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Footnote
<sup>21</sup> 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]. <br><br>
<sup>22</sup> Bedtime H2RA tx can be added prn to daytime PPI in pts w/ nighttime sx, but tachyphylaxis may occur after several wks [C/L].
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<sup>23</sup> 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].
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<sup>24</sup> 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.
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<sup>25</sup> 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.
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<sup>26</sup> Most common adverse event w/ fundoplication: gas-bloat syndrome (15%-20%).
<sup>22</sup> Bedtime H2RA tx can be added prn to daytime PPI in pts w/ nighttime sx, but tachyphylaxis may occur after several wks [C/L].
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<sup>23</sup> 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].
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<sup>24</sup> 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.
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<sup>25</sup> 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.
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<sup>26</sup> Most common adverse event w/ fundoplication: gas-bloat syndrome (15%-20%).
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