David A. Johnson, MD

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April 30, 2013

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5. Surgery for extraesophageal manifestations of reflux disease will not work unless the patient responded to PPIs. If it is well documented that the patients had reflux disease and they responded to PPIs, then they are much more likely to improve. This should never be viewed as refractory extraesophageal GERD on the basis of extraesophageal manifestations alone. The disease needs to be well documented.

4. pH testing is okay whether the patient is on or off therapy. If the patient has a diagnosis of reflux disease, pH testing should be done off therapy. Testing can be done with any type of pH monitoring device. If pH testing is going to be done on therapy, you should do it with pH impedance, because you want to assess some of the nonacidic reflux in correlation with symptoms. If you are using it for a diagnosis to send somebody to surgery, do it off therapy. If you are going to assess symptoms in response to a medication intervention, do it on therapy with impedance.

3. Screening for Barrett esophagus should not be routinely done in the absence of high-risk epidemiologic evidence. We are talking about white men with GERD symptoms in their fourth or fifth decade of life. A very recent study[4] that was published in the same issue of the American Journal of Gastroenterology by Rubenstein and colleagues found that they were much more adept at predicting Barrett esophagus in GERD patients if they used not only GERD symptoms but also age, smoking, and abdominal obesity.

Look at that article as you start to see who should be screened for Barrett esophagus. Remember that when you are screening for Barrett esophagus, it is potentially like screening men for breast cancer. Screening women for Barrett esophagus should not be done only on the basis of symptoms of GERD.

2. The relationship between infectious diseases and PPIs. The guidelines committee suggested that the evidence for community-acquired pneumonia was there, but only in the short term. Extended duration of exposure to PPIs had no effect on repetitive pneumonia.

I don't think that is a hot topic right now. What is a hot topic, and what the committee came down on, is the association with Clostridium difficile. I have become a little more sanguine about this being a potential, not an absolute. It's a strong recommendation with moderate evidence to support it. In fact, the guidelines suggest that C difficile should be considered a factor in patients who are taking PPIs, but when looking at coherent risk, hospitalization, antibiotic exposures, et cetera, I think the C difficile issue is not closed. We can't dismiss it entirely, particularly if you see somebody that has a relapsing C difficile infection. Always look at the patient's medications, and maybe that one could be withdrawn.

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