DIGEST LIVER OIS 2000;32KUPP1.3):S249-52 Long-term therapy of gastro-oesophageal reflux disease: medical or surgical? V. Savarino Digest Liver Ilk 2000;32ISuppL31:S249-52 Key words: anti-reflux surgery;proton pump inhibitor I Fran: Ga.st#anterwlogy Unit, Department of Internal Medicine, UnW&y of Genoa, Italy. Mk#rhr , Prof. V. Saverin~, Unit& di Gaetroenteologia. Dipa~‘manto di Medioina interna, Universitd di Genova, GRnflva. hiv I - -..- __, .--~,. Fax: +39-010-3538956 I Gastro-oesophageal reflux disease (GORD) is one of the most common dis- orders of the gastrointestinal tract. Surveys have found that 44% of all Americans suffer from heartburn at least once per month, 30% at least once per week and up to 7% daily ‘. The cost of over-the-counter (OTC) med- ication to reduce typical symptoms, such as heartburn and acid regurgita- tion, reaches 1 billion dollars in the United States alone 2. The clinical pre- sentation of GORD encompasses a broad spectrum of abnormalities, rang- ing from heartburn without oesophagitis to severe complications represent- ed by strictures, deep ulcers, and Barrett’s oesophagus 3. The natural course of GORD also varies considerably 4 5 Patients seen by gastroenterologists . usually have a chronic condition with frequent recurrences and complica- tions, while those visited by general practitioners usually have less severe disease with intermittent attacks followed by prolonged periods of remis- sion. However, for the majority of patients GORD is a chronic relapsing problem. GORD is essentially due to a motor disorder which favours the retrograde flow of gastric contents into the oesophagus through an incompetent gastro- oesophageal junction. A defective lower oesophageal sphincter (LOS) pres- sure and especially transient relaxations of the sphincter, which are preva- lent postprandially, are the main functional abnormalities. Also the sphinc- teric function of the crural diaphragm may be impaired, particularly in pa- tients with a hiatal hernia. The extent of exposure of the distal oesophagus to refluxate is also governed by the efficiency of oesophageal acid clear- ance, which is altered in patients with GORD. The final result of these mul- tiple abnormalities is that gastric acid remains in contact with oesophageal mucosa for too much time and plays a key role in GORD. It is important to highlight that gastric acid hypersecretion is not a major determinant in the pathogenesis of this disease and also a delay in gastric emptying occurs in a small percentage of patients with GORD. As effective prokinetic drugs are not available at present gastric acid is the main target in medical therapy. However, this therapy is not able to provide any correction of the motor dis- order, so that reflux will recur as soon as antisecretory drugs are stopped. Despite this, medical treatment is the most frequently adopted measure to relieve symptoms and to heal oesophagitis, when present, and the only al- ternative therapeutic approach is represented by antireflux surgery, which has now been re-launched by the development of the laparoscopic tech- nique. Maintenance therapy The majority of patients with reflux disease are treated pharmacologically and proton pump inhibitors (PPIs) are now acknowledged as the most ef- fective therapy for acute healing of oesophagitis, which can be easily achieved in almost all patients, given treatment of sufficient dosage and du- ration 6. An excellent response to these drugs can be even obtained in pa- tients who have failed to improve on prolonged high-dose HZ blocker treat- ment 7. However, relapse on cessation of treatment is common in patients