Applying clinical practice guidelines to a patient with complicated gastroesophageal reflux disease

Disease knowledge after an educational program in patients with GERD--a randomized controlled trial

Background

Patient education has proved beneficial in several but not all chronic disease. Inconsistent findings may rely on varying educational effects of various programs and differential effects on subgroups of patients. Patients' increase in disease knowledge may serve as a feedback to the educator on how well the education program works – but may not be associated to relevant clinical outcomes like quality of life (QoL). This study aimed to investigate the effects of a group based education program for patients with gastroesophageal reflux disease (GERD) on disease knowledge and the association between knowledge and QoL.

Methods

Patients with GERD were randomly allocated to education (102 patients) or control (109 patients). The education program was designed as a structured dialogue conveying information about pathophysiology, pharmacological and non-pharmacological treatment of GERD, patients' rights and use of healthcare. Outcomes were a 24 item knowledge test on GERD (score 0 – 24) 2 and 12 months after the educational program and disease specific and general QoL (Digestive symptoms and disease impact, DSIQ, and General Health Questionnaire, GHQ).

Results

Patients allocated to education achieved higher knowledge test scores than controls at 2 months (17.0 vs. 13.1, p < 0.001) and at 12 months (17.1 vs. 14.0, p < 0.001) follow-up. Knowledge test score was positively associated with having completed advanced school and inversely related to psychiatric illness and poor QoL as perceived by the patients at the time of inclusion. Overall, changes in knowledge test score were not associated with change in QoL.

Conclusion

A group based education program for patients with GERD designed as a structured dialogue increased patients' disease knowledge, which was retained after 1 year. Changes in GERD-knowledge were not associated with change in QoL.

Trial registration

ClinicalTrials.gov: NCT0061850

Patient education in gastro-oesophageal reflux disease: a randomized controlled trial

OBJECTIVES

Gastro-oesophageal reflux disease (GORD) is chronic, affects 8-20% of the population, impairs quality of life (QoL) and generates substantial health-related costs. Patient education is intended to improve patients' disease-related competency, potentially enabling them to deal more efficiently with their disease, eventually improving QoL and reducing healthcare cost. This study aimed to investigate the effects of a group-based education programme for patients with mild GORD.

METHODS

Patients with GORD were randomly allocated to education (n=102) or control (n=109). The education programme was designed as a structured dialogue conveying medical information about the pathophysiology and prognosis, pharmacological and nonpharmacological treatment of GORD, patients' rights and use of healthcare. Outcomes were measured using general QoL [General Health Questionnaire-30 (GHQ-30)], disease-specific QoL [Digestive Symptoms and Impact Questionnaire (DSIQ)], global QoL and healthcare use at 2 and 12 months after the educational programme.

RESULTS

No statistically significant differences were found in GHQ-30, DSIQ or global QoL at 2 or 12 months' follow-up between the GORD-education group and controls. In the GORD-education group, patients who had completed primary school education only showed improved QoL at 12 months on both GHQ and DSIQ, whereas patients who had completed advanced schooling showed no change. No difference was found between the groups in their use of healthcare.

CONCLUSION

A group-based education programme for patients with mild GORD showed no effect on QoL or use of healthcare. Subgroup analyses showed improved QoL only in patients with primary school education, who had been allocated to GORD education.

Management of gastro-esophageal reflux disease in primary care. Results from an observational study of 2 474 patients

OBJECTIVE

The aim of the present study was to describe the management of gastro-esophageal reflux disease (GERD) by primary care physicians (PCPs).

METHODS

This prospective survey was conducted in patients with suspected or previously diagnosed GERD. PCPs completed questionnaires at first consultation (M0) and at a 3-month follow-up visit (M3).

RESULTS

2 474 patients were available for analysis at M0 and 1 993 at M3. GERD was the reason for consultation in 84% of patients; 33% were consulting about reflux symptoms for the first time. Symptoms occurred once daily in 55% of patients and were considered very disruptive or incapacitating by 51%. Upper gastrointestinal endoscopy was performed at any time in 57% of patients and at M0 in 20%. Only 48% of demands for endoscopy agreed with current recommendations and this rate was not influenced by PCP training in the previous 6 months. Lifestyle measures were recommended in 95% of patients at M0. Proton pump inhibitors were prescribed in 98%, to be taken "on-demand" in 22-57% depending on symptom frequency. Therapeutic management was considered as very satisfactory by 81% of patients.

CONCLUSIONS

GERD managed in primary care is severe, leading to expensive, but effective diagnostic investigations and treatments. Agreement with recommendations for endoscopy is poor.

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease is a common, usually lifelong, disorder resulting from chronic abnormal exposure of the lower esophagus to gastric contents. Motor dysfunction of the lower esophageal sphincter is the primary cause of this disease. At this writing, no medical therapies can completely resolve abnormal lower esophageal sphincter function; therefore, the treatment of gastroesophageal reflux disease centers on suppression of intragastric acid secretion. Available acid-suppressant medications include proton pump inhibitors, H2-receptor antagonists, and antacids. Of these, the proton pump inhibitors are recognized generally as the mainstays of both short-term and long-term therapy for gastroesophageal reflux disease. All have a low incidence of side effects and are well tolerated by most patients. Five proton pump inhibitors are available currently for patients with gastroesophageal reflux disease. Of these, esomeprazole has shown greater efficacy in controlling intragastric acidity than the others. For patients with erosive esophagitis, esomeprazole has demonstrated higher healing rates and more rapid sustained resolution of heartburn than omeprazole or lansoprazole after up to 8 weeks of once-daily treatment. Because new therapies for gastroesophageal reflux disease are highly effective, patients can be reassured that their disease will be well controlled and their symptoms resolved with a safe and appropriate treatment.

Perianesthesia care of the patient with gastroesophageal reflux disease

Every day millions of people suffer heartburn and other related symptoms of gastroesophageal reflux disease (GERD). Because symptoms can lead to a reduced quality of life, GERD sufferers are desperate for relief. This article explores the definition and pathophysiology, clinical manifestations, diagnostic procedures, and treatment options for GERD, including lifestyle modifications, medications, surgery, and alternative procedures. It also discusses preoperative, anesthesia/intraoperative, and postoperative special care considerations for the surgical patient with GERD.

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is generally a lifelong illness that affects many people, but its significance is often underestimated. Chronic abnormal gastric reflux results in erosive esophagitis in up to 60% of patients with GERD. Esophageal stricture, Barrett's esophagus, and esophageal adenocarcinoma are the most serious complications of GERD. Although heartburn and acid regurgitation are the most common complaints, extraesophageal symptoms such as noncardiac chest pain, laryngitis, coughing, and wheezing can be manifestations of GERD. Unfortunately, the severity of symptoms is not a reliable indicator of the severity of erosive esophagitis. Endoscopy is the preferred method to diagnose and grade erosive esophagitis, and various classification systems are used to grade disease severity. The Los Angeles Classification is a valid and widely accepted system to evaluate the severity of erosive esophagitis. The immediate goals of treatment are to provide effective symptomatic relief and to achieve healing in patients with esophageal damage. The treatment regimen often begins by prescribing a therapy to reduce gastric acid secretion. A proton pump inhibitor is the preferred agent for many patients. Because GERD is a chronic, relapsing disease, long-term maintenance therapy is usually necessary to relieve symptoms, prevent complications, and improve the quality of life in patients with GERD.

Care of the laparoscopic Nissen fundoplication patient

Gastroesophageal reflux disease can usually be successfully managed with conservative medical treatment. Anti-reflux surgery is a safe alternative when treatment fails or patients desire a more definitive treatment option. Through a case study approach, this article describes the indications for surgery, the essentials of the authors' multi-disciplinary approach to care and the components of a well-designed education plan for a patient undergoing laparoscopic Nissen fundoplication. Although most patients do well after surgery, diligent nursing care is required before and after surgery to prevent or manage complications and ensure patients have a rapid recovery and successful outcome.