GERD

Catie Gray

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.
  • 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 off PPI (Bravo testing).
  • 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 20 mg 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 20mg), re-assess in 4-8 weeks; double dose or switch PPI if uncontrolled.
    • If sx improve, discontinue PPI.
    • If persistent sx after PPI adjustment, 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. Otherwise, manage as noted above.
  • 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) and osteoporosis. 
    • 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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