What is the recommended care plan for Gastroesophageal Reflux Disease (GERD)?

Care Plan for Gastroesophageal Reflux Disease (GERD)

The recommended care plan for GERD should follow a step-wise approach starting with lifestyle modifications and proton pump inhibitors (PPIs) as first-line therapy, with escalation to twice-daily PPIs for inadequate response, and consideration of surgical options for refractory cases. 1

Initial Management

Lifestyle Modifications

• Weight loss for overweight/obese patients 1, 2, 3
• Elevate head of bed by 6-8 inches 1, 3
• Avoid eating 2-3 hours before lying down 1, 3
• Eat smaller, more frequent meals 1, 2
• Smoking cessation (smoking decreases lower esophageal sphincter pressure) 1
• Implement antireflux diet by avoiding trigger foods: 1, 2, 3
  • Fatty and fried foods
  • Citrus fruits and juices
  • Tomatoes and tomato products
  • Chocolate
  • Coffee/tea
  • Spicy foods
  • Carbonated beverages
  • Alcohol

Pharmacological Management

First-Line Therapy

• Proton Pump Inhibitors (PPIs) once daily, 30 minutes before meals 1, 4, 5
  • Options include omeprazole or lansoprazole for 4-8 weeks initially 4, 5
  • PPIs are more effective than H2-receptor antagonists for symptom relief and healing of esophagitis 1, 6

For Breakthrough Symptoms

• Antacids and alginates for rapid relief of post-prandial and nighttime symptoms 1
• H2-receptor antagonists particularly useful for nighttime symptoms 1

Management of Inadequate Response

Optimization of PPI Therapy

• Ensure proper PPI administration (30 minutes before meals) 1
• Consider twice-daily PPI dosing if once-daily dosing is ineffective 1

Add-on Therapies

• H2-receptor antagonists at bedtime for nighttime breakthrough symptoms 1
• Baclofen (GABA-B agonist) specifically for regurgitation and belch-predominant symptoms 1, 6
• Prokinetics may help with regurgitation when gastroparesis is present 1

Diagnostic Evaluation for Refractory GERD

For patients not responding to twice-daily PPI therapy:

1. Endoscopy with biopsy to evaluate for complications, alternative diagnoses, and guide further management 1

   • Multiple esophageal biopsies (at least 5) should be obtained to evaluate for eosinophilic esophagitis

2. Esophageal manometry to evaluate esophageal motor function and identify alternative diagnoses 1

3. Ambulatory pH or Impedance-pH monitoring after withholding PPI therapy for 7 days 1

   • Wireless pH monitoring preferred due to extended recording period (48 hours)
   • pH-impedance monitoring while on PPI therapy can determine if symptoms correlate with acid or non-acid reflux events

Surgical and Endoscopic Options

Consider for patients with objectively documented GERD who remain symptomatic despite optimal medical therapy:

• Laparoscopic fundoplication - effective for non-acid reflux that doesn't respond to acid suppression 1
• Transoral incisionless fundoplication (TIF) - for carefully selected patients 1
• Magnetic sphincter augmentation (LINX) 1

Special Considerations

Management of Intestinal Metaplasia (Barrett's Esophagus)

• Twice-daily PPI therapy to maximize acid suppression 1
• Surveillance endoscopy every 3-5 years if intestinal metaplasia persists without dysplasia 1
• Referral to specialist center if follow-up endoscopy reveals dysplasia, visible lesions, or progression 1

Common Pitfalls to Avoid

1. Inadequate PPI dosing or timing - ensure PPIs are taken 30 minutes before meals 1
2. Failure to address lifestyle factors - weight loss and dietary modifications are crucial components 1, 2, 3
3. Misdiagnosis - lack of response to PPI therapy should raise suspicion that the diagnosis is not GERD 7
4. Inadequate biopsy sampling during endoscopy can lead to missing areas of dysplasia 1
5. Performing biopsies during active inflammation can lead to misinterpretation of reactive changes as dysplasia 1

By following this structured approach to GERD management, most patients can achieve significant symptom relief and prevent complications associated with chronic acid reflux.