A Half Acid Therapeutic Approach to Reflux Disease

Abstract

Purpose: Guidelines for the medical treatment of gastroesophageal reflux disease (GERD) include lifestyle modification, on demand control of symptoms with buffer and antirefluxants, acid control, use of agents to increase motility, and use of agents to decrease lower esophageal sphincter relaxation. The most common approach to the treatment of esophageal reflux disease is acid suppression, however, the mechanisms of esophageal reflux are related to relaxation of the lower esophageal sphincter and other motility factors. This study aims to determine if there is a correlation between the percentage time of intragastric pH < 4 and esophageal acid exposure time. Methods: Data from the 24 hour ambulatory pH monitoring from 398 patients on proton pump inhibitor therapy for GERD symptoms were analyzed using ambulatory pH monitoring. PPIs were taken once daily (n=92), twice daily (n=218), or in combination with H2RA (n=88). Data were recorded on the total percentage time of gastric pH less than 4, the total percentage time of esophageal acid exposure, the upright percentage time of gastric pH less than 4 and upright percentage time of esophageal acid exposure, the recumbent percentage time of gastric pH less than 4 and the recumbent time of esophageal acid exposure. pH electrodes were located 5 cm above the lower esophageal sphincter and 10 cm below the lower esophageal sphincter. The data for individual patients was analyzed and plotted for total, recumbent and upright to determine if there was a correlation between gastric acid control and esophageal acid exposure. Results: Results of the analyses of all groups showed that there was a relatively weak (r=0.38, 0.33, 0.34) although significant (p<0.0001) correlation between intragastric pH < 4 and esophageal acid exposure, whether upright, recumbent, or throughout the duration of the testing. Conclusion: The results of this analysis suggest that control of gastric acid as a primary goal for the control of gastroesophageal reflux disease is not sufficient for all patients. The lack of a strong correlation between gastric pH < 4 and esophageal acid exposure underscores the fact that reflux is a multifaceted problem.