Persistent acid reflux and symptoms in patients with Barrett's oesophagus on proton-pump inhibitor therapy

OBJECTIVES To assess both acid gastro-oesophageal reflux (GOR) suppression in patients with Barrett's oesophagus on proton-pump inhibitors (PPI) and the predictive value of symptoms. DESIGN A prospective study of patients with Barrett's epithelium (> 3 cm, containing specialized intestinal metaplasia). PATIENTS AND METHODS Forty-five patients with Barrett's epithelium were recruited. Therapy was adjusted to omeprazole 20 mg twice daily. Oesophageal manometry and 24 h pH studies were performed on treatment. Heartburn score was calculated before and after PPI dose adjustment. In patients with persisting acid reflux, omeprazole dose was increased to 20 mg three times daily and pH studies repeated. Adequacy of GOR suppression, assessed by pH monitoring, was related to heartburn score (0–3). RESULTS Twenty of the 45 patients were symptomatic (mean score 1.9) on pre-study treatment (mainly omeprazole < 20 mg once daily); on omeprazole 20 mg twice daily, only six patients remained symptomatic (mean score 1.6). Ten patients (22%) had persisting GOR on omeprazole 20 mg twice daily (median % total time with pH < 4 was 8%). Abnormal nocturnal reflux was found in nine and abnormal daytime reflux in only four patients. Heartburn persisted in three of these 10 patients (30%). Those remaining symptomatic had more daytime acid reflux than the asymptomatic patients with persistent reflux (median percentage daytime at pH < 4 was 13.6% vs 0.6%, respectively; P < 0.01). By increasing the omeprazole dose to 20 mg three times daily, only three of the 10 had persistent acid reflux. CONCLUSIONS Persistent acid reflux on PPI therapy is common in patients with Barrett's oesophagus. Although nocturnal acid reflux is the most common finding, symptoms tended to occur in those with abnormal daytime reflux. Symptom resolution does not guarantee acid reflux control.