GERD

Lindsey Creech

Background

  • Reflux of stomach contents causing symptoms and/or endoscopic complications
  • Severity classified based on appearance of esophageal mucosa on EGD and frequency of symptoms.
  • Erosive esophagitis: endoscopically visible breaks in distal esophageal mucosa + GERD
  • Nonerosive reflux disease: presence of symptoms of GERD without esophageal mucosal injury and positive pH testing

Presentation

  • Esophageal symptoms: heartburn, regurgitation, chest pain, dysphagia, globus sensation, odynophagia
  • Extra-esophageal symptoms: chronic cough, hoarseness, asthma, chest pain, dental erosions, globus sensation
  • Complications: Esophageal stricture, Barrett’s esophagus, esophageal adenocarcinoma

Evaluation

  • Clinical diagnosis with classic heartburn and/or regurgitation
  • If dx uncertain, can perform ambulatory pH monitoring
  • EGD indicated for the following:
    • Presence of alarm features (dysphagia, persistent vomiting, GI cancer in 1º relative, odynophagia, GI bleeding, weight loss, iron deficiency anemia, age ≥ 60 y/o with new-onset GERD symptoms)
    • Risk factors for Barrett’s esophagus (duration of GERD at least 5-10 years [must be present], >50 yo, male, white, hiatal hernia, obesity, nocturnal reflux, tobacco use, first-degree relative w/ Barrett’s and/or adenocarcinoma)
    • Abnormal UGI tract imaging (i.e. luminal abnormalities)
    • Continued symptoms despite adequate PPI therapy

Management

  • First and foremost, Lifestyle and dietary modifications:
    • Weight loss, elevate HOB, avoid large meals or meals within 3 hrs of bedtime, elimination/minimization of chocolate, caffeine, spicy foods, citrus, and carbonated beverages
  • Mild/intermittent symptoms (2x/wk) w/o erosive esophagitis (if had EGD):
    • Trial H2RA (famotidine 10mg) PRN; reassess in 4 wks
    • If persistent sx, increase H2RA BID (famotidine 20mg); reassess in 2 wks. If sx improve, step-down therapy as tolerated
    • If persistent sx on H2RA BID, then PPI qd (omeprazole 10mg), increase to omeprazole 20mg if remaining uncontrolled; reassess in 4-8 wks
    • If sx improve, discontinue PPI o
    • If persistent sx, manage as refractory and refer to GI for EGD +/- ambulatory pH testing
  • Frequent symptoms (>2 episodes/wk, and/or severe symptoms that impair QOL):
    • PPI qd (omeprazole 20mg) for 8 wks, if sx improvement, discontinue PPI
  • Recurrent symptoms:
    • 2/3 of patients w/ nonerosive reflux disease relapse when acid suppression is discontinued
    • If ≥3 months after discontinuing, repeat 8-wk course of PPI
    • If <3 months of discontinuing, EGD (if not already performed) to rule out other etiologies or complications
  • Erosive esophagitis and Barrett’s esophagus:
    • Require maintenance acid suppression with a standard dose PPI (omeprazole 20mg) daily given likelihood of recurrent symptoms and complications if stopped
  • PPI use:
    • Should be prescribed at lowest dose and for shortest duration appropriate
    • Most effective if taken 30-60min before first meal of the day
    • Taper if taking >6 mo, then transition to H2RA PRN for mild or intermittent sx
    • Long term side effects: Very well tolerated, high-quality RCTs show slightly higher risk of enteric infections (such as C.diff)
  • If pregnant patient, start with antacids or sucralfate
  • If elderly patient, attempt to wean off PPI/H2RA or discontinue with goal of using antacid PRN (due to side effects of H2RA and PPI)
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