MANAGEMENT STRATEGIES FOR GASTROESOPHAGEAL REFLUX DISEASE

New trials allow management strategies to be proposed with greater con fidence than in the past for the entire spectrum of gastro-oesophageal reflux disease. Symptom evaluation is of key importance. as it is the most cost-effective and sensitive method for diagnosis of gastrooesop hageal reflux disease, and for tailoring of long-term therapy to indiv idual patients. Endoscopy is an important adjunct to symptom assessmen t, but needs to be used sparingly and critically to be cost-effective. Empirical therapy, with evaluation of symptom response, is a central management strategy that can minimize overall costs. In cases of diagn ostic uncertainty, a 1-2-week diagnostic/therapeutic test with high do se acid pump inhibitor is an emerging attractive alternative to oesoph ageal pH monitoring. Choice of therapy, and its subsequent adjustment to individual patients, should be made in the light of a now cell-defi ned hierarchy of efficacy, which is essentially the same for endoscopy -negative and oesophagitis patients. Management strategies must acknow ledge that gastro-oesophageal reflux disease is a chronic disorder in the majority of oesophagitis and endoscopy-negative patients. Manageme nt steps should identify the most cost-effective long-term treatment t hat gives adequate relief of symptoms and so corrects any symptom-rela ted impairment of quality of life. The strategies that are recommended are largely based, on clinical trial outcomes. There is a need for fo rmal clinical trials of management strategies as distinct from evaluat ions of specific therapies.