Description of the condition
Gastro-esophageal reflux disease (GORD) is currently the most common disease of the gastrointestinal system. It is also the most frequently made diagnosis in gastroenterology outpatient practice (Shaheen 2006). Expenses are rising every year on its management (Hunt 2007).
The international Montreal consensus defined GORD as "a condition which develops when the reflux of stomach contents causes troublesome symptoms or complications" (Vakil 2006). Characteristic symptoms of substernal burning or acid regurgitation, or both, are considered troublesome when they affect a patient's well being. GORD often also leads to complications, inflammation leading to oesophagitis and oesophageal strictures, which may lead to Barrett's oesophagus or adenocarcinoma (Kahrilas 2008).
Patients with GORD can be further subdivided by endoscopy into two groups (Vakil 2006):
reflux oesophagitis, which refers to visible erosions of the oesophagus associated with GORD symptoms;
endoscopy negative reflux disease (NERD), which refers to normal oesophageal mucosa on endoscopy but is associated with GORD symptoms. It is often composed of several patient subgroups all leading up to a similar picture of symptoms via different underlying mechanisms (Chal 1995).
Both groups have similar presentations and recently studies have shown that NERD patients suffer from impairment of quality of life as do those patients with erosive oesophagitis (Tew 1997). In most cases, GORD Impacts on a patient's quality of life. GORD patients have been shown to score lower in quality of life assessment than patients with cardiac angina and heart failure (Dimenas 1993).
Proton pump inhibitors (PPIs) have been used for the management of all types of GORD. Erosive oesophagitis accounts for a more predictable response to PPIs. NERD however seems to respond quite differently (Fass 2002). Therefore, a review of the efficacy of PPIs and actual improvement in symptoms in all subgroups of GORD is needed.
Description of the intervention
The goal of treatment in patients is not only healing of oesophagitis but also adequate relief of GORD-related symptoms and thus an improvement in quality of life. Medical management of GORD primarily relies on reduction of gastric acid production and in turn healing of oesophagitis, if present, and relief of symptoms. Medical management includes PPIs, H₂-receptor antagonists (H₂RAs), prokinetics and antacids, either used alone or in combination. The medication analysed in this review will be PPIs, which are oral pharmacological agents prescribed to reduce gastric acid production.
How the intervention might work
PPIs act by binding to the cysteine molecule in the hydrogen pump located in the secreting membranes in the parietal cells, leading to inhibition of acid production in the final metabolic pathway of gastric parietal cells (Zamir 2005). This results in reduced gastric acid secretion and subsequent oesophageal acid exposure hence Improving GORD-related symptoms.
Why it is important to do this review
PPIs are the most commonly used medication for GORD. In 2006, expenditure on PPIs alone reached seven billion dollars globally (Mullin 2009). PPI short term management in non-erosive reflux disease (NERD) has been evaluated in a previous Cochrane review (van Pinxteren 2010) and the maintenance of NERD and reflux oesophagitis is also the subject of a previous Cochrane review (Donnellan 2010). This review will be based on a previous Cochrane review evaluating medical treatments in the short term management of reflux oesophagitis alone (Moayyedi 2011). The previous systematic review assessed the effectiveness of PPIs against other medications in healing of erosive oesophagitis; however, in general only 30% of patients with GORD have erosive disease while the remaining 70% have NERD (Savarino 2008).
Therefore, it is important to assess the overall effectiveness of PPIs not only on healing of mucosal lesions in erosive oesophagitis but actual symptom relief and quality of life in all subgroups of GORD. In addition, further randomised controlled trials have been published and the newer PPIs, specifically dexlansoprazole and esomeprazole, were not evaluated in the previous systematic review. Therefore the systematic review needs updating.