Prilosec can cause low gastric acidity

Is GERD in it if it says GERD?

Gastroesophageal reflux is very common and is usually treated with antisecretory therapy. Even if this leads to an improvement in symptoms in most patients, there are still gaps in the pathophysiological understanding of the disease.

Published algorithms for the treatment of gastroesophageal reflux disease are complicated and often difficult to implement in practice. "I must admit that I never looked at this scheme again after it was published," said Dr. med. Pali Hungin of Durham University, one of the authors of an evidence-based guideline on the subject [1]. This shows how difficult it is to develop practical recommendations for this disease. The problem, according to Hungin, begins with the definition of gastroesophageal reflux disease (GERD). This diagnosis is based on symptoms that are supposed to arise as a result of reflux of gastric contents into the esophagus [2]. Often, however, one does not know how reliable the information on symptoms is and whether these are actually caused by reflux, says Hungin. Possible complications also did not always correlate with the symptoms.

Acid pocket: acid hidden in the cardia

Prof. Dr. med. Kenneth McColl from the University of Glasgow: the acid pocket. This is a zone in the cardia that is barely reached by the buffer effect of a meal and therefore remains strongly acidic. It contains around 70 ml gastric juice, which can cause serious problems. McColl: "This explains why reflux symptoms are often most pronounced after meals, even though the entire stomach contents are the least acidic at these times." The acid pocket causes problems, for example, if it slides up through the diaphragm as a result of a hiatal hernia and can thus more easily cause acid reflux.

In addition, research in recent years has shown that, in addition to the "acid pocket", there is also an "acid mantle", namely that the pH value after meals near the mucosa is generally lower than deeper in the stomach - although not as low like in the acid pocket. Therefore, the question arises whether it makes sense in all cases to raise the pH value in the entire stomach when reflux is more of a local problem.

Concentrating on the acid pocket opens up new avenues in the treatment of gastroesophageal complaints. There are two ways to achieve this: One is to increase gastric motility, which should lead to better mixing of the stomach contents. This strategy has been investigated in small studies in which it was possible, for example, to reduce the acidity of reflux with azithromycin [15]. One way that is already feasible today is the use of alginates, which act on the acid pocket. They meet these requirements because, unlike the aluminum or magnesium-based antacids, they float on the stomach contents. In fact, alginates have been shown to inhibit reflux and thus reduce postprandial acid exposure of the esophagus [16]. Reb

The prevalence is increasing rapidly

These questions are of high practical relevance. Because reflux disease, or at least the associated symptoms, affects more and more people. In Norway, for example, the number of people affected has increased by almost half over the past 20 years [3]. But what is behind this supposed increase in GERD cases? In the Diamond study, the diagnosis could only be confirmed in 66% of the GERD patients diagnosed by the general practitioner after a specialist examination. And of those patients who actually had GERD, only 49% reported heartburn or belching as the most prominent symptoms [4]. Hungin: "This is an alarming result. It tells us that the clinical diagnosis of GERD is not reliable."

A study presented at the UEG Week 2014 in Vienna should further fuel the discussion [5]. It shows that the symptoms doctors think they hear when they talk to patients are not the symptoms the patients think, and that there are still significant differences between countries. "We are so entrenched in our terminology that we disconnect from what the patients actually say," says Hungin.

Unfortunately, the diagnostic use of PPIs does not help either. The mere disappearance of the symptoms after taking a PPI does not say anything about their cause or nature. The significance of the PPI test was examined in the Diamond study and rated negatively. Hungin: "Responding to a PPI means that the patient is responding to the PPI - not that the problem is GERD."

However, since the patient is primarily concerned with their symptoms, PPIs are used in large quantities. An estimated 0.5 to 1.5% of the European population take these drugs continuously. If you add the cheaper H2-receptor antagonists, you get up to 5% of the total population that permanently suppress gastric acid. At the same time, however, up to 50% of long-term PPI users still complain of GERD symptoms [6]. A study of 200 patients on PPIs found that only 14% of this population were symptom-free. However, acid reflux was only the cause of symptoms in a small minority of those affected. Most struggled with non-acid reflux or had symptoms unrelated to reflux at all [7]. Hungin: "So how can we speak of reflux disease when the symptoms in most cases have nothing to do with reflux at all?"

Empirical therapy with PPI

With regard to the effectiveness of PPIs, studies have shown that they work very well when it comes to healing an esophagitis, but that they do not necessarily have an equally marked effect on the symptoms [8]. According to this, the domain of PPI lies more in erosive esophagitis than in typical heartburn, which is more likely to be due to a functional gastrointestinal disorder [9]. Nevertheless, attempting a therapy with PPI for reflux symptoms is useful.

Reflux disease as a diagnostic and therapeutic challenge

However, according to Hungin, further diagnostic steps have to be taken if the patient does not respond. In particular, pH-metry and intraluminal impedance measurement come into question, the latter also allowing the quantification of non-acidic reflux.

Although Hungin makes it clear that a simple algorithm is not possible for all patients with GERD or its associated symptoms, he suggests a very clear concept for the management of uncomplicated patients (Figure). This begins with lifestyle advice and the use of antacids or alginates. If this does not bring the desired result, acid production should be reduced. The substance of choice will usually be a PPI. If that is also unsuccessful, you are not dealing with an uncomplicated patient. A variation of the PPI dosage and the frequency of use can be indicated as well as extensive further diagnostics. All in all, it makes sense to leave the term GERD and speak of heartburn or symptoms of the upper gastrointestinal tract rather than dealing with unreliable diagnoses.

Better symptom control and mucosal healing

Prof. Dr. med. However, Carmelo Scarpignato, University of Modena, points out that antisecretory therapy is sufficient for most patients with symptoms of reflux or upper gastrointestinal tract symptoms. It has been known since the 1980s that the burden of gastroesophageal complaints correlates directly with acid exposure in the esophagus [10]. Scarpignato: "We have two classes of drugs that reduce acid production in the stomach, the H2-receptor antagonists and the proton pump inhibitors. They differ in terms of their mechanism of action, but the effect is ultimately the same." However, the PPIs have proven to be superior in several ways. They are better at controlling symptoms, allow the mucous membrane to heal better and are also better suited for maintenance therapy [11]. However, they only reduce the acid load, but not the reflux. Accordingly, studies have shown that they are extremely effective against heartburn, while the effectiveness against regurgitation is present, but significantly less pronounced [12]. In reflux esophagitis, study data show healing rates of up to 90%, depending on the substance [13].

If there is no response

A special group of patients are people with non-erosive reflux disease (NERD). However, as Scarpignato emphasizes, NERD does not have a uniform pathology. Around 42% of those affected suffer from a "real NERD" with abnormalities in the pH-metry. The rest is divided into people with hypersensitive esophagus (to acid or non-acid reflux) and functional heartburn. Genuine NERD and NERD due to an acid-sensitive esophagus respond well to PPIs [14].

If patients with gastroesophageal symptoms do not respond to therapy with PPIs, there are several possible causes: The antisecretory therapy may not be effective enough (which can be corrected by increasing the dose, taking it more frequently or combining it with an H2 blocker), or the symptoms have their own Do not cause reflux, or at least not acid reflux.

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Source: Symposium "Therapy update: GORD" as part of the 22nd UEG Week, from October 18th to 22nd, 2014 in Vienna.

Approved and edited reprint from Ars medici, Dossier Gastroenterology VII / 2015