Review article: management of mild and severe gastro-oesophageal reflux disease.

Treatment of endosocopy-negative gastro-oesophageal reflux disease (s-GERD) should be directed towards rapid relief of symptoms and then maintenance of relief using minimum yet effective therapy. Responses to proton pump inhibitors are somewhat lower in s-GERD patients compared to GERD with overt erosive damage (e-GERD). The reasons for a lower response rate are not clear but may relate to the inclusion of patients who do not have reflux disease or patients with a lower oesophageal sensory threshold. Also poorly understood is the lower yield of complete heartburn relief when the number of associated dyspeptic symptoms is high. Some form of long-term therapy is needed in the majority of patients. 'On demand' proton pump inhibitor therapy to control reflux symptoms is a new and attractive option. Time to study discontinuation due to insufficient control of heartburn, or any other reason resulting in unwillingness to continue with on-demand therapy, is a pragmatic outcome that is well suited to definition of the efficacy of on-demand therapy. The goals of treatment of e-GERD should be to relieve symptoms and to heal lesions. Symptom severity and much less endoscopic abnormalities drives the therapeutic choices. When symptoms are mild or intermittent and when oesophagitis is of limited degree, standard dose proton pump inhibitor is usually instituted. Fewer and fewer clinicians would still opt for an H2-receptor antagonist. If there is moderate or severe oesophagitis or if symptoms are particularly troublesome, then the patient should start with standard-dose proton pump inhibitor therapy once a day, but not uncommonly a b.d. dosage maybe necessary. Once the dose of the acid suppressant that relieves symptoms is found, this dose should be maintained for a period of 3 months. After this time, an attempt should be made to reduce the dose. If symptoms recur, then the patients should go back to the full-dose proton pump inhibitor and a plan should be formulated for long-term treatment. The long-term treatment options vary between ongoing acid and suppressant therapy, with occasional attempts to reduce the dose, or to go for 'on demand' therapy and (rarely) includes consideration for surgery or endoscopic anti-reflux therapy.