© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 162 (6): ITC6-1. * For Best Viewing:...

© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (6): ITC6-1.

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in the clinic

Gastroesophageal reflux disease


What causes GERD?

Prolonged exposure to reflux of gastric contents

Transient relaxations of lower esophageal sphincter expose esophagus to stomach acid and contents

Factors that increase exposure

Increased intra-abdominal pressure (obesity, pregnancy)

Decreased esophageal or gastric motility

Xerostomia

Hiatal hernia

Increased esophageal sensitivity may predispose to more severe symptoms or tissue damage

Increased acid production is not an important cause of GERD

Zollinger-Ellison syndrome the rare exception


What symptoms and signs should prompt clinicians to consider GERD?

Typical esophageal symptoms

Heartburn

Regurgitation

Atypical esophageal symptoms

Epigastric discomfort

Noncardiac chest pain

Nausea, satiety, dysphagia, globus, eructation, hematemesis

Extraesophageal symptoms

Cough, wheezing

Sore throat, hoarseness

Dental erosions


When should clinicians try an empirical therapeutic trial of acid suppression therapy to support a preliminary diagnosis?

When upper GI complaints are vague and symptom questionnaire is suggestive of GERD

Reflux Disease Questionnaire: 12-question instrument

When esophageal & extraesophageal symptoms present

Trial of PPI: take once or twice daily for 1 to 2 weeks

Assure proper dosing and compliance

If only partial improvement occurs, consider twice-daily dosing or switch to another PPI before declaring non-responder


When should clinicians consider upper endoscopy in evaluating patients with possible GERD?Indications for EGD in Known or Suspected GERD

Typical GERD symptoms that persist after a PPI trial

Alarm symptoms (dysphagia, bleeding, unexplained iron deficient anemia, weight loss, vomiting, epigastric mass)

Atypical GERD symptoms (epigastric pain, early satiety, food impaction): to exclude other upper GI diseases

Confirm healing after severe erosive esophagitis

Screen for Barrett esophagus in men >50 years with chronic GERD and additional risk factors

Surveillance of known Barrett esophagus


What other diagnoses should clinicians consider in patients with suspected GERD?

Esophageal disorders

Cancer (squamous or adenocarcinoma)

Eosinophilic esophagitis

Functional heartburn

Motility disorders (achalasia, spastic disorders, hypotensive lower esophageal sphincter)

Nonreflux esophagitis (infectious, pill- or radiation-induced)

The rumination syndrome

Strictures, webs, or rings

Zenker’s diverticulum

Continued


Other gastrointestinal disorders

Biliary colic

Gastritis

Gastroparesis

Hiatal hernia

Nonulcer dyspepsia

Peptic ulcer disease

Nongastrointestinal disorders

Chest wall pain

Coronary artery disease

Oropharyngeal and laryngeal disorders


What other lab tests should clinicians consider when the diagnosis is uncertain?

Ambulatory reflux monitoring

Esophageal manometry

For refractory cases

For pre-op testing for anti-reflux surgery

Barium radiography (esophagram &/or upper GI series)

For primary complaint of dysphagia

For pre-op or post-op testing for anti-reflux surgery

Laryngoscopy

Presence of laryngeal erythema, edema, or other abnormalities not specific for GERD


Is there any connection between GERD and Helicobacter pylori infection?

Diagnose and manage as separate entities

Both may present with dyspepsia

No reason to test for H. pylori in patients with typical symptoms of heartburn or regurgitation

Patients with H. pylori gastritis may experience increased GERD symptoms even when H. pylori is eradicated

Long-term PPI use may increase risk for atrophic gastritis in patients with undiagnosed H. pylori infection

Routinely checking H. pylori status in patients on long-term PPIs is not recommended


When should clinicians consider gastroenterology consultation during the evaluation of GERD?

Typical symptoms do not respond to an empiric PPI trial

Atypical symptoms overlap with those of other esophageal or gastric disorders

Alarm symptoms

High risk of Barrett esophagus and adenocarcinoma


CLINICAL BOTTOM LINE: Diagnosis... Empiric diagnosis of GERD is based on

Presence of typical esophageal symptoms

Response to a PPI trial

Use of patient-reported questionnaires

If no response to PPI trial or if symptoms are extraesophageal or atypical: consider other disease possibilities

Consider EGD when alarm signs are present (dysphagia, bleeding, weight loss, vomiting or epigastric mass)

Don’t use barium radiography or laryngoscopy for GERD Dx

Reserve other tests for refractory or complex cases


What is the role of dietary modification in the treatment of GERD?

Dietary modifications may improve symptoms or reduce complications, but evidence isn’t strong

Some foods may lower LES tone (carminatives)

Other foods may irritate inflamed esophageal mucosa (citrus)

Patients may report improvement when avoiding particular substances

May control uncomplicated GERD without medical therapy


Are behavioral interventions effective in the treatment of GERD?

Weight loss

Smoking cessation

Elevating head by 6-8 inches when in bed

Avoiding meals in the last 2-3 hours before bed


Which medications cause or exacerbate GERD, and how should clinicians counsel patients regarding their use?

Medications that exacerbate GERD

By decreasing LES pressure and/or slowing esophageal clearance

CCBs, nitrates, anticholinergics, α-adrenergic antagonists, prostaglandins, theophylline, sedatives

Medications that irritate already inflamed tissue

Aspirin, NSAIDs, bisphosphonates

Decide whether to avoid these medications on a case by case basis


Which non-prescription medications are effective in the management of GERD?

Antacids neutralize stomach acid to relieve heartburn

Best used “on-demand” for infrequent symptoms

Regular or frequent use a marker of uncontrolled GERD

H2-receptor antagonists (H2RAs)

Inhibit histamine binding on gastric parietal cell receptor

Help heal erosive esophagitis and improve symptoms

Best used “on-demand” for infrequent symptoms in patients with symptoms after stopping initial PPI therapy

Use when PPIs not tolerated or contraindicated

Use limited by tachyphylaxis


PPIs

First-line agents for patients with erosive disease or with typical esophageal symptoms

Irreversibly inhibit parietal cell proton pump

Most efficacious when taken 30 to 60 minutes before eating

More potent acid suppressors than H2RAs

Initial therapy: 8-week course of once daily PPI

Maintenance therapy indicated if GERD symptoms persist

Continued

When should clinicians consider prescription medications?


tLESR inhibitors (baclofen)

GABA-B agonist increases lower esophageal sphincter tone

Prokinetic agents (metoclopramide)

Promote gastric emptying

Mucosal protectant (sucralfate)

Binds to inflamed mucosa

Antidepressants (SSRIs, tricyclic antidepressants)

May modulate visceral pain sensation due to acid exposure

especially in hypersensitive patients


How should clinicians select from among available antireflux medications?

No real efficacy differences within same medication class

Modest superiority for esomeprazole vs. other PPIs

Dexlansoprazole can be dosed at any time of day

Immediate release omeprazole-sodium bicarbonate may improve nighttime gastric pH compared to other PPIs

Few data to support high- or double-dose of any PPI other than acute healing of esophagitis

Idiopathic side effects (diarrhea, constipation, headache) may occur with one PPI but not another

Pregnancy may affect medication selection


Complicated GERD

Erosive disease, stricture, or Barrett esophagus

Indefinite PPI maintenance therapy avoids relapse

Decreases risk of dysplasia development

How long should patients continue pharmacologic therapy for GERD?

Uncomplicated GERD

Consider maintenance therapy if symptoms recur

Make every attempt to taper and minimize medication use

Manage with intermittent or on-demand PPI therapy

Consider ‘step-down’ approach by using H2RAs on-demand

Balance symptom control against cost, inconvenience, and potential side effects of chronic PPI use


What are the adverse effects of long-term acid suppression therapy?

Gastric acid aids in vitamin and mineral absorption

PPIs may increase iron deficiency or pernicious anemia risk

PPIs may increase hip fracture risk

Gastric acid aids in destruction of ingested potentially pathogenic bacteria

PPIs may increase risk for enteric infections (C. difficile)

Pneumonia may be more common during sh-term PPI use

PPI + clopidogrel may increase cardiovascular risk

Long-term PPI use could predispose to intestinal metaplasia or gastric malignancy


When should clinicians consider surgical therapy for GERD?

Surgical anti-reflux therapy: laparoscopic fundoplication

Long-term treatment option with similar efficacy to medical Rx for some

Those with typical symptoms who respond to PPIs but wish to discontinue use

Those with continued symptoms / damage despite PPIs

Evidence doesn’t support surgery for other patients

Those with atypical symptoms or who don’t respond to PPIs

Those with Barrett esophagus who wish to prevent cancer

Bariatric surgery may be a treatment option for morbidly obese patients with GERD


Is it necessary to evaluate for Barrett esophagus periodically?

Estimated to occur in up to 10% with chronic GERD

Annual risk of esophageal adenocarcinoma is low (≈ 0.12%) even in patients with Barrett esophagus

Consider endoscopy for men >50 who have had GERD ≥5 yrs and who are overweight or have other risk factors

No role for periodic screening endoscopy in patients with uncomplicated GERD

No role for periodic screening endoscopy in patients with normal index endoscopy performed for above indications


How should clinicians manage patients once Barrett esophagus is present?

Periodic surveillance can lead to earlier cancer Dx

In absence of dysplasia, use endoscopy every 3-5 years

Continue PPIs

Document presence of absence of dysplasia

Risk of progression to adenocarcinoma 0.1% to 0.5% per patient-year for non-dysplastic Barrett esophagus

Risk of progression to adenocarcinoma 5%-20% for dysplastic tissue

Data support endoscopic eradication therapy with radio-frequency ablation for high- and low-grade dysplasia


How frequently should clinicians see patients with GERD and what are the components of good follow-up?

At least annually if chronically taking PPIs or H2RAs

Assess symptom character, frequency, and severity

Check for alarm signs

Provide counseling to reduce exacerbating factors

Taper medical therapy to lowest effective dose

Reassure patients that risk for developing complicated disease is very low in uncomplicated GERD

Even with continued symptoms of heartburn and reflux


When should clinicians consider gastroenterology referral for treatment of a patient with GERD?

Alarm symptoms develop in context of previously well-managed GERD

Patients are interested in anti-reflux procedures

Patients are at high risk of Barrett esophagus and adenocarcinoma

Patients have prior documented severe esophagitis or Barrett esophagus

Most gastroenterologists happy to assist in all aspects of care


CLINICAL BOTTOM LINE: Treatment... Nonmedication treatment

Weight loss for obese persons Head-of-bed elevation for people with reflux at night Dietary changes not universally recommended

Medication treatment Initial Rx: PPIs once daily (30-60 mins before meal) for 8 wks For those responsive to PPIs, taper to lowest effective dose For those unable to taper or with significant erosive disease,

Barrett esophagus, or peptic stricture Hx: Continue PPIs H2RAs and antacids may be used for occasional symptoms Surgery is an effective option for some patients with GERD Refer for specialty evaluation when alarm symptoms develop

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 162 (6): ITC6-1. * For Best Viewing:...

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