There are problems with using pH testing for diagnosing GERD. Despite the fact that normal individuals and patients with GERD can be separated fairly well on the basis of pH studies, the separation is not perfect. Therefore, some patients with GERD will have normal amounts of acid reflux and some patients without GERD will have abnormal amounts of acid reflux. It requires something other than the pH test to confirm the presence of GERD, for example, typical symptoms, response to treatment, or the presence of complications of GERD. GERD also may be confidently diagnosed when episodes of heartburn correlate with acid reflux as shown by acid testing.
If there are no symptoms or signs of complications and no suspicion of other diseases, a therapeutic trial of acid suppression with H2 antagonists often is used. If H2 antagonists are not adequately effective, a second trial, with the more potent PPIs, can be given. Sometimes, a trial of treatment begins with a PPI and skips the H2 antagonist. If treatment relieves the symptoms completely, no further evaluation may be necessary and the effective drug, the H2 antagonist or PPI, is continued. As discussed previously, however, there are potential problems with this commonly used approach, and some physicians would recommend a further evaluation for almost all patients they see.
A third type of endoscopic treatment involves the injection of materials into the esophageal wall in the area of the LES. The injected material is intended to increase pressure in the LES and thereby prevent reflux. In one treatment the injected material was a polymer. Unfortunately, the injection of look at these guys polymer led to serious complications, and the material for injection is no longer available. Another treatment involving injection of expandable pellets also was discontinued. Limited information is available about a third type of injection which uses gelatinous polymethylmethacrylate microspheres.
Foam barriers provide a unique form of treatment for GERD. Foam barriers are tablets that are composed of an antacid and a foaming agent. As the tablet disintegrates and reaches the stomach, it turns into foam that floats on the top of the liquid contents of the stomach. The foam forms a physical barrier to the reflux of liquid. At the same time, the antacid bound to the foam neutralizes acid that comes into contact with the foam. The tablets are best taken after meals (when the stomach is distended) and when lying down, both times when reflux is more likely to occur. Foam barriers are not often used as the first or only treatment for GERD. Rather, they are added to other drugs for GERD when the other drugs are not adequately effective in relieving symptoms. There is only one foam barrier, which is a combination of aluminum hydroxide gel, magnesium trisilicate, and alginate (Gaviscon).
Who should consider surgery or, perhaps, an endoscopic treatment trial for GERD? (As mentioned previously, the effectiveness of the recently developed endoscopic treatments remains to be determined.) Patients should consider surgery if they have regurgitation that cannot be controlled with drugs. This recommendation is particularly important if the regurgitation results in infections in the lungs or occurs at night when aspiration into the lungs is more likely. Patients also should consider surgery if they require large doses of PPI or multiple drugs to control their reflux. It is debated whether or not a desire to be free of the need to take life-long drugs to prevent symptoms of GERD is by itself a satisfactory reason for having surgery.