Summary

Esophagitis and esophageal strictures continue to complicate the course of many individuals with reflux symptoms. Much headway has been made, however, with the use of PPIs or antireflux surgery in the acute and maintenance treatment of these conditions. Barrett's esophagus remains a perplexing problem for many clinicians. What is the exact risk of malignant transformation? What interval is appropriate for surveillance of patients with this premalignant stage, and how and when do we treat? A better identification of specific clinical and genetic risk factors for malignant transformation is essential for making surveillance a cost-effective and appropriate way of following these patients. The emergence of more advanced endoscopic therapies may eventually modify the treatment algorithm for individuals with localized intraepithelial neoplasia. Cyclooxygenase-2 inhibition also seems to offer hope for agents that may reduce the risk of progression in individuals with Barrett's esophagus but randomized controlled trials are lacking.

The high prevalence of GERD, yet surprisingly low incidence of Barrett's esophagus and esophageal adenocarcinoma, would suggest that many factors contribute to the progression of reflux to Barrett's to malignancy. Only after a better identification of these factors will more effective treatments aimed at reducing disease progression be realized.

MANAGING FAILED ANTI-REFLUX THERAPY

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