GERD

Dr GI Joe

Diagnosis and Management of Gastroesophageal Reflux Disease (GERD)

1.0 Initial Patient Assessment and Triage

The initial patient encounter is a critical triage point for determining the urgency and direction of the diagnostic workup. The primary objective is to stratify patients based on the presence or absence of "alarm features." These features may indicate underlying complications or alternative diagnoses that require immediate endoscopic investigation to ensure patient safety and guide the subsequent clinical path.

Dysphagia (Difficulty Swallowing)

• Clinical Significance: May indicate a peptic stricture, eosinophilic esophagitis (EoE), or malignancy.
• Required Action: Immediate referral for upper endoscopy (EGD).

Odynophagia (Painful Swallowing)

• Clinical Significance: Suggests severe erosive esophagitis, pill-induced injury, or infectious esophagitis.
• Required Action: Immediate referral for upper endoscopy (EGD).

Unintentional Weight Loss

• Clinical Significance: A potential sign of malignancy or severe malabsorption.
• Required Action: Immediate referral for upper endoscopy (EGD).

Gastrointestinal Bleeding

• Clinical Significance: May present as hematemesis, melena, or hematochezia, indicating severe esophagitis or ulceration.
• Required Action: Immediate referral for upper endoscopy (EGD).

Iron Deficiency Anemia

• Clinical Significance: Can result from chronic occult blood loss due to erosive disease or malignancy.
• Required Action: Immediate referral for upper endoscopy (EGD).

New Onset of Symptoms in Patients >60

• Clinical Significance: The risk of upper GI malignancy increases with age.
• Required Action: Immediate referral for upper endoscopy (EGD).

Protocol for Non-Alarm Presentations

For patients presenting with typical, uncomplicated symptoms of heartburn and regurgitation without any of the alarm features listed above, the protocol begins with an empiric trial of medical therapy. This approach serves as a cost-effective initial step that is both therapeutic and diagnostic. The following sections detail the specifics of initiating and evaluating this empiric therapy.

2.0 Empiric Therapy for Uncomplicated GERD

An empiric trial with a Proton Pump Inhibitor (PPI) is the standard-of-care, cost-effective first step for managing uncomplicated GERD. This strategy serves a dual role: it provides therapeutic relief for the majority of patients and acts as a diagnostic tool. A positive response to therapy strongly suggests an acid-mediated disease process, while a lack of response prompts further investigation.

2.1 Initial PPI Trial Protocol

• Initiate a 4- to 8-week trial of a standard, once-daily PPI.
• The PPI must be administered 30-60 minutes before the first meal of the day (typically breakfast) to ensure maximal inhibition of activated proton pumps and achieve optimal efficacy.
• Standard PPI options and typical once-daily doses include:
  • Omeprazole 20–40 mg
  • Pantoprazole 40 mg
  • Esomeprazole 20–40 mg
  • Lansoprazole 30 mg
  • Rabeprazole 20 mg

2.2 Management of Partial or Incomplete Response

For patients who experience only a partial response to the initial trial, the first step is to confirm adherence to the regimen and correct pre-meal timing. If adherence and timing are appropriate, the dose should be escalated to twice-daily (BID) administration (before breakfast and before dinner) for an additional 8-week period.

2.3 Adjunctive Therapies

Evidence-based adjunctive treatments can be employed to target specific symptom patterns alongside PPI therapy.

• Lifestyle Modifications: Weight loss, particularly addressing central adiposity, has the most significant impact on reducing reflux events. For nocturnal symptoms, advise patients to avoid meals within three hours of bedtime and to elevate the head of the bed.
• Nocturnal Acid Breakthrough: For patients with persistent nighttime symptoms despite BID PPI therapy, an H2-receptor antagonist (H2RA) such as Famotidine (20-40 mg) at bedtime can be effective. It should be noted that tolerance (tachyphylaxis) to H2RAs can develop over time, potentially limiting long-term efficacy.
• Post-Prandial Regurgitation: Sodium alginate preparations (e.g., 10-20 mL after meals and at bedtime) create a physical barrier to reflux. In select cases of refractory regurgitation, Baclofen (5-10 mg TID) can be used to reduce transient lower esophageal sphincter relaxations (tLESRs), but patients must be counseled on potential central nervous system side effects like sedation and dizziness.

Patients who fail to respond adequately to an optimized 8-week course of twice-daily PPIs, or those who present with alarm features, require endoscopic evaluation.

3.0 Endoscopic Evaluation (EGD)

The upper endoscopy (EGD) is the pivotal diagnostic test for patients who fail an empiric trial of medical therapy or present initially with high-risk alarm features. Its primary purposes are to directly visualize the esophageal mucosa to identify injury, rule out complications such as Barrett's Esophagus (BE), and assess for alternative diagnoses that can mimic GERD, including eosinophilic esophagitis (EoE).

3.1 Indications for EGD

• Presence of any alarm features (dysphagia, odynophagia, weight loss, GI bleed, anemia).
• Refractory symptoms despite an optimized 8-week course of twice-daily (BID) PPI therapy.
• Screening for Barrett's Esophagus in patients with chronic GERD and multiple risk factors (Male sex, Age >50, White race, central obesity, history of smoking, family history of BE or esophageal adenocarcinoma).
• Evaluation of atypical chest pain after a thorough cardiac workup has been completed and is negative.
• Assessment of healing after treatment for severe (Los Angeles Grade C or D) erosive esophagitis to rule out underlying Barrett's Esophagus.

3.2 Endoscopic Findings and Diagnostic Implications

The findings on EGD are critical for definitively diagnosing GERD or determining the need for further physiologic testing, as outlined by the Lyon Consensus criteria.

LA Grade C or D Erosive Esophagitis

• Diagnostic Conclusion: Conclusive evidence of GERD.

Peptic Stricture

• Diagnostic Conclusion: Conclusive evidence of GERD.

Long-Segment Barrett’s Esophagus

• Diagnostic Conclusion: Conclusive evidence of GERD.

LA Grade A or B Erosive Esophagitis

• Diagnostic Conclusion: Inconclusive evidence for GERD; requires further physiologic testing.

Normal Mucosa

• Diagnostic Conclusion: Inconclusive evidence for GERD; requires further physiologic testing.

3.3 Biopsy Protocol

A standardized biopsy protocol is essential for accurate diagnosis of key esophageal conditions.

1. Suspected Barrett's Esophagus: Use of t...