What are the different treatment approaches for Gastroesophageal Reflux Disease (GERD) and dyspepsia?

Differential Treatment Approaches for GERD vs Dyspepsia

GERD and dyspepsia require distinct treatment strategies: GERD is primarily managed with proton pump inhibitors (PPIs) taken 30-60 minutes before meals with a focus on long-term acid suppression and objective testing for non-responders, while dyspepsia requires initial H. pylori testing and eradication when positive, followed by empiric PPI therapy for ulcer-like symptoms or prokinetics for dysmotility-like symptoms, with earlier consideration of tricyclic antidepressants for refractory cases. 1, 2

Key Diagnostic Distinction

GERD is characterized by troublesome heartburn, regurgitation, and/or non-cardiac chest pain, with objective confirmation via endoscopy showing erosive esophagitis (Los Angeles grade B or higher) or prolonged wireless pH monitoring demonstrating acid exposure time (AET) ≥6.0% 1

Dyspepsia presents with epigastric pain, fullness, early satiety, or postprandial distress, and requires differentiation into ulcer-like (pain predominant) versus dysmotility-like (fullness/bloating predominant) subtypes 2

Initial Management Pathways

For GERD:

• Start with a 4-8 week trial of once-daily PPI (omeprazole 20 mg or lansoprazole 30 mg) taken 30-60 minutes before breakfast, without requiring endoscopy in patients under 50 years without alarm symptoms 1, 3, 4

• Emphasize PPI safety to patients, as concerns about adverse events should not drive treatment decisions when there is clear indication 1

• Escalate to twice-daily PPI if inadequate response after 4 weeks, or switch to more potent formulations (rabeprazole, esomeprazole, or dexlansoprazole) 1

• Lifestyle modifications are adjunctive: elevate head of bed, avoid meals within 3 hours of bedtime, weight management, and diaphragmatic breathing exercises 1

For Dyspepsia:

• Test for H. pylori first using non-invasive testing (urea breath test or stool antigen), and provide eradication therapy if positive, as this is curative in H. pylori-positive dyspepsia 2

• For ulcer-like dyspepsia (epigastric pain predominant): initiate full-dose PPI (omeprazole 20 mg once daily) as first-line therapy 2

• For dysmotility-like dyspepsia (fullness, early satiety, bloating): consider prokinetic agents rather than PPIs as initial therapy 2

• Perform endoscopy earlier in patients ≥55 years with resistant symptoms, or ≥60 years with weight loss to exclude malignancy 2

Critical Differences in Long-Term Management

GERD Long-Term Strategy:

• Objective testing is central for non-responders: perform endoscopy and 96-hour wireless pH monitoring OFF PPI after 2-4 weeks of withholding therapy to confirm diagnosis and phenotype the disease 1

• Phenotype-based approach: patients with severe GERD (Los Angeles C/D esophagitis, AET >12%, large hiatal hernia) require indefinite PPI therapy or anti-reflux procedures, while those with non-erosive disease can be weaned to lowest effective dose or on-demand therapy 1

• Reassess appropriateness within 12 months of starting long-term PPI in unproven GERD, offering objective testing to establish need for continued therapy 1

• Consider anti-reflux procedures (fundoplication, magnetic sphincter augmentation) after esophageal physiologic testing (high-resolution manometry, pH-impedance) for patients with confirmed GERD who fail optimized medical therapy 1

Dyspepsia Long-Term Strategy:

• Attempt therapy withdrawal after 4-8 weeks if symptoms controlled, then use on-demand therapy with the successful agent (PPI or prokinetic) 2

• Switch treatment class if initial therapy fails: change from PPI to prokinetic or vice versa based on symptom pattern 2

• Escalate to tricyclic antidepressants as second-line: start amitriptyline 10 mg once daily, gradually increasing to 30-50 mg daily for refractory functional dyspepsia 2

• Consider behavioral interventions earlier: recommend regular aerobic exercise for all patients, and reevaluate for behavioral therapies or psychotherapy in resistant cases 2

Management of Treatment Failures

GERD Non-Responders:

• Perform pH-impedance monitoring ON PPI in patients with persistent belching and regurgitation to identify non-acid reflux, weakly acidic reflux, or functional overlay 1

• Add neuromodulators (tricyclic antidepressants) or cognitive behavioral therapy/gut-directed hypnotherapy for patients with psychological comorbidities or visceral hypersensitivity 1

• Assess for alternative diagnoses: evaluate for eosinophilic esophagitis, achalasia, or functional heartburn using high-resolution manometry and esophagram 1

Dyspepsia Non-Responders:

• Do not continue H2-receptor antagonists indefinitely: after 9 weeks of famotidine failure, escalate to full-dose PPI rather than hoping for delayed response 2

• Use tricyclic antidepressants systematically: these are evidence-based second-line agents for functional dyspepsia, not a last resort 2

• Consider antipsychotics as alternative second-line: sulpiride 100 mg four times daily or levosulpiride 25 mg three times daily may be effective 2

Common Pitfalls to Avoid

• Do not use metoclopramide routinely for either condition due to insufficient efficacy evidence and significant risk of tardive dyskinesia 2, 5

• Do not perform repeat endoscopy in GERD non-responders before therapeutic escalation to twice-daily PPI; save endoscopy for after medication optimization fails 1, 2

• Do not ignore H. pylori testing in dyspepsia: this is a critical first step that is curative when positive, unlike GERD where H. pylori testing is not routinely indicated 2

• Do not use the same PPI dosing strategy: GERD requires consistent daily dosing for mucosal healing, while dyspepsia can often be managed with on-demand therapy after initial response 1, 2

• Recognize that baclofen has limited utility: while it inhibits transient lower esophageal sphincter relaxations in GERD, CNS side effects (dizziness, somnolence) significantly limit its practical use 5