Empiric PPI trial recommended in absence of alarm sx

By hgreaney@athen…, 21 January, 2022

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Footnote

1 AGA 2008. Kahrilas PJ, et al. American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroenterology. 2008. Oct;135(4):1383-1391e1-5. <a href=https://www.gastrojournal.org/article/S0016-5085(08)01606-5/fulltext>Free full-text article</a> 

2 ASGE 2015. Muthusamy VR, et al. American Society for Gastrointestinal Endoscopy. The Role of Endoscopy in the Management of GERD. Gastrointest Endosc. 2015;81(6):1305-10. <a href=https://www.giejournal.org/article/S0016-5107(15)00147-9/pdf>Free full-text article PDF</a> 

3 WGO 2017. Alarm features include: 
• dysphagia 
• odynophagia (painful swallowing) 
• recurrent bronchial symptoms, aspiration pneumonia 
• dysphonia 
• recurrent/persistent cough 
• GI tract bleeding 
• frequent nausea and/or vomiting 
• persistent pain 
• iron-deficiency anemia 
• progressive unintentional wt loss 
• lymphadenopathy 
• epigastric mass 
• New-onset atypical sx @ age 45–55 yo. Lower age threshold may be appropriate, depending on local recs. 
• FHx esophageal or gastric adenocarcinoma 

Hunt R, et al. Word Gastroenterology Organisation Global Guidelines. GERD Global Perspective on Gastroesophageal Reflux Disease. J Clin Gastroenterol. 2017. Jul;51(6):467-478. <a href=https://journals.lww.com/jcge/Fulltext/2017/07000/World_Gastroenterology_Organisation_Global.5.aspx>Free full-text article</a> 

4 ACG 2021. Katz PO, et al. American College of Gastroenterology. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2022. Jan 1;117(1):27-56. <a href=https://journals.lww.com/ajg/Fulltext/9900/ACG_Clinical_Guideline_for_the_Diagnosis_and.154.aspx>Free full-text article</a> 

5 WGO 2017. Consider early EGD for those at high risk of Barrett’s, particularly overweight men (or transgender women) over 50 yo w/ chronic GERD sx. 

Hunt R, et al. Word Gastroenterology Organisation Global Guidelines. GERD Global Perspective on Gastroesophageal Reflux Disease. J Clin Gastroenterol. 2017. Jul;51(6):467-478. <a href=https://journals.lww.com/jcge/Fulltext/2017/07000/World_Gastroenterology_Organisation_Global.5.aspx>Free full-text article</a> 

6 WGO 2017. Hunt R, et al. Word Gastroenterology Organisation Global Guidelines. GERD Global Perspective on Gastroesophageal Reflux Disease. J Clin Gastroenterol. 2017. Jul;51(6):467-478. <a href=https://journals.lww.com/jcge/Fulltext/2017/07000/World_Gastroenterology_Organisation_Global.5.aspx>Free full-text article</a>

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If alarm sx eg dysphagia 1 wt loss GI bleed 2 3 or multi risk factors for Barrett s esophagus perform EGD2 4 5

If typical heartburn and or regurgitation w o alarm sx or extraesophageal sx presumptive GERD dx can be established 2 4 tx empirically w qd PPI taken 30 60min before a meal 4 6 use lowest effective dose 4 6 d c PPI at end of 8wk in pts who respond 4 H2 bl

In pts w typical GERD sx extraesophageal sx consider tx w bid PPI x8 12wk before pursuing other testing 4 H2 blocker or qd PPI also an option per AGA1

Recommend wt loss in overweight obese pts1 4

Suggest lifestyle mods in select pts per AGA avoid meals 2 3h before bed trigger foods tobacco elevate head of bed1 4

In pregnancy start w lifestyle mods if not responsive antacids alginates sucralfate are 1st line certain H2 blockers and PPIs are lower risk see Table below 4 6

Consider H pylori in uninvestigated dyspepsia test treat if high prevalence of infxn in community 20 use urea breath test or stool Ag test6

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H2 Blocker & PPI Pregnancy Safety Summaries