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. 1994 May-Aug;67(3-4):223–231.

Medical management of esophageal reflux.

B I Hirschowitz 1
PMCID: PMC2588930  PMID: 7502531

Abstract

Gastroesophageal reflux of varying severity is a common disorder for which medical attention is sought at all levels, from pharmacists to specialist physicians and surgeons. This brief overview represents my current understanding of reflux, its effects on the esophagus and my personal approach to treatment of these disorders. Of necessity, because the literature is so extensive (a Medline search on reflux from 1966 to 1993 yielded over 1500 papers.), I have relied in places on the extensive review by Marks and Richter [1]. My paper emphasizes the evaluation and treatment of patients with symptomatic reflux, esophagitis and its complications. It describes why it is important to grade the disorders so that the treatment used is appropriate to the severity of the disease. The more severe the disease, the more specific the diagnostic information needed and the more exacting the treatment. Various treatments and outcomes of therapy are discussed, and a role for surgery is defined. The essence of effective medical treatment of esophagitis is to reduce acidity of the refluxate to a level outside the optimum proteolytic pH range of pepsin, i.e. greater than pH 3.5.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Bate C. M., Keeling P. W., O'Morain C., Wilkinson S. P., Foster D. N., Mountford R. A., Temperley J. M., Harvey R. F., Thompson D. G., Davis M. Comparison of omeprazole and cimetidine in reflux oesophagitis: symptomatic, endoscopic, and histological evaluations. Gut. 1990 Sep;31(9):968–972. doi: 10.1136/gut.31.9.968. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Behar J., Biancani P., Sheahan D. G. Evaluation of esophageal tests in the diagnosis of reflux esophagitis. Gastroenterology. 1976 Jul;71(1):9–15. [PubMed] [Google Scholar]
  3. Bell N. J., Burget D., Howden C. W., Wilkinson J., Hunt R. H. Appropriate acid suppression for the management of gastro-oesophageal reflux disease. Digestion. 1992;51 (Suppl 1):59–67. doi: 10.1159/000200917. [DOI] [PubMed] [Google Scholar]
  4. Bell N. J., Hunt R. H. Role of gastric acid suppression in the treatment of gastro-oesophageal reflux disease. Gut. 1992 Jan;33(1):118–124. doi: 10.1136/gut.33.1.118. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Brunnen P. L., Karmody A. M., Needham C. D. Severe peptic oesophagitis. Gut. 1969 Oct;10(10):831–837. doi: 10.1136/gut.10.10.831. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Dammann H. G., von zur Mühlen A., Balks H. J., Damaschke A., Steinhoff J., Hennig U., Schwarz J. A., Fuchs W. The effects of lansoprazole, 30 or 60 mg daily, on intragastric pH and on endocrine function in healthy volunteers. Aliment Pharmacol Ther. 1993 Apr;7(2):191–196. doi: 10.1111/j.1365-2036.1993.tb00089.x. [DOI] [PubMed] [Google Scholar]
  7. Dent J., Bremner C. G., Collen M. J., Haggitt R. C., Spechler S. J. Barrett's oesophagus. J Gastroenterol Hepatol. 1991 Jan-Feb;6(1):1–22. doi: 10.1111/j.1440-1746.1991.tb01137.x. [DOI] [PubMed] [Google Scholar]
  8. Hetzel D. J. Controlled clinical trials of omeprazole in the long-term management of reflux disease. Digestion. 1992;51 (Suppl 1):35–42. doi: 10.1159/000200913. [DOI] [PubMed] [Google Scholar]
  9. Hetzel D. J., Dent J., Reed W. D., Narielvala F. M., Mackinnon M., McCarthy J. H., Mitchell B., Beveridge B. R., Laurence B. H., Gibson G. G. Healing and relapse of severe peptic esophagitis after treatment with omeprazole. Gastroenterology. 1988 Oct;95(4):903–912. doi: 10.1016/0016-5085(88)90162-x. [DOI] [PubMed] [Google Scholar]
  10. Hillman A. L., Bloom B. S., Fendrick A. M., Schwartz J. S. Cost and quality effects of alternative treatments for persistent gastroesophageal reflux disease. Arch Intern Med. 1992 Jul;152(7):1467–1472. [PubMed] [Google Scholar]
  11. Hirschowitz B. I. A critical analysis, with appropriate controls, of gastric acid and pepsin secretion in clinical esophagitis. Gastroenterology. 1991 Nov;101(5):1149–1158. doi: 10.1016/0016-5085(91)90062-p. [DOI] [PubMed] [Google Scholar]
  12. Hirschowitz B. I. Acid and pepsin secretion in patients with esophagitis refractory to treatment with H2 antagonists. Scand J Gastroenterol. 1992 Jun;27(6):449–452. doi: 10.3109/00365529209000104. [DOI] [PubMed] [Google Scholar]
  13. Hirschowitz B. I. Pathobiology and management of hypergastrinemia and the Zollinger-Ellison syndrome. Yale J Biol Med. 1992 Nov-Dec;65(6):659–692. [PMC free article] [PubMed] [Google Scholar]
  14. Hongo M., Ohara S., Hirasawa Y., Abe S., Asaki S., Toyota T. Effect of lansoprazole on intragastric pH. Comparison between morning and evening dosing. Dig Dis Sci. 1992 Jun;37(6):882–890. doi: 10.1007/BF01300386. [DOI] [PubMed] [Google Scholar]
  15. Johnson N. J., Boyd E. J., Mills J. G., Wood J. R. Acute treatment of reflux oesophagitis: a multicentre trial to compare 150 mg ranitidine b.d. with 300 mg ranitidine q.d.s. Aliment Pharmacol Ther. 1989 Jun;3(3):259–266. doi: 10.1111/j.1365-2036.1989.tb00212.x. [DOI] [PubMed] [Google Scholar]
  16. Kikendall J. W., Friedman A. C., Oyewole M. A., Fleischer D., Johnson L. F. Pill-induced esophageal injury. Case reports and review of the medical literature. Dig Dis Sci. 1983 Feb;28(2):174–182. doi: 10.1007/BF01315148. [DOI] [PubMed] [Google Scholar]
  17. Kitchin L. I., Castell D. O. Rationale and efficacy of conservative therapy for gastroesophageal reflux disease. Arch Intern Med. 1991 Mar;151(3):448–454. [PubMed] [Google Scholar]
  18. Klinkenberg-Knol E. C., Meuwissen S. G. Combined gastric and oesophageal 24-hour pH monitoring and oesophageal manometry in patients with reflux disease, resistant to treatment with omeprazole. Aliment Pharmacol Ther. 1990 Oct;4(5):485–495. doi: 10.1111/j.1365-2036.1990.tb00495.x. [DOI] [PubMed] [Google Scholar]
  19. Klinkenberg-Knol E. C., Meuwissen S. G. Medical therapy of patients with reflux oesophagitis poorly responsive to H2-receptor antagonist therapy. Digestion. 1992;51 (Suppl 1):44–48. doi: 10.1159/000200915. [DOI] [PubMed] [Google Scholar]
  20. Koelz H. R., Birchler R., Bretholz A., Bron B., Capitaine Y., Delmore G., Fehr H. F., Fumagalli I., Gehrig J., Gonvers J. J. Healing and relapse of reflux esophagitis during treatment with ranitidine. Gastroenterology. 1986 Nov;91(5):1198–1205. doi: 10.1016/s0016-5085(86)80017-8. [DOI] [PubMed] [Google Scholar]
  21. Lanas A., Hirschowitz B. I. Significant role of aspirin use in patients with esophagitis. J Clin Gastroenterol. 1991 Dec;13(6):622–627. doi: 10.1097/00004836-199112000-00005. [DOI] [PubMed] [Google Scholar]
  22. Lundell L. Acid suppression in the long-term treatment of peptic stricture and Barrett's oesophagus. Digestion. 1992;51 (Suppl 1):49–58. doi: 10.1159/000200916. [DOI] [PubMed] [Google Scholar]
  23. Lundell L., Backman L., Ekström P., Enander L. K., Falkmer S., Fausa O., Grimelius L., Havu N., Lind T., Lönroth H. Prevention of relapse of reflux esophagitis after endoscopic healing: the efficacy and safety of omeprazole compared with ranitidine. Scand J Gastroenterol. 1991 Mar;26(3):248–256. doi: 10.3109/00365529109025038. [DOI] [PubMed] [Google Scholar]
  24. Richter J. E. Surgery for reflux disease: reflections of a gastroenterologist. N Engl J Med. 1992 Mar 19;326(12):825–827. doi: 10.1056/NEJM199203193261209. [DOI] [PubMed] [Google Scholar]
  25. Robinson M., Maton P. N., Allen M. L., Humphries T. J., McIntosh D., Cagliola A. J., Bradstreet T. E. Effect of different doses of omeprazole on 24-hour oesophageal acid exposure in patients with gastro-oesophageal reflux. Aliment Pharmacol Ther. 1991 Dec;5(6):645–651. doi: 10.1111/j.1365-2036.1991.tb00532.x. [DOI] [PubMed] [Google Scholar]
  26. Roesch W. Erosions of the upper gastrointestinal tract. Clin Gastroenterol. 1978 Sep;7(3):623–634. [PubMed] [Google Scholar]
  27. Sabesin S. M., Berlin R. G., Humphries T. J., Bradstreet D. C., Walton-Bowen K. L., Zaidi S. Famotidine relieves symptoms of gastroesophageal reflux disease and heals erosions and ulcerations. Results of a multicenter, placebo-controlled, dose-ranging study. USA Merck Gastroesophageal Reflux Disease Study Group. Arch Intern Med. 1991 Dec;151(12):2394–2400. [PubMed] [Google Scholar]
  28. Sandmark S., Carlsson R., Fausa O., Lundell L. Omeprazole or ranitidine in the treatment of reflux esophagitis. Results of a double-blind, randomized, Scandinavian multicenter study. Scand J Gastroenterol. 1988 Jun;23(5):625–632. doi: 10.3109/00365528809093923. [DOI] [PubMed] [Google Scholar]
  29. Sontag S. J., Hirschowitz B. I., Holt S., Robinson M. G., Behar J., Berenson M. M., McCullough A., Ippoliti A. F., Richter J. E., Ahtaridis G. Two doses of omeprazole versus placebo in symptomatic erosive esophagitis: the U.S. Multicenter Study. Gastroenterology. 1992 Jan;102(1):109–118. doi: 10.1016/0016-5085(92)91790-b. [DOI] [PubMed] [Google Scholar]
  30. Spechler S. J. Barrett's esophagus: what's new and what to do. Am J Gastroenterol. 1989 Mar;84(3):220–223. [PubMed] [Google Scholar]
  31. Spechler S. J. Epidemiology and natural history of gastro-oesophageal reflux disease. Digestion. 1992;51 (Suppl 1):24–29. doi: 10.1159/000200911. [DOI] [PubMed] [Google Scholar]
  32. Wienbeck M., Barnert J. Epidemiology of reflux disease and reflux esophagitis. Scand J Gastroenterol Suppl. 1989;156:7–13. doi: 10.3109/00365528909091032. [DOI] [PubMed] [Google Scholar]

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