considered useful. In addition to the recommendations, the patients’ diet Surgical treatment must be personalized considering their complaints about Surgical treatment is indicated for patients who require each food. The measures also contribute to improve the continued drug use, intolerant to prolonged clinical treatment 20 24 doctor-patient rapport and increase treatment adherence . and with complicated forms of GERD. Herbella & Patti (2010) proposed that the surgical treatment must also be indicated Pharmacological treatment for women in the menopause and with osteoporosis, given Various drugs may be used to treat GERD. Currently, PPI the possible interference of PPI in calcium absorption. The are the drugs of choice, inhibiting the production of acid by major difficulty in the clinical treatment is not controlling the the stomach parietal cells, thus reducing the aggression of symptoms, but keeping the patients asymptomatic over time. the esophagus by acid. Omeprazole is the most used PPI and The surgical treatment consists in making an anti- is freely distributed by the Brazilian Health Ministry to the gastroesophageal reflux valve using the gastric fundus low-income population. Full PPI doses for 4-8 weeks are the (fundoplication), as proposed by Nissen (1956) . It corrects initial treatment of choice. If the patient’s symptoms do not an anatomic defect by reducing the slipping hiatal hernia disappear, the dose must be doubled, one before breakfast obser ved in 89% of pathological GERD patients . Furthermore, and another before dinner. it restores LES competence, as demonstrated by experimental 23,24,28,41 Erosive GERD responds satisfactorily to clinical and clinical studies . 18,36 treatment . However, the symptoms reappear after the There are three main surgical GERD procedures: total medication is stopped because the disease is chronic and fundoplication (Nissen), in which the esophagus is completely requires continued PPI use. This is the maintenance treatment surrounded (360°), partial fundoplication (Toupet), and mixed and the dose must be appropriate to keep the patient fundoplication, introduced by Brandalise & Aranha (1996) asymptomatic. This therapy is efficient in the long term and (Figure 1). no dysplasia or neoplasia was observed by Klinkenberg-Knoll et al. (2000) after following up 230 GERD patients under PPI for 11 years. However, it is worth pointing out that this type of treatment requires great discipline due to the associated eating and living habit restrictions. Clinical practice shows that young patients, who fail to adhere to the treatment, may benefit from on-demand treatment, that is, irregular doses as required. Histamine H receptor antagonists and prokinetic drugs are considered second-line drugs. They act by blocking histamine H receptors in parietal cells and reducing acid excretion. The most commonly used are ranitidine, famotidine, cimetidine and nizatidine. Prokinectic drugs act by accelerating gastric emptying; however, they do not act on transient lower esophageal sphincter relaxation. The most used are metoclopramide and domperidone. They must be prescribed when there is gastroparesis. If the patient presents side effects to PPI or histamine H receptor antagonists, alginate and sucralphate antacids may be prescribed for temporary symptom relief. Special attention must be paid to pregnant women due to the teratogenic effect of these drugs. The importance of behavioral measures must be highlighted and the use of systemic absorption drugs must be avoided. The use of antacids is recommended. If the symptoms persist, histamine H receptor antagonists may be prescribed. Among the systemic agents, only its use is safe during lactation, as most FIGURE 1 - Brandalise & Aranha’s fundoplication procedure drugs are excreted in the milk . Regarding the role of PPI in the treatment of GERD, The early 1990s saw a significant increase in the from 20 to 42% of the patients do not respond satisfactorily number of referrals to surgical GERD treatment coincident to it, a condition known as refractory GERD. According to 34 with the description of video-laparoscopic fundoplication Moraes Filho (2012) , the main causes of refractory GERD by Dallemagne et al. (1991) . This technique affords access are: functional heartburn, non-adherence to treatment, to the abdominal cavity without the need of large incisions inadequate prescription, genotypic differences, non-acid and allows performing the surgery with full reproduction gastroesophageal reflux, autoimmune diseases, eosinophilic successfully using the well-established laparotomy surgery, esophagitis, and misdiagnosis. The author also proposes that which was a great advance in surgery . The advantages of GERD may be associated with visceral hypersensitivity, which video-laparoscopic fundoplication are many, among them the interferes in the clinical picture and heightens the symptoms. reduction of post-surgery pain, fast recovery, early hospital This condition may be improved by the prescription of tricyclic discharge, reintegration of daily activities and return to work antidepressants (amitriptyline) and inhibitors of serotonin in a short time, favorable aesthetic aspect, minimal change in reuptake (fluoxetine). life style stand out . Additionally, the reduced incision size and Recent studies have demonstrated that new drugs can minimal post-surgery pain allow early patient deambulation be used in GERD patients refractory to PPI treatment. These and fast recovery of diaphragm movement, minimizing the drugs act by inhibiting transient lower esophageal sphincter development of respiratory complications . relaxation. A promising drug for the treatment of non-acid ABCD Arq Bras Cir Dig 2014;27(3):210-215 REVIEW ARTICLE Excellent and good results have been achieved in 90-93% day associated with weekly voice therapy sessions has given 11,13,19,24,28 45 of the patients submitted to this type of treatment . good results and surgery is rarely used . Esophagus or stomach perforation with ensuing death in most cases is considered the most important video- CONCLUSIONS laparoscopic fundoplication complication. This complication occurs in a small number of patients (0.5-2%) and decreases GERD is a major digestive health problem and affect significantly with the surgeon’s experience. Among the late 12% of Brazilian people. The anamnesis is fundamental for complications, dysphagia occurs in 8% of the patients, mostly the diagnosis of GERD, with special analysis of the typical and in those submitted to total fundoplication. The evolution atypical symptoms (duration, intensity, frequency, triggering is benign in most cases. Symptom persistence requires and relief factors, evolution and impact on the life quality). endoscopic dilation or even a new surgery, with resulting High digestive endoscopy and esophageal pHmetry are the total remission. Andrade et al. (2012) analyzed the quality most sensitive diagnosctic methods. The clinical treatment of life of 43 patients submitted to surgical GERD treatment is useful in controlling the symptoms; however, the great and reported that 58.1% were very satisfied and 37.2% were problem is keeping the patients asymptomatic over time. satisfied with the result. Surgical treatment is indicated for patients who required The definite referral to surgical GERD treatment hinges continued drug use, intolerant to the drugs and with on GERD complications. Various factors must be analyzed complicated forms of GERD. before surgery referral to BE patients, the major ones being age, lesion size, existence and severity of dysplasia. For many years BE was thought not to relapse after clinical or surgical REFERENCES treatment; however, recent studies have demonstrated otherwise. Gurski et al. (2003) evaluated 91 BE patients who 1. Abrahão-Junior LJ, Lemme EMO. Manifestações extra-esofágicas had clinical (14) and surgical (77) treatment and demonstrated da DRGE. J Bras Med. 2012; 100(5):17-21. that the lesions regressed in 36.4% of the surgically treated 2. Andrade FJC, Almeida ER, Santos MTBR,Soares-Filho E, Lopes JB, patients and in 7.1% of those treated with PPI. Regression Silva RCV. Qualidade de vida do paciente submetido à cirurgia occurred mostly in patients with short BE (less than 3 cm videolaparoscópica para tratamento para doença do refluxo long). A similar result was observed by Carvalho et al. gastroesofágico. 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J Bras Med. consensus. Arq Gastroenterol. 2010; 47:99-115. 2012; 100(3):67-71. 34. Moraes-Filho JPP. Doença do refluxo gastroesofágico de difícil 21. Gurski RG, Peters JH, Hagen JÁ, De Meester SR, Bremmer CG, tratamento. RBM Rev Bras Med. 2012; 69(12):41-46. Chandrasoma PT, De Meester TR. Barrett’s esophagus can and 35. Moraes-Filho JPP. Doença do refluxo gastroesofágico. RBM Rev does regress after antireflux surgery: a study of prevalence and Bras Med. 2007; 64(8):348-354. predictive features. J Am Coll Surg. 2003; 169(5):706-713. 36. Moretzsohn LD, Brito EM, Reis MSF, Coelho GV, Castro LP. 22. Henry MACA, Martins RHG, Lerco MM, Carvalho LR, Lamônica- Assessment of effectiveness of different dosage regimens of Gracia VC. Gastroesophageal reflux disease and vocal disturbances. pantoprazole in controlling symptoms and healing esophageal Arq Gastroenterol. 2011; 48(2):98-103. lesions of patients with mild erosive esophagitis. Arq Gastroenterol. 23. Henry MACA, Motta DCP , Silva RA. Avaliação manométrica do esôfago 2002; 39(2):123-125. distal de coelhos submetidos a fundoplicatura total laparotômica e 37. Nasi A, Moraes-Filho JPP, Cecconello I. Doença do refluxo laparoscópica. Arq Gastroenterol. 2002; 39(2):106-110. gastroesofágico: revisão ampliada. Arq Gastroenterol. 2006; 24. Herbella FA, Patti MG. Gastroesophageal reflux disease: From 43(4):334-340. pathophysiology to treatment. World J Gastroenterol. 2010; 38. Nasi A, Moraes-Filho JPP, Zilberstein B, Cecconelo I, Gama- 16(30):3745-3749. Rodrigues J. Doença do refluxo gastroesofágico: comparação 25. Klinkenberg-Knol EC, Nelio F, Dent J, Snel P, Mitchell B, Prichard entre as formas com e sem esofagite, em relação aos dados P, Lloyd D, Havre N, Frame MH, Roman J, Walan A; Long-Term demográficos e às manifestações sintomáticas. Arq Gastroenterol. Study Group. Long-term omeprazole treatment in resistant 2001; 38(2):109-115. gastroesophageal reflux disease: efficacy, safety, and influence on 39. Nissen R. Gastropexy as the alone procedure in the surgical repair gastric mucosa. Gastroenterology 2000: 118:1-9. of hiatus hérnia. Am J Surg. 1956; 92:389-392. 26. Lemme EMO, Almeida SM, Firman CG, Pantoja JP, Nascimento FAP. 40. Oliveira SS, Santos IS, Silva JFP. Prevalência e fatores associados pHmetria esofagiana prolongada – avaliação de 170 exames. Arq a doença do refluxo gastroesofágico. Arq Gastroenterol. 2005; Gastroenterol. 1997; 34:71-77. 42(2):116-121. 27. Lopes LR, Bertanha L, Silva PR, Vedan AB, Carvalheiro AP, Coelho- 41. Oliveira WK, Henry MACA, Lerco MM. Avaliação manométrica Neto JS, Tercioti Junior V, Andreollo NA. Avaliação cirúrgica do esfíncter inferior do esôfago de coelhos submetidos a laparoscópica anti-refluxo nos portadores de sintomas extra fundoplicatura total e parcial. Acta Cir Bras. 2004; 19(5):555-564. esofágicos relacionados à asma na DRGE. Arq Gastroenterol. 2013; 42. Perez AR, Moncure AC, Rattner DW. Obesity adversely affects the 50 – Suplemento. p.44. outcome of antireflux operations. Surg Endosc. 2001; 15:986-989. 28. Lopes LR, Brandalise NA, Andreollo NA, Leonardi LS. Tratamento 43. Sarvat MA, Domingues GRS. Repercussões laríngeas do refluxo cirúrgico videolaparascópica da doença do refluxo gastroesofágico: gastroesofagofaringea. In: Caldas Neto S, Mello Jr JF, Martins técnica de Nissen modificada – resultados clínicos e funcionais. RHG, Costa SS. Tratado de Otorrinolaringologia e Cirurgia Cervico Rev Ass Med Brasil. 2001; 47(2):141-148. Facial. Gen Roca Grupo Editorial Nacional: 2011, p 401-411. 29. Martins RHG, Branco A, Tavares ELM, Iyomassa RM, Carvalho 44. Szachnowicz S, Seguro F, Sallum RAA, Nasi A, Moura EHG, Rocha J, LR, Henry MACA. Laryngeal and voice disorders in patients with Cecconello I. Late endoscopic surveillance in Barrett’s esophagus gastroesophageal symptoms. Correlation with pH – monitoring. submitted to fundoplication. Is it worthwhile? Diseases of Acta Cir Bras. 2012; 27(11):821-828. Esophagus. 2012; 25 Supplement. P.64A. 30. Meining A, Classen M. The role of diet and lifestyle measures 45. Vashani K, Murugesh M, Hattiangadi G, Gore G, Keer V, Ramesh VS, in the pathogenesis and treatment of gastroesophageal reflux Sandur V, Bhatia SJ. Effectiveness of voice therapy in reflux related disease. Amer J Gastroenterol. 2000; 95(10):2692-2697. with voice disorders. Diseases of Esophagus. 2010; 23:27-32. 31. Mittal RK, Holloway RH, Penagini R, Blackshaw LA, Dent J. Transient lower esophageal sphincter relaxation. Gastroenteroloy. 1995; 109(2):601-610. 32. Moraes-Filho JPP, Cecconello I, Gama-Rodrigues JG, Castro LP, Henry MA, Meneghelli UG, Quigley E and the Brazilian Gerd Consensus Group. Brazilian Consensus on gastroesophageal reflux disease: proposals of assessment, classification and management. Amer J Gastroeneterol. 2002; 97(2):241-248. ABCD Arq Bras Cir Dig 2014;27(3):210-215 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Arquivos Brasileiros de Cirurgia Digestiva : ABCD = Brazilian Archives of Digestive Surgery Pubmed Central

DIAGNOSIS AND MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE

Arquivos Brasileiros de Cirurgia Digestiva : ABCD = Brazilian Archives of Digestive Surgery , Volume 27 (3) – Sep 1, 2014

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Abstract

ABCDDV/1011 ABCD Arq Bras Cir Dig Review Article 2014;27(3):210-215 DIAGNOSIS AND MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE Diagnóstico e tratamento da doença do refluxo gastroesofágico Maria Aparecida Coelho de Arruda HENRY From the Department of Surgery and ABSTRACT - Introduction: Gastroesophageal reflux disease (GERD) is probably one of the Orthopedy, School of Medicine, São Paulo most prevalent diseases in the world that also compromises the quality of life of the affected State University (UNESP), Botucatu, SP, Brazil significantly. Its incidence in Brazil is 12%, corresponding to 20 million individuals. Objective: To update the GERD management and the new trends on diagnosis and treatment, reviewing the international and Brazilian experience on it. Method: The literature review was based on papers published on Medline/Pubmed, SciELO, Lilacs, Embase and Cochrane crossing the following headings: gastroesophageal reflux disease, diagnosis, clinical treatment, surgery, fundoplication. Results: Various factors are involved on GERD physiopathology, the most important being the transient lower esophageal sphincter relaxation. Clinical manifestations are heartburn, regurgitation (typical symptoms), cough, chest pain, asthma, hoarseness and throat clearing (atypical symptoms), which may be followed or not by typical symptoms. GERD patients may present complications such as peptic stenosis, hemorrhage, and Barrett’s esophagus, which is the most important predisposing factor to adenocarcinoma. The GERD diagnosis must be based on the anamnesis and the symptoms must be evaluated in terms of duration, intensity, frequency, triggering and relief factors, pattern of evolution and impact on the patient’s quality of life. The diagnosis requires confirmation with different exams. The goal of the clinical treatment is to relieve the symptoms and surgical treatment is indicated for patients who require continued drug use, with intolerance to prolonged clinical treatment and with GERD complications. Conclusion: GERD is a major digestive health problem and affect 12% of Brazilian people. The anamnesis is fundamental for the diagnosis of GERD, with special analysis of the typical and atypical symptoms (duration, intensity, frequency, triggering and relief factors, evolution and impact on the life quality). High digestive endoscopy and esophageal pHmetry are the most sensitive diagnosctic HEADINGS - Gastroesophageal reflux. methods. The clinical treatment is useful in controlling the symptoms; however, the great problem Diagnosis. Therapeutics. Fundoplication. is keeping the patients asymptomatic over time. Surgical treatment is indicated for patients who Surgery. required continued drug use, intolerant to the drugs and with complicated forms of GERD. Correspondence: RESUMO - Introdução: A doença do refluxo gastroesofágico (DRGE) é, provavelmente, uma das Maria Aparecida Coelho de Arruda Henry doenças mais prevalentes no mundo que compromete significativamente a qualidade de vida. e-mail: rhenry@ibb.unesp.br Sua incidência no Brasil é de 12%, o que corresponde a 20 milhões de indivíduos. Objetivo: Atualizar o manuseio da DRGE e as novas tendências no diagnóstico e tratamento, revendo as Financial source: none experiências internacional e brasileira sobre o tema. Método: Foi realizada revisão da literatura Conflicts of interest: none baseada em artigos publicados no Medline/Pubmed, SciELO, Lilacs, Embase e Cochrane cruzando os seguintes descritores: doença do refluxo gastroesofágico, diagnóstico, tratamento Received for publication: 06/12/2013 clínico, cirurgia, fundoplicatura. Resultados: Vários fatores estão envolvidos na fisiopatologia Accepted for publication: 08/05/2014 da DRGE, sendo o mais importante o relaxamento transitório do esfíncter inferior do esôfago. As manifestações clínicas são azia, regurgitação (sintomas típicos), tosse, dor torácica, asma, rouquidão e pigarro (sintomas atípicos), que podem ser seguidos ou não de sintomas típicos. Pacientes com DRGE podem apresentar complicações como estenose péptica, hemorragia e esôfago de Barrett, que é o fator predisponente mais importante para adenocarcinoma. O diagnóstico deve ser baseado na anamnese e os sintomas devem ser avaliados em termos de duração, intensidade, frequência, fatores precipitantes e relevância, padrão de evolução e impacto na qualidade de vida do paciente. O diagnóstico exige confirmação com exames diferentes. O objetivo do tratamento clínico é aliviar os sintomas e o tratamento cirúrgico é indicado para os que necessitam de uso contínuo de drogas, com intolerância ao tratamento clínico prolongado e com complicações. Conclusão: A anamnese é fundamental para o diagnóstico de DRGE, com análise especial dos sintomas típicos e atípicos. Endoscopia digestiva alta e pHmetria esofágica são os métodos diagnósticos mais sensíveis. O tratamento clínico é útil no controle dos sintomas; DESCRITORES - Refluxo Gastroesofágico. no entanto, o grande problema é manter os pacientes assintomáticos ao longo do tempo. O Diagnóstico. Terapêutica. Fundoplicatura. tratamento cirúrgico é indicado para pacientes que necessitaram o uso contínuo de drogas, Cirurgia. intolerantes às drogas e com formas complicadas da DRGE. INTRODUCTION astroesophageal reflux disease (GERD) is a major digestive health problem due to its ever high and increasing incidence and because it is the cause Gof serious complications. It is defined as a condition that involves gastric content reflux with ensuing symptoms or complications . It is one of the most frequent causes of gastroenterological consultations in out-patients and compromises the quality of life of the patients significantly . The objective of this review was to update the GERD management and the new ABCD Arq Bras Cir Dig 2014;27(3):210-215 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercia License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. DIAGNOSIS AND MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE trends on diagnosis and treatment, reviewing the international thorax pain, respiratory manifestations (cough and bronchial and Brazilian experience on it. asthma), otorhinolaryngologic disorders (dysphonia, throat clearing and pharyngeal globus sensation), and oral disorders 1,14,15,22,37 (dental erosion, aphtha and halitosis) (Table 1). METHOD TABLE 1 - Typical and atypical GERD manifestations Symptoms Atypical manifestations A population study was conducted in 22 cities from Typical Othorhyno- different regions of Brazil involving 13,959 adults older than manifestations Pulmonary Orals laringological 16 years of age. The participants replied a questionnaire on Chronic cough heartburn complaints and frequency. Heartburn occurrence Pharyngitis over once a week was reported by 12% of the participants, Heartburn Hoarseness Dental erosion Throat clearing Acid Otitis Halitosis which corresponds to 20 million Brazilians who are affected Pneumonia Regurgitation Sinusitis Aphtha by GERD . Bronchiectasia In a similar study, Oliveira et al. (2005) surveyed 3,934 Asthma individuals from Pelotas, Rio Grande do Sul state regarding heartburn symptoms and/or bitter taste. They reported that Patients with atypical manifestations may not present 31.3% of the investigated population presented symptoms at the typical GERD symptoms. The screening criteria for the least once a week. Association with women, aging and stress investigation of GERD in patients with chronic cough were was reported in population studies . not smoking patients and absence of environmental irritants, Similar and sometimes higher values have been non-asthmatic, retronasal secretion, normal thorax and reported in other Western countries. Lower incidence rates sinus radiographs . Patients with otorhinolaryngological in Eastern countries (India – 7.5%, Malaysia – 3.0%, China – manifestations initially visited an area specialist and 0.8%) suggest that environment, alimentary habits and even performing laryngoscopy, which may reveal GERD-specific race contribute with factors on GERD . lesions, such as edema, erythema, vocal cord nodules, The most relevant contributing factor to GERD is the granulomas . transient lower esophageal sphincter relaxation. It may last from 5 to 35 s and is not related to swallowing; it occurs when Diagnosis methods 5,31 the gastric fundus is distended by food or gas . More frequently the patients had a mean age of 54 In addition to transient lower esophageal sphincter years, presented heartburn and acid regurgitation and GERD relaxation, other factors participate in the physiology of GERD, test sensitivity of 67% and specificity of 77% . Thus, the GERD such as lower esophageal sphincter hypotonia, alteration in diagnosis confirmation required further exams. the gastroesophageal anti-reflux barrier as a result of slipping hiatus hernia, inadequate esophageal peristalsis, lesion of High digestive endoscopy the esophageal mucosa, obesity, pregnancy and the use of This is the exam of choice in the evaluation of patients 5,17,24 estrogens . with GERD symptoms and it is indicated in chronic cases GERD patients, especially with chronic disease, may in patients over 40 years old and with alarm symptoms, present complications such as Barrett’s esophagus (BE), such as dysphagia, odynophagia, weight loss, digestive peptic stenosis, and hemorrhage. BE is a most relevant hemorrhage, nausea, vomits, and family history of cancer. complication due to the susceptibility of evolution to It allows the diagnosis of other disorders as well, such as adenocarcinoma. It involves the substitution of the peptic ulcer, esophageal moniliasis, gastric cancer and esophageal squamous epithelium, usually in the distal eosinophilic esophagitis, which also present dyspepsia portion of the esophagus, with glandular columnar symptoms. It also allows the obser vation of erosions (limited epithelium with calciform cells and affects from 10-15% dissolution of mucosa continuity with at least 3 mm, fibrin of chronic GERD patients. Another major complication deposition and neutrophilic epithelial permeation, which is is peptic stenosis, more frequent in patients with severe characteristic of esophagitis), ulcers (dissolution of mucosa esophagitis associated with dysphagia resulting in continuity reaching at least the mucosa muscle layer), esophageal obstruction. Hemorrhage from esophageal Barrett’s esophageal peptic stenosis . Other lesions that do ulcers is the least frequent complication. not allow GERD diagnosis due to their subjectivity may also be observed, such as edema, erythema and friability. Diagnosis Various classifications have been proposed to The main resource in GERD diagnosis is the clinical characterize the intensity of reflux esophagitis. The most history. The anamnesis must identify the characteristic commonly used is the Los Angeles Classification (Table 2). It is symptoms, their duration, intensity, frequency, triggering worth pointing out that esophagitis is diagnosed in only 40% and relief factors, evolution over time and the impact on the of GERD patients and that its severity does not correlate with quality of life . Typical symptoms reported by most 20 38 the intensity of the symptoms . Nasi et al. (2001) disagree patients are heartburn and acid regurgitation. Heartburn and reported to have observed intense heartburn in 37.5% of is a retrosternal burning sensation that irradiates from the the patients with erosive esophagitis and in 10.3% of patients manubrium of the sternum to the base of the neck or throat. without erosion (p<0.01). It generally occurs 30-60 min after eating, especially a large meal or a meal rich in fat or acid foods. It may be relieved by TABLE 2 - Los Angeles endoscopic classification taking antacid or even water . Acid regurgitation is the reflux of the acid content into the oral cavity. Degree Finding If the patients present these symptoms at least twice A One or more erosions smaller than 5 mm a week in a period of four to eight weeks or more, GERD One or more erosions greater than 5 mm in its greater diagnosis must be considered. However, one must bear in extension, non-continual between esophageal fold apices Contiguous (or convergent) erosions between at least mind that other diseases, such as peptic ulcer, gastritis and C esophageal fold apices, commitment of less than 75% of gastric cancer, have similar symptoms. the esophagus GERD may present other clinical manifestations as well. D Erosion of at least 75% of the esophagus circumference The most frequent atypical manifestations are non-coronary ABCD Arq Bras Cir Dig 2014;27(3):210-215 REVIEW ARTICLE The complementation of the endoscopic exam with receptor attached to the patient’s belt for computer analysis. biopsy must not be a routine procedure and must be reserved It is spontaneously released and is eliminated through the for special situations, such as stenosis, ulcer and BE. digestive tract. The use of this method is rather limited in Brazil due to the high cost of the capsule . After a comparative Radiological examination of the esophagus study of the conventional and the wireless esophageal pH- This examination has low sensitivity and specificity metry methods, Azzar et al. (2012) concluded that both are in the diagnoses of GERD. It must be ordered when the able to diagnose pathological gastroesophageal reflux. patient reports dysphagia and/or odynophagia, since it allows the morphological evaluation of the esophagus and Bernstein test demonstrates the occurrence of stenosis and conditions that This is a provocative test in which the esophageal favor gastroesophageal reflux, such as slipping hiatus hernia mucosa is perfused with a diluted hydrochloric acid solution. and abnormal gastroesophageal angle . The appearance of symptoms during perfusion is associated with sensitivity and specificity of around 80%. However, the Computerized esophageal manometry results are only qualitative and do not allow the quantification Esophageal manometry is not used for diagnosis of gastroesophageal reflux. It has nearly ceased to be used purposes; however, it provides very useful information for the after the development of 24-h esophageal pH-metry . evaluation of the pressure tonus of the esophageal sphincters and the motor activity of the body of the esophagus. It Esophageal impedanciometry has a predictive value in the assessment of the evolution This is a new method that demonstrates the antegrade of GERD. Thus, the diagnosis of severe lower esophageal and retrograde movements of the refluxate. In association sphincter hypotonia (lower than 10 mm Hg) indicates clinical with pH-metry (esophageal impedance-pH-metry), it also maintenance treatment or even surgical fundoplication. evaluates the physical (liquid, gaseous, mixed) and chemical Andreollo et al. (2010) observed its hypotonia in 29.5% of (acid, non-acid, mildly acid) nature of the refluxate. Therefore, the patients submitted to laparoscopic fundoplication. this exam provides the characterization of liquid, gaseous or Other indications for esophageal manometry are: mixed refluxate and whether it is acid or non-acid. In patients a) localization of the esophageal sphincters, essential irresponsive to PPI, non-acid reflux diagnosis is indicative of information for the correct positioning of pH-metry sensors; surgical treatment, as the fundoplication surgery eliminates b) diagnosis of specific motor disorders, such as achalasia, these two types of reflux . collagen disease, aperistalsis and severe hypocontractility; c) motor activity analysis previous to fundoplication to Therapeutic testing ensure that the esophagus has conditions to adapt to a In patients under 40 years old with typical GERD 19,37 gastroesophageal anti-reflux valve . complaints and without alarm manifestations, PPI full doses may be administered for four weeks associated with Esophageal scintigraphy behavioral measures (Table 3). The test is considered positive This exam exhibits the gastroesophageal reflux after when the symptoms disappear, with a strong indication of 99 5 the ingestion on technetium -marked contrast. This is a non- GERD diagnosis . invasive technique that can be used in the diagnosis of GERD in children. However, this exam is expensive and available in TABLE 3 - Behavioral measures proposed by the 3rd Brazilian few advanced centers . GERD Consensus 1. Elevation of the bed head (15 cm) Prolonged esophageal pH-metry Moderation in the ingestion of the following foods (based on This is a specific and sensitive method for the diagnosis 2. symptom correlation): fatty foods, citrus, coffee, alcoholic and/ of gastroesophageal reflux that has a high correlation with its or carbonated beverages, mint, peppermint, tomato, chocolate symptoms (symptom index). In addition to the diagnosis and Special care with “at risk” medicines: anticholinergics, evaluation of the intensity of GERD, this exam characterizes its theophylline, calcium-channel blockers, alendronate pattern, that is, if it is orthostatic, supine or bipositional . This 4. Avoidance of lying down in the 2 h following meals exam is recommended in the following situations: a) GERD 5. Avoidance of large meals diagnosis in normal upper endoscopy; b) characterization of 6. Quitting of smoking the gastroesophageal reflux pattern; c) contribution of acid 7. Reduction of body weight, if overweight reflux to atypical GERD manifestations with examination with a catheter with at least two sensors is advisable - one Treatment positioned at the distal esophagus, and the second at the There are two therapeutic approaches to GERD, upper esophageal sphincter or above -, for the diagnosis of clinical and surgical, the choice of which depends on the gastroesophageal and laryngopharyngeal reflux, respectively; patient’s characteristics (age, treatment adherence, personal d) study of symptom recurrence after surgery; e) evaluation of preference, existence of comorbidity) and on factors such the efficacy of the clinical treatment . as treatment response, existence of esophageal mucosa In patients with normal pH values and with response erosions, atypical symptoms and complications . favorable to proton pump inhibition (PPI), the diagnosis of non-erosive reflux disease is advisable. Another relatively Clinical treatment common situation is the patient who presents normal pH The goal of the clinical treatment is symptom relief, values, a negative symptom index, and is irresponsive to PPI, healing the esophageal mucosa lesions and prevention of the which is suggestive of functional heartburn diagnosis. development of complications. It is based on pharmacological and non-pharmacological measures. Wireless prolonged esophageal pH-metry (Bravo capsule) This method has the advantages of providing a greater Non-pharmacological treatment comfort to the patient, longer esophageal pH recording (up The non-pharmacological treatment involves behavioral to 96 h), and the added advantage of non-displacement measures (Table 3). In the last years, these recommendations of the catheter, which may occur in the conventional pH- have been questioned by some authors based on their lack metry. A capsule temporarily fixed by suction onto the distal of scientific foundation in addition to their deleterious effects esophageal mucosa telemetrically transmits signals to a 30 12 to the patients’ quality of life . Castro et al. (2000) reported ABCD Arq Bras Cir Dig 2014;27(3):210-215 DIAGNOSIS AND MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE that these measures do not benefit the great majority of or weakly acid reflux patients is gamma-aminobutyric acid GERD patients. Nevertheless, these recommendations are type B . time honored and considered useful. In addition to the recommendations, the patients’ diet Surgical treatment must be personalized considering their complaints about Surgical treatment is indicated for patients who require each food. The measures also contribute to improve the continued drug use, intolerant to prolonged clinical treatment 20 24 doctor-patient rapport and increase treatment adherence . and with complicated forms of GERD. Herbella & Patti (2010) proposed that the surgical treatment must also be indicated Pharmacological treatment for women in the menopause and with osteoporosis, given Various drugs may be used to treat GERD. Currently, PPI the possible interference of PPI in calcium absorption. The are the drugs of choice, inhibiting the production of acid by major difficulty in the clinical treatment is not controlling the the stomach parietal cells, thus reducing the aggression of symptoms, but keeping the patients asymptomatic over time. the esophagus by acid. Omeprazole is the most used PPI and The surgical treatment consists in making an anti- is freely distributed by the Brazilian Health Ministry to the gastroesophageal reflux valve using the gastric fundus low-income population. Full PPI doses for 4-8 weeks are the (fundoplication), as proposed by Nissen (1956) . It corrects initial treatment of choice. If the patient’s symptoms do not an anatomic defect by reducing the slipping hiatal hernia disappear, the dose must be doubled, one before breakfast obser ved in 89% of pathological GERD patients . Furthermore, and another before dinner. it restores LES competence, as demonstrated by experimental 23,24,28,41 Erosive GERD responds satisfactorily to clinical and clinical studies . 18,36 treatment . However, the symptoms reappear after the There are three main surgical GERD procedures: total medication is stopped because the disease is chronic and fundoplication (Nissen), in which the esophagus is completely requires continued PPI use. This is the maintenance treatment surrounded (360°), partial fundoplication (Toupet), and mixed and the dose must be appropriate to keep the patient fundoplication, introduced by Brandalise & Aranha (1996) asymptomatic. This therapy is efficient in the long term and (Figure 1). no dysplasia or neoplasia was observed by Klinkenberg-Knoll et al. (2000) after following up 230 GERD patients under PPI for 11 years. However, it is worth pointing out that this type of treatment requires great discipline due to the associated eating and living habit restrictions. Clinical practice shows that young patients, who fail to adhere to the treatment, may benefit from on-demand treatment, that is, irregular doses as required. Histamine H receptor antagonists and prokinetic drugs are considered second-line drugs. They act by blocking histamine H receptors in parietal cells and reducing acid excretion. The most commonly used are ranitidine, famotidine, cimetidine and nizatidine. Prokinectic drugs act by accelerating gastric emptying; however, they do not act on transient lower esophageal sphincter relaxation. The most used are metoclopramide and domperidone. They must be prescribed when there is gastroparesis. If the patient presents side effects to PPI or histamine H receptor antagonists, alginate and sucralphate antacids may be prescribed for temporary symptom relief. Special attention must be paid to pregnant women due to the teratogenic effect of these drugs. The importance of behavioral measures must be highlighted and the use of systemic absorption drugs must be avoided. The use of antacids is recommended. If the symptoms persist, histamine H receptor antagonists may be prescribed. Among the systemic agents, only its use is safe during lactation, as most FIGURE 1 - Brandalise & Aranha’s fundoplication procedure drugs are excreted in the milk . Regarding the role of PPI in the treatment of GERD, The early 1990s saw a significant increase in the from 20 to 42% of the patients do not respond satisfactorily number of referrals to surgical GERD treatment coincident to it, a condition known as refractory GERD. According to 34 with the description of video-laparoscopic fundoplication Moraes Filho (2012) , the main causes of refractory GERD by Dallemagne et al. (1991) . This technique affords access are: functional heartburn, non-adherence to treatment, to the abdominal cavity without the need of large incisions inadequate prescription, genotypic differences, non-acid and allows performing the surgery with full reproduction gastroesophageal reflux, autoimmune diseases, eosinophilic successfully using the well-established laparotomy surgery, esophagitis, and misdiagnosis. The author also proposes that which was a great advance in surgery . The advantages of GERD may be associated with visceral hypersensitivity, which video-laparoscopic fundoplication are many, among them the interferes in the clinical picture and heightens the symptoms. reduction of post-surgery pain, fast recovery, early hospital This condition may be improved by the prescription of tricyclic discharge, reintegration of daily activities and return to work antidepressants (amitriptyline) and inhibitors of serotonin in a short time, favorable aesthetic aspect, minimal change in reuptake (fluoxetine). life style stand out . Additionally, the reduced incision size and Recent studies have demonstrated that new drugs can minimal post-surgery pain allow early patient deambulation be used in GERD patients refractory to PPI treatment. These and fast recovery of diaphragm movement, minimizing the drugs act by inhibiting transient lower esophageal sphincter development of respiratory complications . relaxation. A promising drug for the treatment of non-acid ABCD Arq Bras Cir Dig 2014;27(3):210-215 REVIEW ARTICLE Excellent and good results have been achieved in 90-93% day associated with weekly voice therapy sessions has given 11,13,19,24,28 45 of the patients submitted to this type of treatment . good results and surgery is rarely used . Esophagus or stomach perforation with ensuing death in most cases is considered the most important video- CONCLUSIONS laparoscopic fundoplication complication. This complication occurs in a small number of patients (0.5-2%) and decreases GERD is a major digestive health problem and affect significantly with the surgeon’s experience. Among the late 12% of Brazilian people. The anamnesis is fundamental for complications, dysphagia occurs in 8% of the patients, mostly the diagnosis of GERD, with special analysis of the typical and in those submitted to total fundoplication. The evolution atypical symptoms (duration, intensity, frequency, triggering is benign in most cases. Symptom persistence requires and relief factors, evolution and impact on the life quality). endoscopic dilation or even a new surgery, with resulting High digestive endoscopy and esophageal pHmetry are the total remission. Andrade et al. (2012) analyzed the quality most sensitive diagnosctic methods. The clinical treatment of life of 43 patients submitted to surgical GERD treatment is useful in controlling the symptoms; however, the great and reported that 58.1% were very satisfied and 37.2% were problem is keeping the patients asymptomatic over time. satisfied with the result. Surgical treatment is indicated for patients who required The definite referral to surgical GERD treatment hinges continued drug use, intolerant to the drugs and with on GERD complications. 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Journal

Arquivos Brasileiros de Cirurgia Digestiva : ABCD = Brazilian Archives of Digestive SurgeryPubmed Central

Published: Sep 1, 2014

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