Gastroesophageal reflux disease (
GERD) remains a ubiquitous problem, although therapeutic options continue to evolve. Effective
therapy calls for understanding the pathogenesis. Key factors associated with
GERD include incompetence of the lower esophageal sphincter, esophageal clearance, gastric contents, tissue resistance, and potency of the refluxate. Phase-type directed
therapy remains the best treatment approach and
histamine (H2)-receptor antagonists are now the cornerstone of
therapy for patients not responsive to conservative measures. In a subset of patients with severe
esophagitis who do not respond to conventional H2-receptor antagonist
therapy, efficacy has been demonstrated with high-dose
therapy. The
acid suppressant
omeprazole, highly effective in erosive
esophagitis, is the
drug of choice for
esophagitis resistant to H2-receptor antagonists. Despite effective forms of
therapy, relapse rates are high in patients with severe
GERD, and maintenance
therapy typically is required. With near uniformity, efficacy end points for these agents have been directed toward relief of
heartburn, regurgitation, and
dyspepsia. Few data exist correlating relief of
GERD and improvement of
chest pain. Although therapeutic strategies for treating
GERD have improved, empiric treatment of suspected
GERD in the patient with noncardiac
chest pain does not appear to be the optimal approach and should be reserved for cases where diagnostic testing is limited or unavailable.