para>Antacids or liquid H2 blockers and PPIs are available. Prokinetics have a minimal role due to safety concerns and limited efficacy.
Second Line
- Antacids or barrier agents (sucralfate 1 g PO QID 1 hour before meals and at bedtime for 4 to 8 weeks) may relieve breakthrough symptoms.
- Prokinetics: metoclopramide 5 to 10 mg before meals
- Baclofen as add-on therapy with a PPI
- Precautions
- Blood dyscrasias and anemia with PPIs and H2 blockers
- Metoclopramide is a dopamine blocker; risk of dystonia and tardive dyskinesia
- Tachyphylaxis may occur with H2 blockers.
- Significant possible interactions
- PPIs and H2 blockers: multiple cytochrome P450 drug interactions; that is, warfarin, phenytoin, antifungals, digoxin
SURGERY/OTHER PROCEDURES
- Laparoscopic fundoplication (wrapping gastric fundus around distal esophagus) increases pressure gradient between stomach and esophagus.
- Bariatric surgery
- Surgery indicated if : Patient desires to discontinue medical therapy, has side effects with medical therapy, large hiatal hernia, esophagitis refractory to medical therapy, or refractory symptoms (4)[A].
- Pre-op ambulatory pH monitor is mandatory in patients without evidence of erosive esophagitis (4)[A].
- Rule out esophageal dysmotility prior to surgery by manometry to rule out achalasia or scleroderma like esophagus (4)[A].
- Best surgical response is seen in patients with typical symptoms who respond well to PPI therapy.
- If it is estimated that a patient will require >10 years of PPI treatment, surgery may be more cost-effective.
- Bariatric surgery can be considered for patients with comorbid obesity. Gastric bypass is preferred (4)[A].
Pediatric Considerations
Surgery for severe symptoms (apnea, choking, persistent vomiting)
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Monitor and follow symptoms over time.
- Repeat endoscopy at 4 to 8 weeks if there is a poor symptomatic response to medical therapy, especially in older patients.
- Endoscopic surveillance every 2 to 3 years in patients with Barrett esophagus to screen for malignant transformation (in patients who would opt for treatment if cancer is detected)
DIET
Avoid foods that can trigger or make symptoms worse.
PATIENT EDUCATION
Lifestyle and dietary modifications: Eat small meals; avoid lying down soon after meals; elevate head of bed; weight loss; smoking cessation; avoid alcohol and caffeine.
PROGNOSIS
- Symptoms and esophageal inflammation often return promptly when treatment is withdrawn. To prevent relapse of symptoms, continue antisecretory therapy (in addition to lifestyle and dietary modifications).
- PPI maintenance therapy likely improves quality of life better than H2 blocker maintenance.
- Full-dose PPIs are more effective than half-dose for maintenance (4)[A].
- In erosive esophagitis, daily maintenance therapy with PPI prevents relapse; intermittent PPI therapy not as effective (2)[A]
- Medical and surgical therapy are equally effective for symptom reduction (4)[A].
- Antireflux surgery
- 90-94% symptom response. Patients with persistent symptoms should have repeat anatomic evaluation (endoscopy or esophagram).
- Some surgically treated patients eventually require medical therapy.
- Regression of Barrett epithelium does not routinely occur despite aggressive medical or surgical therapy.
COMPLICATIONS
- Peptic stricture: 10-15%
- Barrett esophagus: 10%
- Adenocarcinoma cancer develops at an annual rate of 0.5%.
- Primary treatment for Barrett esophagus with high-grade dysplasia is endoscopic radiofrequency ablation.
- Extraesophageal symptoms: hoarseness, aspiration, (including pneumonia)
- Bleeding due to mucosal injury
- Noncardiac chest pain
Geriatric Considerations
Complications more likely (e.g., aspiration pneumonia)
REFERENCES
11 Lee YY, McColl KE. Pathophysiology of gastroesophageal reflux disease. Best Pract Res Clin Gastroenterol. 2013;27(3):339-351.22 Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135(4):1383.e5-1391.e5.33 Agency for Healthcare Research and Quality. Comparing effectiveness of management strategies for gastroesophageal reflux disease. An update to the 2005 report. http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=781&pageaction=displayproduct/. Accessed 2015.44 Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(10):308-328.
ADDITIONAL READING
- Anderson WDIII, Strayer SM, Mull SR. Common questions about the management of gastroesophageal reflux disease. Am Fam Physician. 2015;91(10):692-697.
- Campanozzi A, Boccia G, Pensabene L, et al. Prevalence and natural history of gastroesophageal reflux: a pediatric prospective survey. Pediatrics. 2009;123(3):779-783.
- El-Serag HB, Sweet S, Winchester CC, et al. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2014;63(6):871-880.
SEE ALSO
Algorithms: Dyspepsia; Epigastric Pain
CODES
ICD10
- K21.9 Gastro-esophageal reflux disease without esophagitis
- K21.0 Gastro-esophageal reflux disease with esophagitis
ICD9
- 530.81 Esophageal reflux
- 530.11 Reflux esophagitis
SNOMED
- 235595009 Gastroesophageal reflux disease (disorder)
- 266433003 Gastroesophageal reflux disease with esophagitis (disorder)
- 266435005 Gastroesophageal reflux disease without esophagitis (disorder)
- 371132002 Hiatal hernia with gastroesophageal reflux disease (disorder)
CLINICAL PEARLS
- GERD is primarily diagnosed by history.
- GERD should be considered in nonsmokers who have chronic cough (> 3 weeks).
- PPI treatment does not appear to inhibit neoplastic progression in Barrett esophagus.
- No evidence to support that patients with GERD should routinely be tested for Helicobacter pylori.
- Empiric treatment with H2 blockers or PPI leads to symptomatic relief in most cases. Persistent symptoms should be evaluated with endoscopy.