What is the typical workup and treatment for Gastroesophageal Reflux Disease (GERD)?

Diagnostic Workup and Treatment Algorithm for Gastroesophageal Reflux Disease (GERD)

The standard workup for GERD should include symptom assessment, empiric PPI trial for typical symptoms, and objective testing with endoscopy and ambulatory reflux monitoring for refractory or atypical presentations. 1

Initial Assessment and Diagnosis

• Symptom evaluation: Assess for typical symptoms (heartburn, regurgitation) and atypical/extraesophageal manifestations (cough, laryngitis, asthma, dental erosions) 1
• For patients <50 years with typical symptoms and no alarm features: Empiric PPI trial (once daily for 4-8 weeks) is appropriate as initial diagnostic approach 2, 3
• For patients with typical GERD symptoms: Initial single-dose PPI trial, titrating up to twice daily if needed for 8-12 weeks 1
• For patients with extraesophageal symptoms only: Consider diagnostic testing before initiating PPI therapy, as 50-60% of these patients will not have GERD and won't respond to anti-reflux therapies 1

Diagnostic Testing

Endoscopy

• Indications for early endoscopy:

  • Age >50 years
  • Alarm symptoms (dysphagia, odynophagia, weight loss, GI bleeding, anemia)
  • Persistent symptoms despite PPI therapy
  • Long-term GERD symptoms (to assess for Barrett's esophagus)
  • Before anti-reflux surgery 1, 4, 5

• Endoscopy findings: Assess for erosive esophagitis, Barrett's esophagus, hiatal hernia, and rule out alternative diagnoses (e.g., eosinophilic esophagitis) 6, 4

Ambulatory Reflux Monitoring

• Indications:

  • Persistent symptoms despite PPI therapy
  • Extraesophageal symptoms without typical GERD symptoms
  • Before anti-reflux surgery
  • To confirm GERD diagnosis when endoscopy is normal 1

• Testing options:

  • pH monitoring (catheter-based or wireless capsule)
  • pH-impedance monitoring (detects both acid and non-acid reflux) 1

• Testing protocol:

  • For initial diagnosis: Testing off PPI therapy
  • For refractory symptoms with established GERD: Testing on PPI therapy 1

High-Resolution Manometry

• Indications:
  • Before anti-reflux surgery
  • To rule out motility disorders
  • To assess esophageal peristaltic function 6, 4

Treatment Algorithm

First-Line Treatment

• Lifestyle modifications:

  • Weight loss for overweight/obese patients
  • Elevation of head of bed
  • Avoiding meals 2-3 hours before bedtime
  • Avoiding trigger foods (fatty, spicy, acidic foods, chocolate, coffee)
  • Smoking cessation
  • Limiting alcohol consumption 2, 7, 8

• Pharmacologic therapy:

  • PPIs (omeprazole, lansoprazole) once daily for 4-8 weeks for typical GERD symptoms 2, 7
  • For extraesophageal symptoms with concurrent typical GERD symptoms: Twice daily PPI for 8-12 weeks 1

Management of Refractory Symptoms

• For patients who fail initial PPI trial:

  • Optimize PPI therapy (take 30-60 minutes before meals)
  • Consider objective testing (endoscopy, reflux monitoring) 1, 4

• If reflux testing confirms GERD:

  • Consider alternative PPIs or twice-daily dosing
  • Add H2-receptor antagonists at bedtime
  • Consider alginate-containing antacids 1, 2, 3

• If reflux testing is negative:

  • Consider functional disorders
  • Evaluate for non-GERD causes
  • Consider neuromodulators or cognitive-behavioral therapy 1, 4

Advanced Treatment Options

• Endoscopic fundoplication: Consider for patients with:

  • Confirmed pathologic GERD
  • Small or no hiatal hernia
  • Normal esophageal peristaltic function
  • Regurgitation-predominant symptoms 6

• Surgical fundoplication: Consider for patients with:

  • Documented GERD unresponsive to medical therapy
  • Good response to PPI (predicts surgical success)
  • Large hiatal hernia
  • Volume regurgitation 6, 7

Special Considerations

• Extraesophageal GERD: Requires multidisciplinary approach with ENT, pulmonary, or allergy specialists to rule out non-GERD causes before attributing symptoms to reflux 1

• Long-term PPI therapy: For patients requiring long-term PPI therapy, titrate to lowest effective dose and consider endoscopy and reflux monitoring to support continued use 1

• Pitfalls to avoid:

  • Assuming all extraesophageal symptoms are due to GERD (50-60% are not)
  • Continuing PPI therapy without objective evidence of GERD
  • Referring for anti-reflux surgery without documented reflux and PPI response
  • Missing alternative diagnoses that can mimic GERD 1, 4