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    Gastroesophageal Reflux Disease (GERD) – Diagnosis and Treatment

    Gastrointestinal

    Last Updated Dec 10, 2020
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    By Julian Marsden, Brenna Mackay

    Context

    Gastroesophageal Reflux Disease (GERD) affects women and men of all ages. It is one of the most common gastrointestinal diseases worldwide (prevalence ~8-33%) and is the most prevalent acid-related disorder in Canada.

    • GERD occurs when gastric contents reflux into the esophagus causing damage or worsening quality of life.
    • Patients with GERD report poorer health-related quality of life than those with hypertension, mild diabetes, arthritis or mild heart disease.
    • Symptoms are often worse after meals, when bending over, or when laying down.
    • 70% of patients with GERD symptoms have normal endoscopy.
    • Endoscopy is not required to make a diagnosis of GERD.
    • Potential complications of chronic GERD include esophageal stricture, ulcers, Barrett’s esophagus, and esophageal cancer.

    Diagnostic Process

    Diagnosed clinically:

    • Heartburn ± regurgitation:
      • Burning pain in the chest that usually occurs after eating and may occur at night.
      • Pain that worsens when lying down or bending over.
      • Bitter or acidic taste in the mouth.
    • Risk factors: family history of GERD, older age, hiatus hernia, obesity.
    • Start PPI trial (once daily for 8 weeks) in patients with suspected GERD who have symptoms more than twice a week. See table below.

     

    Red Flags For Further Investigations:

    • Dysphagia, odynophagia, GI bleeding/anemia, recurrent vomiting, involuntary weight loss, chest pain, choking.
    • Relapsing, persistent, or atypical symptoms.
    • Persistent symptoms despite an adequate PPI trial (4-8 weeks).
    • Investigations:
      • Consider/rule out cardiac causes.
      • Refer for endoscopy and if normal endoscopy, ambulatory pH monitoring.
    • Screening for H. Pylori not recommended.

    Recommended Treatment

    Mild or Infrequent GERD (symptoms less than 3 times per week)

      • Over-the-counter medications:
        • Alginates, antacids, and low dose H2RAs + lifestyle modification.
      • Lifestyle modification and education include:
        • Weight loss in patients who are overweight.
        • Avoid large meals 3h before sleep and elevate the head of the bed.
        • Identify and avoid triggers (ie. Smoking, mint, alcohol, carbonated beverages, spicy/acidic foods, chocolate, and caffeine).

    Severe or Frequent GERD

        • The above is not effective for the management of severe GERD.
        • PPIs are superior to H2Ras for the management of GERD.
        • 8-week trial of standard once-daily PPI therapy.

    • If symptoms resolve, can attempt to discontinue or titrate to the lowest effective dose. Consider an on-demand acid suppression approach for some patients.
    • If the inadequate response can try twice-daily PPI therapy for another 8 weeks or change to a different once-daily PPI.
    • Not recommended to use prokinetic or promotility agents for initial treatment of GERD.

    Quality Of Evidence?

    Justification

    • Evidence is from the last Canadian Consensus Conference on the management of GERD in adults, which was back in 2004.
    Moderate

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