More than 15 million patients in the United States have prescriptions for proton pump inhibitors (PPIs), in most cases for “heartburn,” reflux, and swallowing problems, and many more are taking over-the-counter PPIs or histamine 2 receptor antagonists.
Gastroesophageal reflux disease (GERD) seems to be the initial reflexive diagnosis given to most patients who complain of chest or epigastric burning or seemingly nonspecific swallowing difficulties. The prevalence of diagnosed GERD is high; in addition to causing “heartburn,” in my clinic it seems to be the most commonly attributed cause of chronic cough with a normal chest radiograph or hoarseness, and a frequent contributing comorbidity warranting treatment in patients with bronchospasm—diagnosed by my otolaryngology and pulmonary colleagues.
GERD is so common that it is no surprise that patients are increasingly diagnosed with it on the basis of a superficial history, or that patients diagnose and treat it themselves based on information they find on the Internet. Objective diagnostic tests are suggested when PPIs do not produce the expected response.
But long-term, high-dose PPI therapy may not be totally benign. Omeprazole, commonly prescribed and also available over the counter, may in some patients interfere with clopidogrel and increase the risk of coronary events, although this increase may actually be due to the underlying medical condition for which the PPI is prescribed— “confounding by indication.” PPI use is associated with decreased absorption of iron and vitamin B12, perhaps contributing to anemia. The estimated risks of vertebral and hip osteoporosis, interstitial nephritis, and dementia are slightly increased. Patients with severe liver disease seem to be at far higher risk of bacterial peritonitis. Clostridium difficile infection and some pneumonias may also be increased in chronic PPI users. Therefore, we should think twice when making a clinical diagnosis of GERD, a diagnosis that often leads us to prescribe antacid therapy (usually a PPI) for a long time, sometimes unnecessarily.1
Kichler and Gabbard, in this issue of the Journal (page 443), work through a clinical management scenario focusing on the evaluation of a patient with dysphagia, a common symptom described in many ways by patients who may have previously been diagnosed with GERD. The authors remind us of the value of a careful, focused, and detailed medical history, and provide updated information on the performance and utility of motility and endoscopic studies in diagnosing esophageal disorders.
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