PPI Treatment: Resolution of Heartburn Does Not Mean Elimination Of Cancer Risk
Proton pump inhibitors (PPIs) are drugs that inhibit the acid secretion in the stomach. Thus PPIs are potent and highly effective to reduce the symptoms of gastroesophageal reflux disease (GERD), namely heartburn and acid regurgitation.
As a novelty, proton pump inhibitor is now available as over the counter (OTC) medication in Austria. This means, that prescription by a physician is not any more required and opens the field for self medication.
This is to inform on the uncritical use of proton pump inhibitors for the treatment of heartburn and acid regurgitation, the symptoms of gastroesophageal reflux disease. In 30% of the cases, heartburn is associated with a premalignant lesion (Barrett's Esophagus). Resolution of the symptoms does not rule out eliminate a potential cancer risk.
Therefore, following the initiation of PPI therapy, the patients should undergo adequate endoscopy of the esophagus with biopsy sampling of the esophagogastric junction for exclusion of premalignant reflux associated lesions: Barrett's esophagus (0.5% annual cancer risk), low- and high-grade dysplasia. The management of heartburn should be based on the histopathology of these biopsies.
In the absence of Barrett's esophagus, low- and high grade dysplasia, PPI therapy can be continued. Control endoscopy is recommended in 5 years.
In the presence of Barrett's esophagus, low- and high-grade dysplasia we recommend radiofrequency ablation (RFA, HALO®, Barrx Medical) of the premalignant mucosa. This modern technique allows the elimination of the abnormal tissue without affecting the transport function and the integrity of the esophagus. The treatment is conducted as an endoscopic procedure during a short anesthesia. Four to six weeks after the treatment the ablated segment of the esophagus is resealed by a normal mucosa in 90-100% of the cases. During the healing phase and thereafter, high dose PPI treatment is required to ensure the development of a normal tissue.
Conceptually, anti-reflux surgery represents the most effective way to eliminate reflux of gastric content into the esophagus. Therefore fundoplication should be considered after the successful elimination of Barrett's esophagus and dysplasia. The patients should be offered the opportunity to talk to a surgeon. Taken together, GERD management should be histopathology based.
Figure 1: Heartburn management algorithm. Initiation of PPI therapy is followed by an adequate endoscopy + biopsy sampling to exclude Barrett's esophagus. For the histopathology based management see the Text.