How should I manage a patient presenting with severe gastro‑oesophageal reflux disease (GERD)?

Management of Severe GERD

For severe GERD, initiate high-dose PPI therapy with twice-daily dosing immediately (rather than starting with once-daily), perform upper endoscopy to assess for erosive esophagitis and Barrett's esophagus, and consider surgical or endoscopic interventions if symptoms remain refractory despite optimized medical therapy. 1

Initial Diagnostic Evaluation

Perform upper endoscopy in all patients with severe GERD to:

• Grade erosive esophagitis using the Los Angeles classification 1
• Assess the diaphragmatic hiatus and measure hiatus hernia length 1
• Screen for Barrett's esophagus using Prague classification with biopsy if present 1
• Exclude alternative diagnoses such as eosinophilic esophagitis, pill injury, or achalasia 2

Obtain objective reflux testing with prolonged wireless pH monitoring (96-hour preferred) off medication to confirm pathologic GERD and phenotype the disease severity 1

Pharmacologic Management

Initial Therapy

Start with twice-daily PPI therapy immediately for severe GERD rather than the standard once-daily approach used for mild-moderate disease 1, 2:

• Omeprazole 40 mg twice daily or equivalent PPI 3
• Take 30-60 minutes before meals 3
• Continue for 8 weeks initially 1, 2

This aggressive upfront approach is justified because twice-daily PPI normalizes esophageal acid exposure in 93-99% of patients with GERD 1, and severe disease requires maximal acid suppression from the outset.

Adjunctive Pharmacotherapy (Phenotype-Specific)

Personalize add-on medications based on symptom pattern rather than empirically adding agents 1:

• Alginate antacids for breakthrough symptoms between PPI doses 1
• Nighttime H2-receptor antagonists (e.g., famotidine 20-40 mg at bedtime) for nocturnal acid breakthrough 1, 2
• Baclofen 5-20 mg three times daily for regurgitation-predominant or belch-predominant symptoms (reduces transient lower esophageal sphincter relaxations) 1, 2
• Prokinetics only if coexistent gastroparesis is documented 1

Common pitfall: Do not add medications empirically without first verifying PPI compliance and optimizing timing of doses 2

Assessment of Treatment Response

Reassess at 8 weeks:

• If symptoms persist despite twice-daily PPI, the patient is a treatment failure and requires further workup 2
• Perform ambulatory 24-hour pH-impedance monitoring on PPI to determine mechanism of persistent symptoms (inadequate acid suppression vs. non-acid reflux vs. functional overlay) 1

Surgical and Endoscopic Interventions

Consider invasive anti-reflux procedures for patients with proven severe GERD who meet the following criteria 1:

• Confirmatory evidence of pathologic GERD on objective testing
• Exclusion of achalasia (perform esophageal manometry)
• Assessment of esophageal peristaltic function (adequate peristalsis required for fundoplication)

Surgical Options (in order of preference for severe GERD):

1. Laparoscopic fundoplication - most established surgical option with long-term efficacy data 1
2. Magnetic sphincter augmentation - effective alternative with less dysphagia than fundoplication 1
3. Transoral incisionless fundoplication - endoscopic option for carefully selected patients 1

For obese patients with severe GERD: Roux-en-Y gastric bypass is an effective primary anti-reflux intervention that addresses both obesity and GERD 1

Critical warning: Sleeve gastrectomy has potential to worsen GERD and should be avoided in patients with severe pre-existing reflux disease 1

When to Recommend Surgery Over Medical Therapy:

Surgery should be offered when 1:

• Patient is responsive to PPI but intolerant of medication (side effects, cost concerns)
• Persistent troublesome regurgitation despite optimized PPI therapy
• Patient preference for definitive treatment after informed discussion of risks vs. benefits

Surgery should NOT be offered when 1:

• Symptoms are well-controlled on medical therapy (no quality of life benefit)
• As an "antineoplastic measure" in Barrett's esophagus (does not prevent cancer)

Neuromodulation for Refractory Symptoms

If symptoms persist despite proven adequate acid suppression (documented on pH-impedance monitoring on PPI), consider 1:

• Pharmacologic neuromodulation with tricyclic antidepressants or SSRIs
• Referral to behavioral therapist for hypnotherapy, cognitive behavioral therapy, or diaphragmatic breathing exercises
• This addresses esophageal hypervigilance, reflux hypersensitivity, and functional heartburn that may coexist with or mimic GERD

Long-Term Management

For patients requiring chronic PPI therapy:

• Continue at the lowest effective dose that maintains symptom control 2, 4
• Long-term PPI use is safe with minimal established risks (slight increase in C. difficile and bacterial gastroenteritis only) 2, 4
• Do not routinely discontinue PPIs in patients with documented severe erosive esophagitis or Barrett's esophagus 2
• Maintenance therapy is driven by impact on quality of life, not by concern for disease progression 4

Monitoring: Routine endoscopic surveillance to assess disease progression is not recommended and does not reduce cancer risk 1