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Discussion IV

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Question: What should we do with those patients who respond to the omeprazole test? When should a trial of proton pump inhibitor therapy end, or should patients receive long term therapy?

Dr Fennerty: None of the studies looked at patients in the long term. I would find the lowest effective dose that leaves patients in remission, and then continue treating with this dose.

Question: To what extent do a negative Helicobacter pylori test and a negative omeprazole test reassure the physician that the patient does not have a serious or significant disease? Would you investigate such a patient further and, if yes, how does a physician who is not reassured manage to reassure the patient that he/she does not have a serious disease?

Professor Talley: As a gastroenterologist, when such a patient comes to me of course I will investigate him/her further, because that is why patients are sent to me. We really need to ask a primary care physician whether, in a young patient who does not have alarm features, who is H pylori negative, and in whom acid suppressive therapy has failed, further tests would be performed or whether other treatments would be tried. Based on my discussions, it seems that most primary care physicians would feel reassured that the patient does not have a serious disease.

Question: Should we assess gastric emptying in patients with gastro-oesophageal reflux disease (GORD) that is difficult to control?

Professor Dent: The role of gastric emptying as a major factor in causing GORD has, in my opinion, been overrated. Many patients with delayed gastric emptying respond very well to acid suppressive therapy with a proton pump inhibitor. I might consider investigating gastric emptying in a few cases, looking for an anatomical abnormality that could be impairing gastric emptying, such as a pyloric stenosis or a duodenal obstruction. However, I do not consider this in the majority of patients, in whom I would determine how effectively gastric acid could be suppressed or oesophageal acid exposure reduced.

Question: Professor Dent included cisapride in his management algorithm. Based on Dr Bytzer's presentation, why was this included rather than simply reassuring patients, as suggested by Professor Jones?

Dr Bytzer: I admit that I may use a trial of cisapride in patients with functional dyspepsia if everything else has failed, and I obtain benefit in some patients.

Professor Dent: We must not get confused between the treatment of clearcut GORD with cisapride and the treatment of functional dyspepsia. Data on the treatment of GORD with cisapride indicate that it is approximately equal in efficacy to standard doses of H2 receptor antagonists. To my mind, the choice between these two agents should be determined by what you consider to be safest and I would recommend the use of H2 receptor antagonists in this instance.

Question: Isn't there a good reason for doing at least one endoscopy, to determine the likely therapeutic regimen? For example, if you see patients who have Los Angeles grade A or B oesophageal damage, can you not tell them to take omeprazole when they want—every second day, or every third day, or once a week—as they are not going to cause problems by doing this. For a patient with grade C or D, about 50% will need permanent therapy, possibly up to 40 mg omeprazole per day; however, even 50% of patients with grade C or D may be able to step down to alternate day therapy.

Professor Dent: Yes, I agree with this.

Question: Should the high dose omeprazole test be reserved for patients with persistent reflux symptoms instead of performing endoscopy and pH monitoring?

Professor Dent: This is a reasonable proposition but we require more data before we can make any firm recommendations. I would err on the side of caution and perform an endoscopy as I believe that this investigation is the most useful at this stage of management. The data on diagnostic testing leave us with uncertainties, and we therefore need to see more published papers with critical assessments of how to measure the response to short term, high dose omeprazole therapy, and how this correlates with the actual clinical status of the patient. I think that it is a very promising option for the future, though.