The relationship between the control of pH and healing and symptom relief in gastro‐oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD) is generally considered to be the result of a motility disorder which permits the abnormal and prolonged exposure of the lumen of the oesophagus to the acidic gastric contents. This view is supported by experimental data, intra-oesophageal pH measurement, and the dramatic results of symptom relief and healing seen with effective antisecretory treatment. Oesophageal mucosal injury is determined by the pH of the refluxate and duration of acid exposure. Most patients experience meal-stimulated reflux during the day and the more severe cases experience 24-h acid exposure. In contrast to the H2-receptor antagonists (H2RAs), the proton pump inhibitors (PPIs) are more effective at controlling meal-stimulated acid secretion when each is given in standard doses. Therefore, the degree and duration of acid suppression throughout 24 h is greater. Treatments which maintain intra-oesophageal pH > 4 for 96% or more of the 24 h normalize acid exposure and are associated with the highest healing rates. Peptic activity is minimized at or above pH 4. The time above pH 4 is significantly longer with the PPIs than with the H2RAs. Thus, the healing-time curves for GERD (grades II-IV) are shifted to the left for the PPIs which heal a significantly greater proportion of patients earlier than the H2RAs or sucralfate. Symptoms in GERD are related to the degree and duration of oesophageal acid exposure. Symptom relief is more rapid and complete with the PPIs than with the H2RAs or other treatments in standard doses.