What is the best approach to manage GERD-like symptoms in a patient with a history of recurrent COVID-19 infections and dyspnea?

Management of GERD-like Symptoms in Post-COVID-19 Patients

In patients with recurrent COVID-19 infections presenting with GERD-like symptoms and dyspnea, consider chronic pulmonary embolism as a potential cause before attributing symptoms to gastroesophageal reflux, as these symptoms may resolve with anticoagulation rather than acid suppression. 1

Initial Diagnostic Approach

Rule Out Life-Threatening Causes First

• Obtain chest CT with contrast to evaluate for pulmonary embolism, which is a known complication of COVID-19 and can present with chest pain, dyspnea, and symptoms mimicking GERD 2, 1
• COVID-19 sequelae may masquerade as gastrointestinal conditions, making PE a critical differential diagnosis in the post-pandemic era 1
• One case report documented complete resolution of refractory GERD symptoms within 2 days of anticoagulation initiation for chronic PE in a post-COVID patient 1

Assess Respiratory Muscle Function

• Screen for respiratory muscle weakness using respiratory muscle testing, as SARS-CoV-2 infection itself can cause direct damage to respiratory muscles contributing to both dyspnea and chest discomfort 2
• Approximately 82% of hospitalized and 38% of non-hospitalized COVID-19 patients develop dyspnea, with 43% still experiencing symptoms at 2 months post-hospitalization 2
• Persistent dyspnea occurs in 10% of patients at both 4 and 12 weeks following COVID-19 diagnosis, and over 71% of never-hospitalized patients reported dyspnea at 79 days post-infection 2

Evaluation of True GERD Symptoms

When to Pursue Endoscopic Evaluation

During the acute COVID-19 period, defer endoscopic evaluation for mild to moderate dysphagia, nausea, or vomiting unless the patient cannot tolerate sufficient liquid diet with ongoing dehydration/profound weight loss 2

For patients with persistent symptoms:

• Consider upper endoscopy and 24-hour pH monitoring if symptoms persist despite empiric treatment and after ruling out cardiopulmonary causes 1
• Noninvasive barium esophagram may be useful to triage the need for endoscopy, though local radiology availability should be considered 2

Medical Management of GERD-like Symptoms

Exercise caution with proton pump inhibitors in COVID-19 patients, as emerging evidence suggests potential harm:

• Intravenous PPIs during hospitalization were independently associated with worse clinical outcomes in COVID-19 patients (OR = 7.00,95% CI = 4.57-10.71) after adjusting for confounders 3
• This association remained significant for intravenous omeprazole but not for oral lansoprazole or rabeprazole 3
• Most patients can tolerate dexamethasone (if prescribed for COVID-19) without prophylactic PPI use 4

If acid suppression is deemed necessary after ruling out other causes:

• Start with omeprazole 20 mg once daily for up to 4 weeks for symptomatic GERD 5
• For erosive esophagitis, use omeprazole 20 mg once daily for 4 to 8 weeks 5
• Alternative: lansoprazole 15 mg once daily for up to 8 weeks for symptomatic GERD 6
• Take before meals; antacids may be used concomitantly 5

Management of Associated Symptoms

Chest Pain Without Ischemia

• For pleuritic chest pain or inflammatory component (costochondritis), trial NSAIDs for 1-2 weeks, with addition of low-dose colchicine as needed 2
• If symptoms worsen with NSAIDs, consider esophagitis and esophageal spasm 2
• For suspected endothelial dysfunction, trial calcium-channel blocker, long-acting nitrate, and/or ranolazine 2

Dyspnea Management

• Provide supplemental oxygen to maintain SpO2 above 90-96% 7
• Position patient upright to improve ventilatory capacity 7
• Consider pulmonary consultation for dyspnea unrelated to cardiovascular disease 2
• Physical therapy incorporating aerobic training and diaphragmatic breathing exercises can address underlying ventilatory abnormalities and respiratory muscle dysfunction 2

Nausea and Vomiting

COVID-19 can present with nausea, vomiting, and diarrhea that may predate respiratory symptoms 2:

• Up to 61% of outpatients who tested positive for COVID-19 experienced GI symptoms 2
• Optimize medical management with anti-emetics and antidiarrheals (loperamide) 2
• Monitor QTc carefully, as many anti-emetics prolong QT interval, particularly when combined with other COVID-19 treatments 2
• Consider GI pathogen testing including C. difficile, particularly in patients with leukocytosis or recent antibiotic use 2

Critical Pitfalls to Avoid

• Do not assume GERD-like symptoms are benign reflux in post-COVID patients without first ruling out PE and respiratory muscle dysfunction 1
• Avoid routine PPI prophylaxis in COVID-19 patients on dexamethasone unless specific GI risk factors exist (history of gastritis, peptic ulcer disease, or GI bleeding) 4
• Do not discharge patients on PPIs without clear indication, as 53% of patients prescribed PPIs during COVID-19 hospitalization were discharged with this medication, taking it for an average of 3 months (up to 7 months) unnecessarily 4
• Recognize that normal pulmonary function tests do not exclude respiratory causes of dyspnea in post-COVID patients, as regional ventilation inhomogeneity may persist despite normal spirometry and DLCO 8