Key Points
- Weight loss should be advised for overweight and obese patients with GERD symptoms. (II)
- The only other lifestyle modification that has sufficient evidence to support its efficacy is elevating the head of the bed.
- Antisecretory drugs recommended for patients with esophageal symptoms. (I)
- Proton pump inhibitors (PPIs*) are more effective than histamine2-receptor antagonists (H2RAs) for both symptoms and esophageal mucosal injury. (II)
- In case of chest pain, a cardiac cause must first be ruled out.
- Chronic cough, laryngitis, and asthma due to GERD may present atypically without accompanying esophageal symptoms.
- Long-term treatment of esophageal symptoms, but not extra-esophageal symptoms, with lowest effective dose PPI* is recommended.
- Antireflux surgery is successful when patients demonstrate good PPI* response.
- Progression from nonerosive disease to erosive esophagitis to Barrett’s esophagus is distinctly unusual. Endoscopic monitoring of patients with chronic GERD is limited to excluding Barrett’s esophagus once in a lifetime.
- No direct evidence supports routine biopsy (when a suspicious lesion is absent).
- The use of endoscopy as a screening test for Barrett’s esophagus or esophageal adenocarcinoma in the setting of chronic GERD remains an area of intense controversy, but one endoscopy during a patient’s lifetime to rule-out Barrett’s esophagus is recommended.
*Proton pump inhibitors may increase the risk of fractures of the hip, wrist, and spine with high-dose or chronic use.
Assessment
Diagnostic Tests
- Endoscopy with biopsy is recommended in patients with GERD symptoms and troublesome dysphagia who have not responded to an empirical trial of twice-daily PPI* therapy (at least 5 samples to evaluate for eosinophilic esophagitis) and have either a normal endoscopy or multiple esophageal rings, furrows or narrow esophagus on endoscopy. (II)
- Routine endoscopy in subjects with erosive or nonerosive reflux disease to assess for disease progression is NOT recommended. (IV)
- Manometry is recommended to evaluate GERD patients who are candidates for anti-reflux surgery. (II)
Remark: Manometry will serve to localize the lower esophageal sphincter for potential subsequent pH monitoring, to evaluate peristaltic function preoperatively, and to diagnose subtle presentations of the major motor disorders. Evolving information suggests that high-resolution manometry has superior sensitivity to conventional manometry in recognizing atypical cases of achalasia and distal esophageal spasm.
- Ambulatory impedance-pH, catheter pH, or wireless pH monitoring is recommended to evaluate patients with a suspected esophageal GERD syndrome who have not responded to an empirical trial of PPI* therapy, have normal findings on endoscopy, and have no major abnormality on manometry.
- Wireless capsule pH monitoring for refractory GERD is suggested for 4 days (first day off treatment and the other 3 days on treatment). (II)
Remark: Wireless pH monitoring has superior sensitivity to catheter studies for detecting association between symptoms and acid reflux events because of the extended period of recording (48 hours) and has also shown to be better tolerated by patients.
Figure 1. Patient With GERD-Related Symptoms
