TREATMENT OF ACID LARYNGITIS

• If patient has acid laryngitis, with the present state of knowledge, it seems reasonable to try treatment with omeprazole for two months to suppress the output of acid, with monitoring of the clinical response and the appearance at laryngoscopy.

TREATMENT DURING PREGNANCY
• The smooth muscle relaxation that occurs during pregnancy predisposes to gastroesophageal reflux [26].
• Lifestyle modifications or antacids should be first-line therapy in symptomatic women [26].
• The greatest experience with pharmacologic acid-suppressive therapy in pregnant women has been with the H2 receptor antagonist ranitidine and cimetidine, which appear to be safe during pregnancy [27].
• There is less experience using proton pump inhibitors during pregnancy. However, they are probably safe [26, 28].





FOLLOW UP
• Following up at 8 weeks to see if there has been some improvement in symptoms may be done, once treatment has been started. If there is no improvement, the patient should be referred for endoscopy.

• Symptoms unchanged
If symptoms remain unchanged in a patient who has had a prior normal endoscopy, evidence for the need for repeat endoscopy is not known, but currently not recommended [16].
• Warning signs.
Patients with warning signs and symptoms suggesting complications from GERD should be referred to a GERD specialist [16]
• Risk for complications
Consider further diagnostic testing (e.g., esophagogastroduodenoscopy [EGD], pH monitoring) for those who do not respond to acid suppression therapy [16].
Further diagnostic testing should also occur in patients with a chronic history of GERD who are at risk for complications (e.g., Barrett’s esophagitis, adenocarcinoma, and stricture) [16]
• It is reasonable to assess vitamin B12 levels periodically in patients who are on long-term treatment with PPIs [24]


SURVEILLANCE

• Endoscopy to screen for Barrett’s esophagus is recommended in patients with a long duration of GERD symptoms (e.g., > 5 years), particularly white males who are 50 or more years of age [7].
• If patient has developed Barrett’s esophagus, the grade of dysplasia determines the endoscopy interval, and an abnormal epithelial surface such as a nodule or ulcer requires special sampling attention. Surveillance endoscopy intervals are lengthening in the absence of dysplasia on two consecutive endoscopies with biopsy—a 3-yr interval is appropriate [21].
• In patients without Barrett's esophagus on an initial examination, the cancer risk is too low to justify a follow-up endoscopy. Exceptions are patients who develop bleeding, dysphagia, or a significant change in symptoms while on effective therapy [21]
• In patients with low-grade dysplasia repeat endoscopic surveillance in 3-6 months to screen for coexisting high-grade dysplasia or cancer.
• If low-grade dysplasia persists (which occurs in < 25% of patients), endoscopic surveillance should be repeated yearly.
• If patient has high grade dysplasia, close endoscopic surveillance every 3-6 months with biopsy may also be considered, reserving surgery or alternative therapies for treatment of proven intramucosal or invasive adenocarcinoma.
•