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INTRODUCTION

KEY CONCEPTS

  1. Gastroesophageal reflux disease (GERD) can be described on the basis of either esophageal symptoms or esophageal tissue injury. The common symptoms include heartburn, regurgitation, chest pain, and dysphagia.

  2. Endoscopy is commonly used to evaluate mucosal injury from GERD and to assess for the presence of Barrett’s esophagus or other complications, such as strictures or adenocarcinoma.

  3. Whereas ambulatory reflux monitoring only measures acid reflux, combined impedance–pH monitoring measures both acid and nonacid reflux.

  4. The goals of GERD treatment are to alleviate symptoms, decrease the frequency of recurrent disease, promote healing of mucosal injury, and prevent complications.

  5. GERD treatment is determined by disease severity and includes: (a) lifestyle changes and patient-directed therapy with antacids, nonprescription H2-receptor antagonists, and/or nonprescription proton pump inhibitors; (b) pharmacologic treatment with prescription-strength acid suppression therapy; (c) surgery; and (d) endoscopic therapies.

  6. Patients with typical GERD symptoms should be treated with lifestyle modifications as appropriate and a trial of empiric acid suppression therapy. Those who do not respond to empiric therapy or who present with alarm symptoms such as dysphagia, weight loss, or GI bleeding should undergo endoscopy.

  7. Surgical intervention is a viable alternative treatment for select patients when long-term pharmacologic management is undesirable or when patients have complications.

  8. Acid suppression is the mainstay of GERD treatment. Proton pump inhibitors provide the greatest symptom relief and the highest healing rates, especially for patients with erosive disease or moderate-to-severe symptoms or with complications.

  9. Many patients with GERD will relapse if medication is withdrawn; so long-term maintenance treatment may be required. A proton pump inhibitor is the drug of choice for maintenance of patients with moderate-to-severe GERD.

  10. Patient medication profiles should be reviewed for drugs that may aggravate GERD. Patients should be monitored for adverse drug reactions and potential drug–drug interactions.

PATIENT CARE PROCESS

Patient Care Process for The Management of Gastroesophageal Reflux Disease

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Collect

  • Patient characteristics (eg, age, race, sex, weight, body mass index, pregnant)

  • Patient history (past medical, family, social, dietary habits, tobacco use)

  • Health literacy and barriers to medication access

  • Thorough history of prescription, nonprescription, and natural medication use

  • Medication allergies and intolerances (include actual reaction to medication)

  • Laboratory results for major organ function (eg, SCr to calculate CrCL, liver enzymes to assess hepatic function)

Assess

  • Assess major organ function (eg, creatinine clearance, hepatic impairment)

  • Determine the type, frequency, duration of symptoms, and identify exacerbating factors

  • Identify alarm symptoms or extraesophageal symptoms that require further diagnostic evaluation by clinician (see section "Clinical Presentation")

  • Review lifestyle factors, including foods that may be contributing to symptoms (see Table 49-1)

  • Review medication profile for medications that may be contributing to symptoms (see Table 49-1) and potential drug–drug interactions

  • Assess what has been done so far (including medications and lifestyle modifications)

  • Establish goals of therapy and if they are currently being met. (see section "Desired Outcomes")

  • Assess the appropriateness and effectiveness of current GERD regimen

Plan*

  • Identify individualized lifestyle ...

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