Table 1.

The basis of over-expectation, subsequent disillusion and enlightenment in the use of PPIs for GORD

The genesis of expectations	The genesis of disillusion	The beginnings of enlightenment
Clinical trials show PPIs produce excellent oesophagitis healing and good heartburn relief	Patient satisfaction with GORD symptom control is often incomplete	Modulation of sensory processes is a major influence on symptom perception and on autonomic reflexes
	Symptoms persist in 45% of primary care patients on PPIs
	Regurgitation responds less well than heartburn to PPIs	Anxiety enhances symptom perception
	Dyspepsia, throat symptoms and IBS contribute to the overall symptom burden of GORD patients	Some heartburn is unrelated to reflux
They are potent suppressors of gastric acid secretion	NERD is more prevalent than erosive disease and responds less well to medication	Most patients given a presumptive GORD diagnosis who have persistent symptoms on PPI probably do not have reflux disease
	The ‘acid pocket’ is the source of postprandial reflux
	Acid reflux is not the only cause of heartburn – weak acid reflux may be symptomatic and some patients have heartburn without reflux	Many patients with GORD are well satisfied with PPI treatment
Adverse reactions are infrequent and mostly minor	Accumulating reports of adverse reactions	Adverse reaction reports may be exaggerated

GORD = gastro-oesophageal reflux disease; IBS = irritable bowel syndrome; NERD = non-erosive reflux disease; PPI = proton pump inhibitor