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No known reflux complications
Typical heartburn/regurgitation only, presumed GERD Empiric PPI1 tx recommended [S/M] + lifestyle modification - Initiate PPI once-daily dosing, before 1st meal of day [S/M]2,3
- If PPI side-effects: switch PPIs [C/L]
- If long-term PPI required: use lowest effective dose, incl. on-demand or intermittent tx [C/L]. If pts experience heartburn relief3 w/ H2RA: H2RA can be a maintenance option in pts w/o erosive dz [C/M]
Lifestyle modification - Weight loss recommended for overweight pts or if recent weight gain [C/M]
- If nocturnal GERD: avoid meals 2-3h before bedtime, elevate head of bed [C/L]
- Not recommended: routine global elimination of food triggers (chocolate, caffeine, EtOH, acidic/spicy foods) [C/L]
Footnotes 1 PPIs safe in pregnancy if clinically indicated [C/M]. Do not alter PPI use if on clopidogrel [S/H]. Pts w/ osteoporosis may remain on PPI; fx concern should not affect PPI decision unless other known fx risk factors exist [C/M]. Use PPIs w/ caution if risk for C diff infxn [M/M]. CAP risk may be ↑ w/ short-term (not long-term) PPI [C/M].
GERD tx other than acid suppression (eg, prokinetic tx, baclofen) should NOT be used w/o dx eval [C/M]; there is no role for sucralfate in the nonpregnant pt [C/M]. Routine tx of H pylori infxn NOT recommended in GERD tx [S/L].
2 Traditional delayed-release PPIs should be administered 30-60 min ac for max pH control [S/M]; newer PPIs may offer dosing flexibility relative to mealtime [C/M].
3 Bedtime H2RA tx can be added prn to daytime PPI in pts w/ nighttime sx, but tachyphylaxis may occur after several wks [C/L].
Extraesophageal sx (asthma, cough, laryngitis) w/o chest pain Consider GERD as potential cofactor in pts w/ asthma, chronic cough, or laryngitis; carefully evaluate for non-GERD causes in all pts [S/M] - If typical GERD sx also present: consider PPI4 trial [S/L]
- If no typical GERD sx: reflux monitoring5 prior to PPI trial [C/L]
- If alarm sx (eg, dysphagia) or high risk of GERD complications: endoscopy6 recommended
If extraesophageal sx persist despite PPI optimization: - Concomitant evaluation by ENT, pulmonary, and allergy specialists6 [S/L]
- If refractory GERD after these evals negative: ambulatory reflux5 monitoring [S/L]
- For typical GERD sx nonresponsive to PPI: endoscopy6 to exclude non-GERD etiologies [C/L]
- Surgery can be effective in carefully selected pts w/ extraesophageal/atypical symptoms; response rates are lower vs in pts w/ heartburn.7
Footnotes 4 Give traditional DR-PPIs 30-60 min ac for max pH control [S/M]; newer PPIs may offer dosing flexibility relative to meals [C/M]. Bedtime H2RA tx can be added prn to daytime PPI if nighttime sx, but tachyphylaxis may occur after several wks [C/L]. For pts needing long-term PPI tx, administer lowest effective dose, incl. on-demand/intermittent tx [C/L]. PPIs safe in pregnancy if clinically indicated [C/M]. Do not alter PPI use if on clopidogrel [S/H]. Pts w/ osteoporosis may remain on PPI; fx concern should not affect PPI use unless other known fx-risk factors exist [C/M]. Use PPIs w/ caution if risk for C diff infxn [M/M]. CAP risk may be ↑ w/ short-term (not long-term) PPI [C/M]. Do NOT use nonacid-suppressing GERD tx (eg, prokinetic tx, baclofen) w/o dx eval [C/M]; no role for sucralfate in the nonpregnant pt [C/M]. Routine tx of H pylori infxn NOT recommended in GERD tx [S/L].
5 Reflux monitoring off meds by either pH or impedance-pH [C/M]; if on meds, should be performed w/ impedance-pH monitoring [S/M].
6 Upper endoscopy not recommended to establish dx of GERD-related asthma, cough, laryngitis [SL]. Reflux laryngitis dx should not be based solely on laryngoscopy [S/M].
7 Surgery should generally not be performed to treat extraesophageal GERD sx in pts who do not respond to acid suppression w/ PPI [S/M]. Pre-op ambulatory pH monitoring is mandatory in pts w/o evidence of erosive esophagitis.
Noncardiac chest pain suspected as GERD Exclude cardiac cause prior to GI eval [S/L] - After r/o cardiac cause: pts w/ noncardiac chest pain should have diagnostic eval before instituting tx [C/M]; consider dx eval w/ endoscopy8 + pH monitoring, before a PPI trial.9
Footnotes 8 A systematic review suggests that response of noncardiac chest pain to PPI trial was significantly higher vs placebo in pts w/ objective GERD evidence (endoscopy and/or pH monitoring), while response vs. placebo was almost nonexistent in absence of objective GERD documentation.
9 Do not initiate tx before diagnostic eval [C/M]. Consider endoscopy early for elderly, pts at risk for Barrett, noncardiac chest pain, and pts unresponsive to PPI. If alarm sx (eg, dysphagia) or high risk of GERD complications: endoscopy recommended.
First optimize PPI dose, timing, and drug10 - Increase PPI dosing11 to bid or consider a switch to a different PPI12 [C/L]
- If nocturnal sx, sleep disturbance, &/or variable schedules: consider dose-timing11 adjustment &/or bid dosing [S/L]. Bedtime H2RA tx can be added prn to daytime PPI in pts w/ nighttime sx, but tachyphylaxis may occur after several wks [C/L]
- If PPI side-effects: switch PPIs12 [C/L]
Refer PPI nonresponders for eval [C/L] - If typical/dyspeptic sx PPI-refractory: upper endoscopy13 to r/o non-GERD etiologies [C/L]; if endoscopy negative: ambulatory reflux monitoring [S/L]; if tests negative, unlikely to have GERD, so discontinue PPI [S/L]
- If extraesophageal sx13 persist despite PPI optimization: concomitant evaluation by ENT, pulmonary, and allergy specialists14 [S/L]; if refractory after these evals negative: ambulatory reflux15 monitoring [S/L]
If refractory w/ evidence of ongoing reflux on eval: consider additional antireflux tx (eg, TLESRI drug or surgery)16 [C/L] - If objective documentation of symptomatic reflux despite optimal PPI tx: consider baclofen17 trial 5-20 mg tid
- If abnl amounts of nonacid reflux on PPI tx w/ good symptom correlation on esophageal pH-impedance monitoring: consider for surgery
Footnotes 10 For pts requiring long-term PPI tx, it should be administered in the lowest effective dose, incl. on-demand or intermittent tx [C/L]. If pts experience heartburn relief w/ H2RA: H2RA can be a maintenance option in pts w/o erosive dz [C/M].
GERD tx other than acid suppression (eg, prokinetic tx, baclofen) should NOT be used w/o dx eval [C/M]; there is no role for sucralfate in the nonpregnant pt [C/M]. Routine tx of H pylori infxn NOT recommended in GERD tx [S/L].
11 Traditional delayed-release PPIs should be administered 30-60 min ac for max pH control [S/M]; newer PPIs may offer dosing flexibility relative to mealtime [C/M].
12 PPI switching is common in practice; there are limited data to support this; no data to support switching PPIs ≥1x in partial/nonresponders. Meta-analyses fail to show significant efficacy difference for sx relief between PPIs.
13 Consider endoscopy early for elderly, pts at risk for Barrett, noncardiac chest pain, and pts unresponsive to PPI. If alarm sx (eg, dysphagia) or high risk of GERD complications: endoscopy recommended.
14 Upper endoscopy not recommended to establish dx of GERD-related asthma, cough, laryngitis [SL]. Reflux laryngitis dx should not be based solely on laryngoscopy [S/M].
15 Reflux monitoring off meds by either pH or impedance-pH [C/M]; if on meds, should be performed w/ impedance-pH monitoring [S/M].
16 Surgical tx generally not recommended in PPI-nonresponders [S/H]. High-quality controlled trials in PPI-nonresponders are lacking, so surgery advised only in highly selected pts; reflux monitoring test off-PPI can confirm pathological reflux before surgery. Pre-op ambulatory pH monitoring mandatory in pts w/o evidence of EE. If no PPI response, surgery unlikely to be effective, even w/ abnl pH study. Surgery should generally not be performed to treat extraesophageal GERD sx in pts not responsive to acid suppression w/ PPI [S/M]. Highest surgical responses seen in pts w/ typical heartburn/regurg sx who demonstrate good PPI response or have abnl ambulatory pH studies w/ good sx correlation. Refractory dyspeptic sx (eg, nausea, vomiting, epigastric pain) less likely to demonstrate sx response. All pts need pre-op manometry to r/o achalasia/scleroderma-like esophagus [S/M].
17 Baclofen shown to decrease reflux episodes and sx d/t all reflux types, but high-quality controlled trials evaluating baclofen in refractory sx not available.
Optimize PPI dose, timing, and drug18 - Increase PPI dosing19 to bid or consider a switch to a different PPI20 [C/L]
- If nocturnal sx, sleep disturbance, &/or variable schedules: consider dose-timing19 adjustment &/or bid dosing [S/L]. Bedtime H2RA tx can be added prn to daytime PPI in pts w/ nighttime sx, but tachyphylaxis may occur after several wks [C/L]
- If PPI side-effects: switch PPIs20 [C/L]
Footnotes 18 For pts requiring long-term PPI tx, it should be administered in the lowest effective dose, incl. on-demand or intermittent tx [C/L]. If pts experience heartburn relief w/ H2RA: H2RA can be a maintenance option in pts w/o erosive dz [C/M].
GERD tx other than acid suppression (eg, prokinetic tx, baclofen) should NOT be used w/o dx eval [C/M]; there is no role for sucralfate in the nonpregnant pt [C/M]. Routine tx of H pylori infxn NOT recommended in GERD tx [S/L].
19 Traditional delayed-release PPIs should be administered 30-60 min ac for max pH control [S/M]; newer PPIs may offer dosing flexibility relative to mealtime [C/M].
20 PPI switching is common in practice; there are limited data to support this; no data to support switching PPIs ≥1x in partial/nonresponders. Meta-analyses fail to show significant efficacy difference for sx relief between PPIs.
PPI responder (including relapse post-d/c PPI) Prescribe PPI21 at lowest effective dose, incl. on-demand or intermittent tx [C/L] - If relapse post-d/c of PPIs: tx w/ maintenance PPI [S/M]
- If pts experience heartburn relief22 w/ H2RA: H2RA can be a maintenance option in pts w/o erosive dz [C/M]
Surgical tx is an option for long-term GERD tx [S/H]23 - Surgery w/ experienced surgeon is as effective as medical tx in carefully selected chronic GERD pts [S/H].24 Referral reasons include: desire to d/c medical tx, noncompliance, medical tx side-effects, etc25
- Pre-op ambulatory pH monitoring is mandatory in pts w/o evidence of erosive esophagitis. All pts need pre-op manometry to r/o achalasia or scleroderma-like esophagus [S/M]
- Options: laparoscopic fundoplication or bariatric sx. Obese pts should be considered for gastric bypass [C/M]. Current endoscopic tx or transoral incisionless fundoplication26 not recommended as alternative to traditional med/surg tx [C/M]
Footnotes 21 Traditional delayed-release PPIs should be administered 30-60 min ac for max pH control [S/M]; newer PPIs may offer dosing flexibility relative to mealtime [C/M].
22 Bedtime H2RA tx can be added prn to daytime PPI in pts w/ nighttime sx, but tachyphylaxis may occur after several wks [C/L].
23 Surgery can be effective in carefully selected pts w/ extraesophageal/atypical symptoms; response rates are lower vs in pts w/ heartburn. Pre-op ambulatory pH monitoring is mandatory in pts w/o evidence of erosive esophagitis. Surgery should generally not be performed to treat extraesophageal GERD sx in pts who do not respond to acid suppression w/ PPI [S/M].
24 Highest surgical responses seen in pts w/ typical sx of heartburn/regurgitation who demonstrate good PPI response or have abnl ambulatory pH studies w/ good symptom correlation. Refractory dyspeptic sx including nausea, vomiting, epigastric pain are less likely to demonstrate sx response.
25 Referral reasons include: desire to d/c medical tx, noncompliance, medical tx side-effects, large hiatal hernia, esophagitis refractory to medical tx, persistent sx documented to be caused by refractory GERD.
26 Most common adverse event w/ fundoplication: gas-bloat syndrome (15%-20%).
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Reflux complications (EE/Barrett/stricture/other)
Erosive esophagitis: 8-wk PPI27 course as tx of choice for sx relief/erosion healing [S/H] - No major differences between individual PPIs [S/H]
- Repeat endoscopy after PPI course to exclude Barrett [C/L]
- Maintenance PPI tx [S/M] at lowest effective dose, incl. on-demand or intermittent tx [C/L]28
- Surgery w/ experienced surgeon is as effective as medical tx in carefully selected chronic GERD pts [S/H].29 Referral reasons include: esophagitis refractory to medical tx, desire to d/c medical tx, noncompliance, medical tx side-effects, etc
Barrett esophagus: maintenance PPI tx [S/M] - Maintenance PPI tx [S/M] at lowest effective dose, incl. on-demand or intermittent tx [C/L]28
- Pts should undergo periodic surveillance according to guidelines [S/M]
Strictures: continuous PPI tx [S/M] - Peptic stricture: continuous PPI tx recommended post dilation to improve dysphagia and ↓ need for repeat dilation [S/M]
- Refractory complex strictures d/t GERD: consider intralesional steroids [C/L] (triamcinolone INJ 40 mg in four 1-mL aliquots) in a 4-quadrant pattern in peptic strictures refractory to dilation
Lower esophageal (Schatzki) ring: - Dilation remains mainstay
- Many recommend postdilation PPI tx [C/L], particularly if recurrent
Footnotes 27 PPIs safe in pregnancy if clinically indicated [C/M]. Do not alter PPI use if on clopidogrel [S/H]. Pts w/ osteoporosis may remain on PPI; fx concern should not affect PPI decision unless other known fx risk factors exist [C/M]. Use PPIs w/ caution if risk for C diff infxn [M/M]. CAP risk may be ↑ w/ short-term (not long-term) PPI [C/M].
GERD tx other than acid suppression (eg, prokinetic tx, baclofen) should NOT be used w/o dx eval [C/M]; there is no role for sucralfate in the nonpregnant pt [C/M]. Routine tx of H pylori infxn NOT recommended in GERD tx [S/L].
28 Initiate PPI once-daily dosing, before 1st meal of day [S/M]. Traditional delayed-release PPIs should be administered 30-60 min ac for max pH control [S/M]; newer PPIs may offer dosing flexibility relative to mealtime [C/M]. Bedtime H2RA tx can be added prn to daytime PPI in pts w/ nighttime sx, but tachyphylaxis may occur after several wks [C/L].
29 Surgical tx generally not recommended in PPI-nonresponders [S/H]. High-quality controlled trials in PPI-nonresponders are lacking, so surgery advised only in highly selected pts; reflux monitoring test off-PPI can confirm pathological reflux before surgery. Pre-op ambulatory pH monitoring mandatory in pts w/o evidence of EE. If no PPI response, surgery unlikely to be effective, even w/ abnl pH study. Surgery should generally not be performed to treat extraesophageal GERD sx in pts not responsive to acid suppression w/ PPI [S/M]. Highest surgical responses seen in pts w/ typical heartburn/regurg sx who demonstrate good PPI response or have abnl ambulatory pH studies w/ good sx correlation. Refractory dyspeptic sx (eg, nausea, vomiting, epigastric pain) less likely to demonstrate sx response. All pts need pre-op manometry to r/o achalasia/scleroderma-like esophagus [S/M].
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