Maximal acid reflux control for Barrett's oesophagus: feasible and effective

Introduction: The treatment of patients with Barrett's oesophagus is contro versial. Debate exists regarding the use and value of high dose acid suppre ssion as the standard of practice, Despite prolonged use of high dose proto n pump inhibitors (40 mg omeprazole, 60 mg lansoprazole), most studies have shown no convincing evidence of significant regression of Barrett's length . These studies, however, have used fixed doses of proton pump inhibitors a nd did not regularly document control of oesophageal acid exposure. Aim: To determine whether regression of Barrett's epithelium can be achieve d with documented maximal acid suppression. Methods: We have prospectively followed nine patients with Barrett's oesoph agus (eight male; mean age 60 years) for more than 1 year. They were all tr eated using medical therapy with pH monitoring documenting oesophageal acid exposure over 24 h < 1.6% of the time, and with two or more esophagogastro duodenoscopies performed by the same endoscopist. Results: Acid control was individually tailored and achieved with proton pu mp inhibitor b.d. (omeprazole 20 mg or lansoprazole 30 mg) and ranitidine a t bedtime (HS) (Ran) if necessary. All nine patients (100%) showed some evi dence of regression. All nine patients (100%) showed a decrease in Barrett' s length (mean 2 cm, range 1-3 cm). Six out of nine (66.67%) patients showe d evidence of squamous islands on the last oesophagogastroduodenoscopy. The mean total distal oesophageal acid exposure was 0.38% (range: 0-1.5%), The mean follow-up of patients was 54 months (range: 13-118 months). Conclusions: Consistent and individually tailored maximal acid suppression documented by pH-metry is achievable and may result in decreased length and development of squamous islands in patients with Barrett's epithelium. Thi s approach should be further evaluated as potentially the preferred medical treatment for these patients.