The role of the specialist in the diagnosis and short and long term care of patients with gastroesophageal reflux disease

Abstract

Advances in knowledge about reflux disease and its treatment allow a better focused discussion about cost-effective management compared to 5 yr ago. These developments also offer opportunities for patient management to be more firmly based in a primary care setting, with consequent reductions of cost. This opportunity arises from the recognition that endoscopy is an insensitive test for reflux disease, and from a more complete understanding of the treatment efficacy of proton pump inhibitors. Symptom pattern evaluation and a test of therapy with a proton pump inhibitor is now recognized as the best mainstream option for diagnosis, and is an approach that is well suited to primary care. Currently, though, specialists are more familiar with this, so there is a need for effective transfer of these strategies into primary care, along with the message that endoscopy will not show any diagnostically reliable changes in more than half of patients with troublesome reflux-induced symptoms, though it is the only reliable method for recognition of the complications of reflux esophagitis. Most patients with troublesome reflux-induced symptoms require long term management, either with antireflux surgery or with medication given daily only whenever symptoms are troublesome, or in short intermittent courses. The specialist's role in this is to advise the patient and his or her primary care doctor as to the available options for effective control of reflux disease, with due regard to the costs of the therapy and patient preference. The routine delivery of long term medical therapy should be in primary care, because there is no need for specialized testing or assessment in the course of this treatment.