Acid inhibition in GERD-how much is enough?

Abstract

Gastric acid plays a fundamental role in the development of mucosal injury and symptoms in gastro-esophageal reflux disease(GERD). In this issue of the Journal, Milkes et al report the inability of proton pump inhibitor (PPIs) therapy to "normalize" 24-hour intraesophageal pH parameters despite good symptom control. Twenty-five of fifty H. pylori negative patients with chronic uncomplicated GERD failed to normalize their pH parameters. Failure of esophageal acid control correlated with inadequate gastric acid inhibition. These findings are provocative and interesting but difficult to reconcile against a large body of evidence supporting the superior therapeutic efficacy of PPIs in symptom control, healing of esophagitis, and decreasing the rate of dilations in patients with GERD. No information is provided regarding the status of the esophageal mucosa in patients failing to achieve normalization of pH values. This raises the question about the clinical significance of this finding: i.e., does the lack of normalization of esophageal pH parameters correlate with esophageal epithelial damage (endoscopically visible injury) or complications of the disease? The patient population for this study was highly selected, thus the true prevalence of this observation for the large pool of patients with GERD remains unknown. Despite this and other limitations, the study will likely stimulate further research to examine ultimately how much acid inhibition-and for how long-is critical to the healing of GERD and to prevent the complications of the disease.