Outpatient / Gastroenterology
Gastroesophageal Reflux Disease (GERD)
# GERD
Intake
-- Onset: ***
-- Timing: ***
-- Symptoms: *** chest pain/burning, regurg, sour taste in AM, sore throat, dysphagia, globus, cough, hoarseness
-- Red Flags: *** dysphagia, anorexia, weight loss, anemia/bleeding, iron deficiency, persistent vomiting, new age >60
-- DDx: pill esophagitis, hiatal hernia, malignancy, Schatzki ring, eosinophilic esophagitis, motility disorder, functional dyspepsia, rumination, infectious esophagitis - HSV, CMV, candida
Plan
-- PPI: *** omeprazole 20mg before AM meal for 4-8 weeks → 40mg → BID; assess at 8 weeks if can trial discontinuation, if sxs recur or Barrett’s put on maintenance PPI; if on PPI >6 months, taper 50% per week due to rebound
-- Other Meds: *** Histamine blocker (ranitidine, famotidine 10-20mg BID or qhs) for nighttime sxs PRN; can add baclofen 5-20mg and desipramine on top of PPI; OTC - antacids (Tums)
-- Lifestyle: *** avoid eating 2-3 hrs before bed, small meals, sleep with head propped, avoid triggering foods, weight loss, smoking cessation, limit caffeine and alcohol, exercise
-- EGD: *** If alarm sxs or no relief after 8 weeks of high-dose BID PPI - stop PPI for 2 weeks before EGD, get biopsies; if nothing seen → ambulatory pH monitoring (NERD, rule out functional) and barium swallow + esophageal manometry (achalasia, hypermotility, esophageal spasm)
Template coming soon!
Patient Guidance and Information
New GERD Diagnosis - Lifestyle and PPI
Based on your symptoms, you likely have gastroesophageal reflux disease (GERD), otherwise known as heartburn or just reflux.
We recommend considering lifestyle factors to help with your reflux. These include avoiding meals within 2-3 hours of bed, and lying down shortly after eating. Certain foods and drinks can be triggering, including fatty or spicy foods, chocolate, caffeine, alcohol, or carbonated beverages. Many patients also report improved reflux symptoms after losng weight and stopping smoking.
We also recommend beginning a medicine called *** which is a proton pump inhibitor (PPI). This medicine will reduce the production of acid in your stomach that is causing your symptoms. We will plan to trial it for 4-8 weeks before re-assessing your symptoms. You should take *** 30-60 minutes before your AM meal to maximize its efficacy.
Some who take PPI medications over a long period of time can develop low magnesium levels, iron deficiency, or inflammation in their kidneys. We will periodically monitor these levels while you are taking the medicine.
Preparing for an EGD
A esophagogastroduodenoscopy (or EGD) is a procedure where a physician guides a scope down your mouth to visualize your upper gastrointestinal system (esophagus, stomach, parts of your small intestine). While there, they can take pictures and collect samples for biopsy if there is anything concerning.
If you take a PPI medicine, please stop taking it for 2 weeks before the procedure.
5-7 days before the procedure, you shoul stop taking any iron, aspirin, peptol bismol, or NSAID medicnes. The night before the procedure, do not eat any solid food after midnight, and avoid liquids 8 hours before the procedue.
Its okay to take your other medications 4 hours before the examination with small sips of clear water.
If You Remember Nothing Else
GERD is a common cause of heartburn and cough. PPI trials are sensitive for diagnosing GERD. You can start with a low dose PPI once daily for 4 weeks, then transition to higher doses or BID dosing. At 8 weeks, re-assess if the symptoms have improved and you can trial discontinuation. If the patient's symptoms recur after discontinuation, or they are diagnosed with Barrett's, the patient should remain on maintenance PPI therapy. Histamine blockers are often used for nighttime symptoms qhs and often lead to tachyphylaxis. Lifestyle changes include avoiding meals 2-3 hours before bed, sleeping with yoru head propped, losing weight, smoking cessation, and limiting alcohol and caffeine use. Alarm symptoms prompting evaluation with an EGD include no relief after a PPI trial, dyaphagia, globus sensation, anorexia, weight loss, anemia, and iron deficiency.
Clinical Pearls
- When to Refer: EGD for alarm symptoms and sxs persistent on high dose BID PPI
- GERD is caused by decreased tone or excessive transient relaxation of the lower esophageal sphincter (LES) - normally body has transient LES relaxations to allow venting of accumulated gasses to prevent stomach distention - GERD can be caused by more frequent relaxations but also by higher intragastric pressures pushing back on LES
- GERD has a 15-30% prevalence in the U.S
- Acid always refluxes a bit, but it is neutralized by bicarbonate from saliva and pushed back into the stomach by peristalsis - smoking is thought to interupt both salivation and peristalsis
- Classified based on appearance of mucosa on EGD - NERD is non-erosive, ERD is erosive with evidence of damage
- PPI trial has sensitivity of 78% for diagnosing GERD
- Sliding hernias tend to be asx, but paraesophogeal hernias often cause GERD
- Barrett’s Esophagus is a transition from squamous epithelium seen in esophagus to columnar intestinal epithelium due to irritation and damage over time from gastric acid
- Risk factors for Barrett’s Esophagus include age >50, white, male, smoker
- Barrett’s Esophagus has a 0.1-2% risk per year of transitioning to adenocarcinoma
- There was concern that PPIs were associated with dementia, but there is no data to support this, though due to press, patient’s might ask; possible real associations include C Diff infection, osteoporosis, and CKD
- H2-blockers commonly have tachyphylaxis (stop working over time with use) and are most commonly used for symptoms at night
- Common causes of pill esophagitis - doxycycline, clindamycin, amoxicillin, NSAIDs, aspirin, acetaminophen, bisphosphonates, warfarin, vitamin C,
- HSV causes superficial, punched out ulcers in distal esophagus, CMV causes lineat ulcers in middle-upper esophagus
- Aspiration of refluxed gastric contents can lead to pneumonitis, often confused for PNA
- Many pregnant patients have GERD, and it usually improves after delivery
Trials and Literature
- Review on the Management of GERD
- Cochrane Analysis - GERD > H2 antagonists for relieving heartburn who are treated empirically
- No Association between PPI use and dementia - based on 11 observational studies
- Gastric fundoplication > medical tx if truly refractory reflux
Other Resources
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