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Long-term medical management of gastro-esophageal reflux disease: how long and when to consider surgery?

Gastro-esophageal reflux disease is a chronic, long standing disease. Spontaneous remission of GERD is rare and conservative management including life style modification measures is unlikely to relieve symptoms. Majority of patients with reflux disease require long-term acid suppressants. Proton pump inhibitors are the choice of drugs in management of these patients. The end point of treatment is not clear. Duration of treatment is individual based. The symptoms may be intermittent or on most days of the week. The treatment is therefore either a short course which may be for 8 to 12 weeks or 6 months, or continuous, intermittent or 'on-demand' basis. The maintenance therapy is with the lowest proton pump inhibitor (PPI) dose necessary for adequate symptom relief. Whether long-term PPI actually alters the natural history of reflux disease other than to reduce the incidence of peptic stricture is not known. Reported adverse effects due to PPI include Clostridium difficile colitis and bacterial gastroenteritis, osteoporosis, and vitamin B12 deficiency. Anti-reflux surgery is indicated for youngsters, those not willing for long-term PPI i.e. for years, large volume refluxers, especially the supine refluxers and bile refluxers.

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