CANADIAN CONSENSUS CONFERENCE ON THE TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE

This was the first Consensus Conference of the Canadian Association of Gastroenterology (CAG). The subject of gastroesophageal reflux disease (GERD) was selected because of the existence of widespread controversy regarding first the classification, pathophysiology and methods of investigation; and secondly, the approach to the therapy of GERD. In relation to the first area, tour issues were discussed: definition of disease severity; methods of investigation; relative importance of acid and motility in the pathogenesis of GERD; and complications. Regarding the approach to therapy, four areas were considered: therapy with lifestyle modification and over-the-counter therapy; approach to initial therapy; maintenance therapy; and medical versus surgical therapy, including treatment of complications. Each section was introduced to the entire group of participants by prepared talks on background information. This was followed by discussion in small groups of seven to 12 participants each. The small group sessions were then summarized by the session Chairperson, and were presented for further discussion to the entire group of 40 participants. The Chairperson then prepared a written summary of the group discussion. Agreement was reached in most areas and a suggested decision tree for the management of patients with GERD was developed: the majority of persons with GERD symptoms have mild gastroesophageal reflux disease; most people with GERD do not see a physician, and most do well on self-administered over-the-counter therapy. When the person presents to his/her family physician, the suggested initial treatment for symptomatic GERD should consist of lifestyle modification, over-the-counter therapy and H-2-blockers. Prokinetics as initial treatment should be used only under special conditions. Probably about two persons in three will improve on lifestyle modification, over-the-counter therapy and H-2-blockers. If the patient with symptoms of GERD does not respond to this initial four to eight weeks of therapy, the physician has to suspect the presence of more serious disease such as erosive esophagitis, esophagitis with complications, or disease other than GERD. Therefore, before starting proton pump inhibitors, endoscopy is indicated. Diagnostic motility studies (24 h pH and/or motility and Bernstein test) are needed only under special conditions. GERD is a chronic relapsing disease and frequently maintenance therapy is needed, particularly when the patient has had endoscopically-proven erosive esophagitis. Maintenance therapy should be undertaken with the least potent drug that prevents relapse. To date, in severe disease the best data for maintenance therapy would favour the use of a proton pump inhibitor over standard doses of an H-2-blocker, but higher doses of H-2-blocker therapy may prove to be useful in some patients. Most patients with GERD (even those with complications) can be managed medically, but there are surgical indications to be considered in individual patients. A 'Decision Tree' for the suggested management of patients with GERD was developed to facilitate the clinical approach to this common clinical condition. The opinions expressed at this conference represent a consensus based on what we know today, and should not be taken as a definitive guide to practice for every patient and under all circumstances.