Whistler Meeting
Journal of Clinical Gastroenterology. 41(Suppl 2):S45-46, July 2007
Modlin, Irvin M MD, PhD; Hunt, Richard FRCP FRCPC
Foreword:
In September of 2006, a group of distinguished gastroenterologists met at Whistler, Canada to discuss current considerations in the field of gastroesophageal reflux disease (GERD). This supplement contains the presentations from the meeting. It reviews the major current challenges in the field of reflux disease and its complications, and provides some approaches that may be useful in management. The issues to be faced include the very limited comprehension of the reasons behind the increasing prevalence of the disease, difficulties in correlating symptoms with objective endoscopic and histologic data of pathologic gastroesophageal reflux and the relatively unsophisticated tools employed to investigate the underlying pathophysiology.
Despite the widespread attention of the medical community and gastroenterologists in particular to the entity of GERD, the problem continues to grow not only in terms of complexity but also in incidence and prevalence. Indeed it ranks high in the list of the most common and serious chronic diseases in the West. Of particular note is its steady increase in Asia and the recognition that it has the potential of becoming a major component of health care in the East within the next 5 to 10 years. It is an important public health issue owing to the considerable health care resources used in its management, its deleterious effect on quality of life, and the increasing prevalence of the relatively rare but devastating complication of reflux disease-esophageal adenocarcinoma.
It is certain that the lack of well-defined and characterized methodologies to compare the effects of therapy required the development of more effective questionnaire-type analytic tools. In regard to treatment, there is little doubt that the widely prescribed proton pump inhibitors (PPIs) have dose-equivalent efficacy and are the most highly effective agents capable of suppressing acid, controlling many of the symptoms of GERD and healing erosions. As yet, there are no reasonable alternatives and currently, PPIs remain the mainstay of GERD therapy. Nevertheless, many patients continue to experience symptoms on withdrawal or at night. Indeed nocturnal symptomatology is a critical area of interest that needs to be defined and resolved to improve quality of life. Reliable and effective pharmacologic agents that can effectively increase lower esophageal sphincter pressure or promote motility are as yet unavailable.
Although the introduction of laparoscopic techniques has resulted in a modest revival in surgical intervention using a variety of "wrap-type" operations, the indications are few and the procedure is often associated with significant morbidity and even mortality, especially if the expertise of the surgeon is an issue. In addition, the durability of the procedure remains under review. Endoscopic techniques for regulating reflux remain at this time, for the most part experimental and are as yet not applicable to the general population. Intestinal metaplasia in the lower esophagus is probably more common than previously thought and the precise biology and significance of this phenomenon is as yet far from clear and requires considerable further investigation. Whether and how to, first, screen for, and then, perform surveillance in Barrett esophagus remains highly problematic and contentious. Overall, however, the long-term severe consequences of GERD only affect a very small minority of patients and quality of life remains the core issue for most of the sufferers.
It is apparent that GERD/nonerosive reflux disease (NERD) continue to be important diseases and that both conditions are increasing globally. Thus the subject remains a forefront area for gastroenterologists and patients alike worldwide. Nevertheless despite the major focus on the problem substantial areas of the pathophysiology remain ill understood. A particular area of difficulty is this respect is the entity currently referred to as NERD. Whether this is a component of evolving GERD, a state of preerosive GERD or part of the irritable bowel syndrome spectrum remains unclear and is an important area that requires scientific and clinical resolution. As a result of the relative limitations of endoscopy in defining GERD and in particular NERD the issue of the relation of symptoms to disease progress or remission has become an important area of interest. The further recognition that symptoms are of critical relevance to the patient and his quality of life has led to the realization that symptoms are now regarded as the most relevant treatment target. Thus the development and use of patient administered scientific assessment tools such as ReQuest are critical for the accurate determination of symptom amelioration and thus treatment success and the identification of remission.
Thus, despite much advance in both the scientific and clinical areas of GERD, it is evident that the disease is still a key disease medically and economically in the West and a rapidly increasing and relevant problem in the East. The fact that GERD is not a single entity but represents a spectrum, which needs further exploration, was clearly evident from the international assessments available at the meeting. Of note, however, was the growing consensus among gastroenterologists that diagnosis was dependent on a broad spectrum of symptoms and that therapeutic efficacy of PPIs could be accurately assessed by symptom evaluation. Although this class of drugs remains the most effective therapy, it is apparent that there are still substantial unmet needs in the pharmacotherapeutic and endosurgical management of GERD.