choice. Instead, they should be considered when medication isn't the
most viable option. Still, that leaves a significant subset of patients
who may be good candidates for surgery or endoscopic therapy.
Which treatment makes the most sense? The answers aren't always
black and white, but there are some factors to consider.
Which patients?
The first consideration, of course, is pinpointing which patients we're
talking about. Some patients simply aren't interested in medical thera-
py, which is usually administered in the form of proton pump
inhibitors (PPIs). Those patients may not want to deal with having to
take pills on a daily basis, or they might not trust themselves to be
compliant. There are also a growing number of patients who are con-
cerned about the potential side effects of PPIs. Taken, together, these
make up one subset of patients who may be good candidates for
endoscopic or surgical therapy.
Some patients have side effects from medical therapy and thus can't
take the appropriate medication. For others, PPIs aren't enough to
fully control their symptoms, and they have a poor quality of life as a
result. Or they may be symptomatic because they also have large
hiatal hernias, a condition that definitely requires surgery.
Patients whose predominant symptom is regurgitation or who con-
tinue to have an abnormal pH test despite being on the maximum PPI
dosage (and who are assessed to be fully compliant) are also candi-
dates for surgical or endoscopic interventions. And patients who have
symptoms that correlate with what's called non-acid reflux, despite
taking maximum PPI doses, may also benefit from interventions. (The
term non-acid reflux is common, but it's really a misnomer. These are
the patients who have weakly acidic reflux [pH between 4 and 7], neu-
tral reflux [7] or alkaline reflux [above 7]).
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