How to best treat severe and chronic heartburn

Heartburn, a burning sensation behind the breastbone, is the most frequent symptom of gastroesophageal reflux disease (GERD) causing acidic stomach contents to be pushed up into the esophagus, the muscular tube connecting the mouth to the stomach. Troublesome heartburn is a very common medical condition, and affects approximately 15-20% of the adult population in western countries. In severe and chronic cases of heartburn, complications can occur and the internal lining of the esophagus can be damaged. Severe and chronic heartburn is also a risk factor for cancer of the esophagus (specifically adenocarcinoma).

It is still debated how to best treat severe heartburn. The two main treatment options are medication, using proton-pump inhibitors, and surgery. This study aimed to compare these treatment options in patients suffering from severe heartburn. We searched and evaluated the best available literature in the aspects of symptom control, quality of life, treatment complications, cancer risk, and cost-effectiveness.

Regarding symptom control, recurrence of heartburn seemed to be equally common following medication and surgery. However, surgery appeared to be slightly more effective regarding time per day with stomach acid in the esophagus.

Although the general quality of life is improved by both medication and surgery, it was slightly more improved following surgery.

There is a small risk of severe complications and even mortality following surgery, a risk that exists for any surgical procedure. Complications following medication are less common and less severe.

Considering the potential of prevention of cancer of the esophagus, the available literature does not allow any robust conclusions about which therapy option is most effective. It is still debated whether it is possible at all to prevent cancer through treatment of severe and chronic heartburn.

Finally, the literature addressing cost-effectiveness indicated that surgery is expensive in the short-term, but perhaps more cost-effective in the long-term. However, there are too few studies available for a valid long-term cost-effectiveness comparison.

In conclusion, the literature indicates that both medication with proton-pump inhibitors and surgery are effective in the treatment of severe and chronic heartburn. Due to the potential risk of complications following surgery, medication should be first line treatment in most patients. Surgery is a good treatment option in young and physically fit patients, among whom surgical complications are unlikely to be severe and medical treatment would likely continue for a very long period of time.

 

Publication

What is the most effective treatment for severe gastro-oesophageal reflux disease?
Maret-Ouda J, Brusselaers N, Lagergren J
BMJ. 2015 Jun 24

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