SUMMARY:

Gastroesophageal reflux disease (GERD) is a chronic condition characterized by the recurrent and troublesome heartburn and regurgitation of acidic stomach contents into the esophagus. Complications include Barrett esophagus, peptic stricture, esophagitis, and gastric adenocarcinoma. It is caused by dysfunction of the esophagogastric junction barrier. GERD has been estimated to occur in 15% to 25% of the population of high-income countries. This condition may be diagnosed in association with classic symptoms or following recognition of GERD-related complications.

Symptoms

Esophageal Symptoms

Symptoms of GERD may be limited to the esophagus and GI tract (typical GERD) and/or may be extra-esophageal

• Heartburn
• Acid regurgitation
• Chest pain
• Nausea
• Dysphagia
• Belching
• Bloating
• Bleeding

Extra-esophageal symptoms

Will occur with or rarely without typical GERD symptoms | Silent GERD is an unlikely diagnosis

• Extra-esophageal symptoms may include those of laryngopharyngeal reflux (LPR)
  • Hoarseness/chronic laryngitis
  • Chronic cough, including cough that awakens from sleep
  • Asthma/wheezing
  • Recurrent throat irritation and/or throat clearing
  • Excessive pharyngeal mucus
  • Globus (sensation of a lump in the throat)
  • Chronic sinusitis
  • Eustachian tube dysfunction and otitis
  • Change in tone or pitch of speech
• Additional extra-esophageal symptoms may include
  • Halitosis
  • Dental caries
  • Erosion of dental enamel

Complications

• Esophagitis
• Peptic esophageal stricture
• Barrett’s esophagus (premalignant condition)
• Esophageal carcinoma: Adenocarcinoma may follow Barrett’s with dysplasia, lower esophageal location
• Aspiration

Risk Factors 

• Obesity
• Female gender
• Genetic predisposition
• Role of H. Pylori unclear in GERD
• Tobacco Use

Note: Although alcohol consumption is associated with upper GI symptoms, it is not considered a risk factor specifically for GERD | There are many overlapping symptoms between GERD, esophagitis and gastritis

Differential Diagnosis

• Coronary Disease
  • Careful evaluation required
• Gastritis
  • Associated with infections, alcohol and certain medications (e.g., NSAIDs)  
• Other causes of esophagitis
  • Associated with smoking, alcohol, food triggers, medications (e.g., NSAIDs)  
• Peptic ulcer disease
  • Nausea | Vomiting | Epigastric pain
• GI malignancy
  • Dysphagia | Vomiting | Weight loss
• Biliary disease
  • Abdominal pain | Jaundice
• Upper GI motility disorder
  • Dysphagia | Vomiting of undigested food
  • Achalasia | difficulty swallowing liquids as well solids
• Eosinophilic esophagitis
  • Dysphagia | Food impaction | Chest pain

Treatment

Lifestyle modification

• Weight reduction
• Smoking cessation
• Avoid food and beverage triggers and eating 2 to 3 hours prior to bedtime
• Head elevation and sleeping on left side if nocturnal GERD present

Medications

Proton Pump Inhibitors (PPIs)

PPI List and Dosing

• Pantoprazole: 20 to 40 mg daily or twice a day or bid, always 30 to 60 minutes before meal(s)
• Omeprazole: 20 to 40 mg daily or twice a day, always 30 to 60 minutes before meal(s)
• Esomeprazole: 20 to 40 mg daily or twice a day, always 30 to 60 minutes before meal(s) (second strongest PPI)
• Lansoprazole: 30 mg daily or twice a day, always 30 to 60 minutes before meal(s)
• Rabeprazole: 20 mg once daily, always 30 to 60 minutes before a meal (strongest PPI)
• Dexlansoprazole: 30 to 60 mg once daily, not related to meals, (weakest PPI)

• PPIs recommended over histamine-2-receptor antagonists for healing and maintenance of healing from erosive esophagitis
• Indication
  • Relief of heartburn | Regurgitation | Healing of esophageal injury
• Peak benefit: 8 to 12 weeks
• Overall GERD symptom relief and healing differ little between available PPIs
• Dosing: 30 to 60 minutes before a meal | Bedtime dosing discouraged
• If GERD (without Barrett’s esophagus or erosive esophagitis) resolves, try to discontinue PPI or switch to on-demand therapy

Note: If patient requires maintenance therapy, use PPIss at lowest dose to control symptoms and maintain healing

• Patients Who Need PPIs Indefinitely
  • Barrett’s esophagus
  • Severe erosive esophagitis
  • Definitive response to PPI with chronic symptoms not responding to other treatments
• PPI’s do not increase risk of the following or data supporting an association are weak or conflicting
  • Bone fractures | Osteoporosis
  • Cancer
  • Early death
  • Dementia
  • Pneumonia
  • Chronic kidney disease | Do consider monitoring kidney function in patient with kidney disease who require long term PPI
  • Cardiovascular disease
  • B12 deficiency
• PPIs do increase risk for the following
  • C. difficile and other enteric infections
  • Severe hypomagnesemia (Rare, and monitoring magnesium levels not recommended)

Note: Patients who need the PPI daily but are afraid of possible side effects should be advised about the dangers of NOT taking the PPI 

• To optimize PPI therapy
  • Twice daily dosing may be superior to once daily dosing
  • Consider doubling dose if inadequate response to initial dose
  • Confirm timing of medications 30-60 minutes before meal
  • If inadequate response to one PPI, consider switch once to a different one
• Treatment recommended for 4 to 8 weeks
  • 4 weeks if uncomplicated | 8 weeks for confirmed erosive esophagitis
  • Follow by taper or cessation of medication, then use of PPI as needed
• In general, avoid long-term treatment with PPIs
  • Potential for enteric infections with weak associations to other complications
  • Acid rebound may occur following acute cessation of long-term PPI treatment so consider taper (controversial)
• Refractory GERD: Persistent heartburn and/or regurgitation after 8 to 12 weeks of twice daily PPI
  • Consider referral for further evaluation
  • Work-up: Upper endoscopy | Reflux monitoring | Esophageal manometry

Other Medications

• Histamine-2-receptor antagonists may be use as needed at bedtime for
  • Nocturnal symptoms: Documented nocturnal acid reflux despite PPI treatment
• Prokinetic
  • Not recommended unless there is objective evidence of gastroparesis
• Baclofen
  • Not recommended
• Sucralfate              
  • Possible indication for GERD in pregnancy not responsive to lifestyle modification, antiacids

Evaluation and Treatment of Extra-esophageal GERD

• Investigate for non-GERD related etiologies
• Those who present with dysphagia and weight loss either solely or in combination with GERD should be evaluated initially for upper GI malignancy
• American Gastroenterological Association recommends against acid suppression therapy for acute treatment in the absence of concurrent typical GERD symptoms
• pH monitoring is recommended before starting PPI in patients without typical GERD
• If no response to twice-daily PPI, consider upper endoscopy off PPI for 2 to 4 weeks and if normal, consider reflux monitoring
• Consider evaluation for extraesophageal symptoms by otolaryngology, pulmonary and allergy specialist depending on symptoms

Anti-reflux Surgery

• Surgical option for long-term treatment of patients with objective evidence and thorough work-up of GERD, especially those with
  • Severe reflux esophagitis | Large hiatal hernias | Persistent troublesome GERD symptoms
• When PPI and surgery offer similar efficacy, recommend PPI for safety
• Consider surgery if patient responds to PPI treatment but is intolerant or does not wish to continue PPI long term
• Consider surgery if no response to PPI
• Surgical procedures include
  • Laparoscopic fundoplication: Following endoscopy to rule out malignancy and manometry to rule out motility disorders (achalasia) | If GERD recurs after surgery –recommend endoscopy and pH monitoring
  • Stretta procedure: Radiofrequency ablation above and below the LES to thicken the LES
  • Trans-oral incisionless fundoplication: Involves circumferentially suturing the gastroesophageal area with non-absorbable material, applied via endoscopy | Long-term efficacy uncertain
  • LINX procedure (magnetic sphincter augmentation) for regurgitation symptoms: Involves endoscopically placing titanium beads with magnetized centers around the lower esophagus to increase tone
  • Roux-en-Y gastric bypass in obese patients who are candidates for this procedure

LEARN MORE  – PRIMARY SOURCES

Gastroesophageal Reflux Disease: A Review

ACG Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease

AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review