Q1. Answer: A
While heartburn responds well to acid suppression with a proton pump inhibitor, regurgitation does not necessarily improve. It is well known that reflux persists despite acid suppression; in some patients, this manifests as troublesome postprandial regurgitation. Transient LES relaxations (TLESRs) are the prime mechanism for persisting reflex, in patients both with and without hiatal hernias.
Baclofen, a gamma amino butyric acid B (GABA-B) agonist, inhibits TLESRs and has potential to improve persisting regurgitation. Metoclopramide has been demonstrated to have no adjunctive value in treating reflux disease. Hyoscyamine and sucralfate are similarly not of particular benefit in this setting. Cholesytramine is a bile salt binding resin that has value in the management of postcholecystectomy diarrhea.
References
1. Kahrilas P.J., Jonsson A., Denison H., et al. Regurgitation is less responsive to acid suppression than heartburn in patients with gastroesophageal reflux disease. Clin Gastroenterol Hepatol. 2012;10(6):612-9.
2. Vela M.F., Camacho-Lobato L., Srinivasan R., et al. Simultaneous intraesophageal impedance and pH measurement of acid and nonacid gastroesophageal reflux: effect of omeprazole. Gastroenterology. 2001 Jun;120(7):1599-606.
3. Vela M.F., Tutuian R, Katz PO, et al. Baclofen decreases acid and non-acid post-prandial gastro-oesophageal reflux measured by combined multichannel intraluminal impedance and pH. Aliment Pharmacol Ther. 2003 Jan;17(2):243-51.
