- Gastroesophageal reflux disease (GERD) can be described on the basis of either esophageal symptoms or esophageal tissue injury. The common symptoms include heartburn, acid brash, regurgitation, chest pain, and dysphagia.
- 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 bleeding or stricture.
- Ambulatory pH monitoring (with or without impedance monitoring) is useful for confirming acid or nonacid reflux in patients with persistent symptoms without evidence of mucosal damage or for patients with atypical symptoms such as hoarseness of voice, chest pain, persistent cough/throat clearing, or erosion of dental enamel; manometry is useful for patients who are candidates for antireflux surgery and for ensuring proper placement of pH probes.
- The goals of GERD treatment are to alleviate symptoms, decrease the frequency of recurrent disease, promote healing of mucosal injury, and prevent complications.
- GERD treatment is determined by disease severity and includes lifestyle changes and patient-directed therapy, pharmacologic treatment, and antireflux surgery.
- 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, anemia, or GI bleeding should undergo endoscopy, or, less commonly, a barium swallow study.
- Surgical intervention is a viable alternative treatment for select patients when long-term pharmacologic management is undesirable or when patients have refractory symptoms or complications.
- 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.
- Many patients with GERD will relapse if medication is withdrawn; so long-term maintenance treatment may be required.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. Both step-up and step-down therapies have been advocated.
- 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.
On completion of the chapter, the reader will be able to:
Explain the pathophysiologic mechanisms associated with gastroesophageal reflux disease (GERD).
Distinguish between symptom-based (typical or alarm) and tissue injury–based (esophagitis, strictures, Barrett’s esophagus, or esophageal adenocarcinoma) esophageal GERD syndromes and extraesophageal GERD syndromes (chronic cough, chest pain, laryngitis, or asthma).
Identify alarm symptoms that mandate further diagnostic evaluation.
List medications or foods that can worsen the symptoms of GERD.
Discuss the risk factors that can predispose a patient to GERD.
Discern which diagnostic test is appropriate based on the patient’s clinical presentation.
Describe the goals of treating a patient with GERD.
Debate the benefits and limitations of lifestyle modifications in the treatment of GERD.
Compare and contrast the differences between patient-directed therapy, pharmacologic therapy (with acid suppression agents), and interventional approaches to treating GERD.
Discuss the benefits of proton pump inhibitors over H2-receptor ...