Extraesophageal Presentations
Acid reflux–related chest pain is easily treated by H 2RAs or PPIs, with efficacy substantiated by placebo-controlled studies. The efficacy of acid suppression therapy in asthma, cough, and other pulmonary complications of GERD is more mixed. Medical antireflux therapy improves asthma symptoms and reduces the need for asthma medications in more than 60% of patients, but objective improvement of peak expiratory flow rates is observed in only 25% of patients. Best results are found with higher doses of PPIs (usually twice-daily administration) given for 2 to 3 months. Potential positive predictors of PPI response include asthma that is difficult to control, associated acid regurgitation, proximal reflux on pH testing, and healing of esophagitis with antireflux therapy. Case studies report that 60% to 96% of patients with suspected acid-related ear, nose, and throat symptoms and signs improve with acid suppression. Here again, PPIs are more effective than H 2RAs, and extended therapy for up to 3 months may be required. Predictors of response have not been identified, although patients with milder laryngeal signs show better symptom improvement. In all these possible extraesophageal presentations of GERD, failure to respond to aggressive PPI therapy, confirmed by adequate acid control by pH testing, suggests a cause of these complaints other than acid.
Esophageal Strictures
Dysphagia in patients with esophageal strictures is related to stricture diameter and severity of esophagitis. When the esophageal lumen diameter is less than 13 mm, dysphagia is a major complaint and esophageal dilation is required. Simple short strictures can be dilated by blind peroral passage of rubber Hurst (round ends) or Maloney (taper ends) mercury-filled dilators of increasing sizes (16 to 60 French, 3 French = 1 mm) to disrupt the fibrous bands producing the obstruction. Complicated longer, tighter, or more irregular strictures will require bougienage over a guidewire using hollow-centered Savary plastic-covered polyvinyl dilators or balloon (Gruentzig) dilators. Before and after dilation, medical therapy with PPI is indicated; it has been shown to be superior to H 2RAs in relieving symptoms and in reducing the frequency for repeat dilations. Maintenance PPI therapy for patients with strictures has dramatically reduced the incidence of repeat esophageal dilations and the cost of treating these patients. Recalcitrant strictures, requiring surgery, are now very uncommon and suggest another aggravating factor such as chronic pill injury.