Gastroesophageal Reflux Disease (GERD)

Background

• Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of stomach contents into the esophagus causes troublesome symptoms and/or complications.
• Esophageal complications of GERD include reflux symptoms, chest pain, esophagitis, stricture, Barrett esophagus, and adenocarcinoma, although the absolute risk of the development of esophageal adenocarcinoma is low.
• Possible extraesophageal complications of GERD include cough, laryngitis, asthma, and dental erosions.

Evaluation

• Diagnose GERD based on troublesome heartburn or regurgitation symptoms. Objective testing is not required in patients with typical GERD symptoms, unless there is lack of response to a trial of empiric treatment, usually in the form of proton pump inhibitors (PPIs).
• Evaluate for non-GERD causes of extraesophageal symptoms before attributing such symptoms to GERD (Strong recommendation). Extraesophageal symptoms may include hoarseness, sore throat, throat clearing, chronic cough, nausea, halitosis, chest pain, erosion of dental enamel, pharyngitis, sinusitis, recurrent otitis media, and asthma.
• Perform an upper endoscopy in patients with heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss, recurrent vomiting) (Strong recommendation) or unresponsiveness to empiric trial of 4-8 weeks of twice-daily proton pump inhibitor therapy (Weak recommendation).
• Perform pH monitoring (Strong recommendation) in unresponsive patients with suspected GERD and a normal endoscopy. Esophageal manometry can complement pH monitoring in patients with suspected GERD who are unresponsive to PPI therapy, and should be performed to rule out a motor disorder prior to invasive treatment.

Management

• Encourage weight loss if patient has overweight/obesity or recent weight gain, especially considering other health benefits (Strong recommendation).
• If patient has nocturnal GERD, consider advising patient to elevate head of bed and avoid meals 3-4 hours before bedtime (Weak recommendation).
• Prescribe a PPI, usually in the morning before breakfast, for 8 weeks as empiric therapy to relieve symptoms and confirm diagnosis.
  • In patients with uncomplicated GERD who respond to short-term PPI, attempt to stop or reduce PPI use.
  • In patients with Barrett esophagus, continue long-term maintenance PPI therapy.
  • In patients taking long-term PPI, periodically reevaluate dose and offer lowest-effective dose to manage condition.
• In patients with inadequate response to PPI therapy:
  • Optimize PPI therapy by ensuring compliance and considering adjustments to PPI dosage:
    • In patients with nighttime symptoms and/or sleep disturbance, consider adjusting dose timing and/or adding a second dose prior to the evening meal (Strong recommendation).
    • In patients with partial response, consider switching to a different PPI or increasing dose to twice daily in effort to enhance symptom relief (Weak recommendation).
• For nonresponders to PPI, consider referral for further diagnostic evaluation (Weak recommendation).
• In patients with refractory GERD and negative evaluation by endoscopy or other specialists, offer ambulatory pH monitoring to establish diagnosis.
• Consider antireflux surgery as an alternative option for long-term treatment in patients responsive to but intolerant of PPIs. Surgery is not recommended if not responsive to PPI therapy (Strong recommendation).