Medical Management of Reflux Disease

Rationale for Medical Management as First-Line Approach

• The American Gastroenterological Association (AGA) and National Institute for Health and Care Excellence (NICE) guidelines recommend medical management of GERD as the initial approach for patients with Barrett's esophagus 1, 2
• Medical therapy with proton pump inhibitors (PPIs) is the cornerstone of treatment for patients with Barrett's esophagus, as it effectively controls reflux symptoms and reduces esophageal acid exposure 3, 4
• Acid suppression therapy has been shown to improve symptoms and heal and prevent relapse of erosive esophagitis in patients with Barrett's esophagus 5

Limitations of Other Management Options

• Antireflux surgery is not more effective than medical GERD therapy for the prevention of cancer in Barrett's esophagus 6, 7
• The AGA specifically states that attempts to eliminate esophageal acid exposure through antireflux surgery are not recommended for the prevention of esophageal adenocarcinoma 6

Management Algorithm

• The initial approach should be to start with optimal PPI therapy to control reflux symptoms 1, 2
• Once reflux is controlled, establish appropriate endoscopic surveillance schedule based on Barrett's length and presence/absence of dysplasia 2, 8
• Consider endoscopic therapy for patients who develop dysplasia or early neoplasia 1, 3
• Reserve surgery for patients with persistent symptoms despite maximal medical therapy or those with high-grade dysplasia/early cancer not amenable to endoscopic treatment 1