Diagnosis and management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is commonly encountered in the primary care setting, occurring in between 10% and 20% of patients in the Western world. GERD is defined as symptoms or complications resulting from the reflux of gastric contents into the esophagus, oral cavity, and/or lung. While GERD may lead to erosions seen on endoscopic examination, this is not part of the definition.

Symptoms

Most common GERD symptoms are heartburn and regurgitation. Chest pain, dysphagia, laryngitis, and respiratory symptoms may also occur. When dysphagia is present, further workup is needed to rule out the presence of an underlying motility disorder, stricture, Schatzki’s ring, or malignancy. Atypical symptoms include dyspepsia, epigastric pain, nausea, bloating, and belching.

Secondary symptoms that may raise suspicion for GERD include respiratory symptoms such as cough, dental erosions, sinusitis, chronic laryngitis, and voice disturbance.

Diagnosis

GERD can be presumed in the setting of typical symptoms of heartburn and regurgitation. Endoscopy is not required in the presence of typical symptoms. Empiric medical therapy with a proton pump inhibitor (PPI) is strongly recommended in this setting. Improvement with a PPI essentially confirms the diagnosis of GERD, but a negative trial does not exclude GERD.

If a patient with suspected GERD continues to have symptoms on a PPI, then endoscopy is warranted. Endoscopy is also indicated in the presence of alarm symptoms, such as dysphagia. The guidelines state that screening with endoscopy to rule out Barrett’s esophagus "may be reasonable" in certain high-risk groups such as overweight white males over age 50 with chronic GERD symptoms. Once Barrett’s esophagus is ruled out, there is no role for repeat endoscopy.

Ambulatory esophageal reflux monitoring is the only test that actually shows abnormal reflux of stomach acid into the esophagus. The percent of time that the esophageal pH is less than 4 is the best indication of the diagnosis of GERD. Ambulatory esophageal reflux monitoring is indicated before consideration of endoscopic or surgical therapy in patients with nonerosive disease and in situations where the diagnosis of GERD is in question. Screening for Helicobacter pylori infection is not recommended in GERD.

Management

Weight loss is recommended in all patients who are overweight or have had a recent weight gain. Head-of-bed elevation and avoidance of meals 2-3 hours before bedtime is also recommended for patients with nocturnal GERD, although there is a low level of evidence to support this recommendation.

While tobacco, chocolate, and carbonated beverages have been shown in some studies to decrease the lower esophageal pressure, eliminating these substances, as well as eliminating alcohol, has not been shown to lead to improvement in GERD symptoms and so is not recommended for the treatment of GERD. Elimination of a specific food that causes symptoms in an individual may be considered.

An 8-week course of a PPI is the therapy of choice for symptom relief and healing of erosive esophagitis. This has a high level of evidence and is strongly recommended. There are no significant differences in efficacy for symptom relief between the different PPIs. Whichever one is prescribed, PPIs should be dosed once daily, 30-60 minutes before the first meal of the day. If patients have partial response, dose adjustment, twice-daily dosing, or switching to another PPI may be considered. Patients who do not respond to PPI therapy should be evaluated by endoscopy.

Maintenance PPI use should be administered for patients with GERD who continue to have symptoms after a PPI is discontinued or in patients with complications including erosive esophagitis and Barrett’s esophagus. The lowest dose that provides symptomatic relief is the recommended dose. H₂ receptor antagonist therapy can be used as maintenance options in patients without erosive disease if patients experience heartburn relief.

Adverse effects of PPIs include osteoporosis and increased risk for Clostridium difficile infection and community-acquired pneumonia. There is strong evidence that PPI therapy does not need to be altered in concomitant clopidogrel users.

There is a high level of evidence that surgical options including laparoscopic fundoplication or bariatric surgery in obese patients with GERD produce good long-term control of GERD symptoms. However, surgery is not recommended for GERD in patients who do not respond to PPIs.

Extraesophageal presentations of GERD

GERD can be a cofactor either causing or exacerbating asthma, chronic cough, and laryngitis. GERD is apparent in approximately 50% of patients with asthma and may be the cause in approximately one-third of patients with chronic cough. It is unusual for GERD to be a factor in these disorders without symptoms of GERD being apparent. If a patient has typical symptoms of GERD in addition to the aforementioned illnesses, then treatment with a PPI should be initiated. If a patient does not have typical symptoms, reflux monitoring may be considered before a PPI is started.

Bottom line

The diagnosis of GERD is based on clinical presentation with typical symptoms of heartburn and regurgitation. Empiric therapy with a plan for weight loss and a PPI for 8 weeks is strongly recommended. Endoscopy should be done for individuals who do not respond to initial therapy.

Reference

Katz, Philip et al. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am. J. Gastroenterol. 2013;108:308-28.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Rosner is a graduate of Jefferson Medical College, Philadelphia, and a third-year resident in the family medicine residency at Abington Memorial Hospital.

Gastroesophageal reflux disease (GERD) is commonly encountered in the primary care setting, occurring in between 10% and 20% of patients in the Western world. GERD is defined as symptoms or complications resulting from the reflux of gastric contents into the esophagus, oral cavity, and/or lung. While GERD may lead to erosions seen on endoscopic examination, this is not part of the definition.

Symptoms

Most common GERD symptoms are heartburn and regurgitation. Chest pain, dysphagia, laryngitis, and respiratory symptoms may also occur. When dysphagia is present, further workup is needed to rule out the presence of an underlying motility disorder, stricture, Schatzki’s ring, or malignancy. Atypical symptoms include dyspepsia, epigastric pain, nausea, bloating, and belching.

Secondary symptoms that may raise suspicion for GERD include respiratory symptoms such as cough, dental erosions, sinusitis, chronic laryngitis, and voice disturbance.

Diagnosis

GERD can be presumed in the setting of typical symptoms of heartburn and regurgitation. Endoscopy is not required in the presence of typical symptoms. Empiric medical therapy with a proton pump inhibitor (PPI) is strongly recommended in this setting. Improvement with a PPI essentially confirms the diagnosis of GERD, but a negative trial does not exclude GERD.

If a patient with suspected GERD continues to have symptoms on a PPI, then endoscopy is warranted. Endoscopy is also indicated in the presence of alarm symptoms, such as dysphagia. The guidelines state that screening with endoscopy to rule out Barrett’s esophagus "may be reasonable" in certain high-risk groups such as overweight white males over age 50 with chronic GERD symptoms. Once Barrett’s esophagus is ruled out, there is no role for repeat endoscopy.

Ambulatory esophageal reflux monitoring is the only test that actually shows abnormal reflux of stomach acid into the esophagus. The percent of time that the esophageal pH is less than 4 is the best indication of the diagnosis of GERD. Ambulatory esophageal reflux monitoring is indicated before consideration of endoscopic or surgical therapy in patients with nonerosive disease and in situations where the diagnosis of GERD is in question. Screening for Helicobacter pylori infection is not recommended in GERD.

Management

Weight loss is recommended in all patients who are overweight or have had a recent weight gain. Head-of-bed elevation and avoidance of meals 2-3 hours before bedtime is also recommended for patients with nocturnal GERD, although there is a low level of evidence to support this recommendation.

While tobacco, chocolate, and carbonated beverages have been shown in some studies to decrease the lower esophageal pressure, eliminating these substances, as well as eliminating alcohol, has not been shown to lead to improvement in GERD symptoms and so is not recommended for the treatment of GERD. Elimination of a specific food that causes symptoms in an individual may be considered.

An 8-week course of a PPI is the therapy of choice for symptom relief and healing of erosive esophagitis. This has a high level of evidence and is strongly recommended. There are no significant differences in efficacy for symptom relief between the different PPIs. Whichever one is prescribed, PPIs should be dosed once daily, 30-60 minutes before the first meal of the day. If patients have partial response, dose adjustment, twice-daily dosing, or switching to another PPI may be considered. Patients who do not respond to PPI therapy should be evaluated by endoscopy.

Maintenance PPI use should be administered for patients with GERD who continue to have symptoms after a PPI is discontinued or in patients with complications including erosive esophagitis and Barrett’s esophagus. The lowest dose that provides symptomatic relief is the recommended dose. H₂ receptor antagonist therapy can be used as maintenance options in patients without erosive disease if patients experience heartburn relief.

Adverse effects of PPIs include osteoporosis and increased risk for Clostridium difficile infection and community-acquired pneumonia. There is strong evidence that PPI therapy does not need to be altered in concomitant clopidogrel users.

There is a high level of evidence that surgical options including laparoscopic fundoplication or bariatric surgery in obese patients with GERD produce good long-term control of GERD symptoms. However, surgery is not recommended for GERD in patients who do not respond to PPIs.

Extraesophageal presentations of GERD

GERD can be a cofactor either causing or exacerbating asthma, chronic cough, and laryngitis. GERD is apparent in approximately 50% of patients with asthma and may be the cause in approximately one-third of patients with chronic cough. It is unusual for GERD to be a factor in these disorders without symptoms of GERD being apparent. If a patient has typical symptoms of GERD in addition to the aforementioned illnesses, then treatment with a PPI should be initiated. If a patient does not have typical symptoms, reflux monitoring may be considered before a PPI is started.

Bottom line

The diagnosis of GERD is based on clinical presentation with typical symptoms of heartburn and regurgitation. Empiric therapy with a plan for weight loss and a PPI for 8 weeks is strongly recommended. Endoscopy should be done for individuals who do not respond to initial therapy.

Reference

Katz, Philip et al. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am. J. Gastroenterol. 2013;108:308-28.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Rosner is a graduate of Jefferson Medical College, Philadelphia, and a third-year resident in the family medicine residency at Abington Memorial Hospital.

Gastroesophageal reflux disease (GERD) is commonly encountered in the primary care setting, occurring in between 10% and 20% of patients in the Western world. GERD is defined as symptoms or complications resulting from the reflux of gastric contents into the esophagus, oral cavity, and/or lung. While GERD may lead to erosions seen on endoscopic examination, this is not part of the definition.

Symptoms

Most common GERD symptoms are heartburn and regurgitation. Chest pain, dysphagia, laryngitis, and respiratory symptoms may also occur. When dysphagia is present, further workup is needed to rule out the presence of an underlying motility disorder, stricture, Schatzki’s ring, or malignancy. Atypical symptoms include dyspepsia, epigastric pain, nausea, bloating, and belching.

Secondary symptoms that may raise suspicion for GERD include respiratory symptoms such as cough, dental erosions, sinusitis, chronic laryngitis, and voice disturbance.

Diagnosis

GERD can be presumed in the setting of typical symptoms of heartburn and regurgitation. Endoscopy is not required in the presence of typical symptoms. Empiric medical therapy with a proton pump inhibitor (PPI) is strongly recommended in this setting. Improvement with a PPI essentially confirms the diagnosis of GERD, but a negative trial does not exclude GERD.

If a patient with suspected GERD continues to have symptoms on a PPI, then endoscopy is warranted. Endoscopy is also indicated in the presence of alarm symptoms, such as dysphagia. The guidelines state that screening with endoscopy to rule out Barrett’s esophagus "may be reasonable" in certain high-risk groups such as overweight white males over age 50 with chronic GERD symptoms. Once Barrett’s esophagus is ruled out, there is no role for repeat endoscopy.

Ambulatory esophageal reflux monitoring is the only test that actually shows abnormal reflux of stomach acid into the esophagus. The percent of time that the esophageal pH is less than 4 is the best indication of the diagnosis of GERD. Ambulatory esophageal reflux monitoring is indicated before consideration of endoscopic or surgical therapy in patients with nonerosive disease and in situations where the diagnosis of GERD is in question. Screening for Helicobacter pylori infection is not recommended in GERD.

Management

Weight loss is recommended in all patients who are overweight or have had a recent weight gain. Head-of-bed elevation and avoidance of meals 2-3 hours before bedtime is also recommended for patients with nocturnal GERD, although there is a low level of evidence to support this recommendation.

While tobacco, chocolate, and carbonated beverages have been shown in some studies to decrease the lower esophageal pressure, eliminating these substances, as well as eliminating alcohol, has not been shown to lead to improvement in GERD symptoms and so is not recommended for the treatment of GERD. Elimination of a specific food that causes symptoms in an individual may be considered.

An 8-week course of a PPI is the therapy of choice for symptom relief and healing of erosive esophagitis. This has a high level of evidence and is strongly recommended. There are no significant differences in efficacy for symptom relief between the different PPIs. Whichever one is prescribed, PPIs should be dosed once daily, 30-60 minutes before the first meal of the day. If patients have partial response, dose adjustment, twice-daily dosing, or switching to another PPI may be considered. Patients who do not respond to PPI therapy should be evaluated by endoscopy.

Maintenance PPI use should be administered for patients with GERD who continue to have symptoms after a PPI is discontinued or in patients with complications including erosive esophagitis and Barrett’s esophagus. The lowest dose that provides symptomatic relief is the recommended dose. H₂ receptor antagonist therapy can be used as maintenance options in patients without erosive disease if patients experience heartburn relief.

Adverse effects of PPIs include osteoporosis and increased risk for Clostridium difficile infection and community-acquired pneumonia. There is strong evidence that PPI therapy does not need to be altered in concomitant clopidogrel users.

There is a high level of evidence that surgical options including laparoscopic fundoplication or bariatric surgery in obese patients with GERD produce good long-term control of GERD symptoms. However, surgery is not recommended for GERD in patients who do not respond to PPIs.

Extraesophageal presentations of GERD

GERD can be a cofactor either causing or exacerbating asthma, chronic cough, and laryngitis. GERD is apparent in approximately 50% of patients with asthma and may be the cause in approximately one-third of patients with chronic cough. It is unusual for GERD to be a factor in these disorders without symptoms of GERD being apparent. If a patient has typical symptoms of GERD in addition to the aforementioned illnesses, then treatment with a PPI should be initiated. If a patient does not have typical symptoms, reflux monitoring may be considered before a PPI is started.

Bottom line

The diagnosis of GERD is based on clinical presentation with typical symptoms of heartburn and regurgitation. Empiric therapy with a plan for weight loss and a PPI for 8 weeks is strongly recommended. Endoscopy should be done for individuals who do not respond to initial therapy.

Reference

Katz, Philip et al. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am. J. Gastroenterol. 2013;108:308-28.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Rosner is a graduate of Jefferson Medical College, Philadelphia, and a third-year resident in the family medicine residency at Abington Memorial Hospital.