What is the treatment for gastroesophageal reflux?

Treatment of Gastroesophageal Reflux Disease (GERD)

Proton pump inhibitors (PPIs) are the first-line medical treatment for gastroesophageal reflux disease, with twice-daily dosing recommended for patients with severe symptoms or inadequate response to once-daily therapy. 1

Diagnostic Approach

Before initiating treatment, it's important to distinguish GERD from other conditions with similar presentations:

• Alarm symptoms requiring prompt endoscopic evaluation:

  • Weight loss
  • Dysphagia
  • Epigastric mass
  • Hematemesis 2

• In infants and children, consider alternative diagnoses such as:

  • Cow's milk protein allergy (overlaps with GERD in 42-58% of infants)
  • Neurologic disorders
  • Constipation
  • Infection 3

Treatment Algorithm

Step 1: Lifestyle and Dietary Modifications

• Weight loss for overweight/obese patients
• Elevate head of bed by 6-8 inches
• Sleep in left lateral decubitus position
• Avoid food intake 2-3 hours before lying down
• Limit daily fat intake to less than 45g
• Avoid trigger foods: coffee, tea, chocolate, mints, citrus, tomatoes, spicy foods, alcohol 1, 4

Step 2: Medical Therapy

First-line:

• PPIs (omeprazole 20-40mg, lansoprazole 15-30mg, esomeprazole 20-40mg, rabeprazole 20mg)
  • Start with once-daily dosing before the first meal of the day
  • For inadequate response, increase to twice-daily dosing 1
  • Treatment duration: 4-8 weeks initially 5

Second-line options:

• H2-receptor antagonists (e.g., ranitidine)
  • Can be used for maintenance after initial PPI therapy
  • Effective for healing of erosive esophagitis in 84% of patients after 12 weeks 6

Adjunctive therapies:

• Prokinetics (limited evidence supports routine use)
• Baclofen for regurgitation symptoms
• Antacids for breakthrough symptoms 1, 2

Step 3: Evaluation of Treatment Response

After 4-8 weeks of therapy:

• Complete response: Continue therapy and consider step-down to lowest effective dose
• Partial response: Increase to twice-daily PPI if not already prescribed
• No response: Re-evaluate diagnosis with endoscopy and additional testing 7

Step 4: Management of Refractory GERD

For patients with persistent symptoms despite 8-12 weeks of optimized PPI therapy:

1. Endoscopy to assess for complications and rule out other diagnoses
2. Esophageal manometry to evaluate for motility disorders
3. Ambulatory pH or pH-impedance monitoring (off PPI therapy unless previous objective evidence of GERD exists) 2, 1

Step 5: Consider Surgical Intervention

Antireflux surgery (fundoplication) should be considered for:

• Patients with confirmed GERD who remain symptomatic despite optimal medical therapy
• Those with adequate esophageal peristalsis
• Patients unwilling to take long-term PPI therapy 1, 8

Special Populations

Infants and Children

• Most infant reflux resolves spontaneously by 12 months of age
• Parental reassurance and education are often sufficient
• For GERD with erosive esophagitis, esomeprazole is approved for infants 1-12 months 2, 3

Pregnancy

1. Start with lifestyle and dietary modifications
2. Step-up approach: antacids → sucralfate → H2-receptor antagonists → PPIs for refractory cases 1

Long-term Management

• After initial healing, titrate to lowest effective PPI dose
• Consider periodic attempts at discontinuation
• For patients requiring long-term PPI therapy (>12 months), obtain objective confirmation of GERD
• Surveillance endoscopy every 3-5 years for patients with Barrett's esophagus 1

Common Pitfalls to Avoid

1. Misdiagnosis: Not all heartburn is GERD; consider functional disorders, eosinophilic esophagitis, and cardiac disease
2. Inadequate PPI dosing: PPIs should be taken 30-60 minutes before meals for optimal effect
3. Premature discontinuation: Symptoms may recur if therapy is stopped too soon
4. Overlooking lifestyle factors: Dietary and behavioral modifications are essential components of therapy
5. Prolonged empiric therapy: Patients with persistent symptoms despite PPI therapy should undergo diagnostic testing rather than continued empiric treatment 2, 9