Brazilian Consensus on Gastroesophageal Reflux Disease: proposals for assessment, classification, and management

Abstract

The Brazilian Consensus on Gastroesophageal Reflux Disease considers gastroesophageal reflux disease to be a chronic disorder related to the retrograde flow of gastroduodenal contents into the esophagus and/or adjacent organs, resulting in a variable spectrum of symptoms, with or without tissue damage. Considering the limitations of classifications currently in use, a new classification is proposed that combines three criteria-clinical, endoscopic, and pH-metric-providing a comprehensive and more complete characterization of the disease. The diagnosis begins with the presence of heartburn, acid regurgitation, and alarm manifestations (dysphagia, odynophagia, weight loss, GI bleeding, nausea and/or vomiting, and family history of cancer). Also, atypical esophageal, pulmonary, otorhinolaryngological, and oral symptoms may occur. Endoscopy is the first approach, particularly in patients over 40 yr of age and in those with alarm symptoms. Other exams are considered in particular cases, such as contrast radiological examination, scyntigraphy, manometry, and prolonged pH measurement. The clinical treatment encompasses behavioral modifications in lifestyle and pharmacological measures. Proton pump inhibitors in manufacturers' recommended doses are indicated, with doubling of the dose in more severe cases of esophagitis. The minimum time of administration is 6 wk. Patients who do not respond to medical treatment, including those with atypical manifestations, should be considered for surgical treatment. Of the complications of gastroesophageal reflux disease, Barrett's esophagus presents a potential development of adenocarcinoma; biopsies should be performed, independent of Barrett's esophagus extent or location. In this regard the designation "short Barrett's" is not important in terms of management and prognosis.

Management of Reflux Symptoms with Over-the-Counter Proton Pump Inhibitors: Issues and Proposed Guidelines

“…A formal diagnostic workup, beyond history and clinical examination, is not required in the vast majority of reflux sufferers. This is consistent with usual clinical practice worldwide and is in accordance with many international guidelines [7,8,9,10,11,12,13,14,15]. …”

“…These are beyond the scope of this article, as they are generally only available in tertiary specialist care centers. The role of these specialized tests in those with (suspected) reflux symptoms is dealt with in other recent reviews [7,8,9,10,11,12,13,14,15]. …”

“…As reviewed above, patients with mild and uncomplicated symptoms of heartburn and/or regurgitation do not need to be investigated prior to initiating therapy [7,8,9,10,11,13]. At present, these individuals frequently seek OTC therapy and will either use OTC antacids, alginates or H2RAs.…”

“…Often this results in symptoms, most commonly and most typically heartburn or acid regurgitation [5,6,7,8,9,10,11,12,13]. Recent opinion defines GER as a disease (GERD) when either the sufferer considers symptoms troublesome and/or GER results in complications [16].…”

“…There are many comprehensive written guidelines for the management of GERD directed at the medical community [7,8,9,10,11,12,13,14,15], but these are not for pharmacy use, where much reflux treatment is obtained. This document aims to address the appropriate OTC use of PPIs and limitations that should apply when reflux sufferers initially seek to self-medicate prior to consulting a physician.…”