What are the steps in managing gastro‑oesophageal reflux disease (GERD)?

Management of GERD: A Stepwise Algorithmic Approach

For uncomplicated GERD, initiate empirical PPI therapy (once daily, 30-60 minutes before first meal) for 4-8 weeks without requiring endoscopy, reserving diagnostic testing for alarm symptoms, treatment failures, or when considering long-term therapy or surgery. 1, 2, 3

Initial Management: Empirical Treatment

Step 1: Start PPI Therapy Without Endoscopy

• Begin with once-daily PPI (e.g., omeprazole 20 mg) taken 30-60 minutes before the first meal of the day for 4-8 weeks 2, 3, 4
• Combine with lifestyle modifications (elevate head of bed, modify meal size and composition) 3
• This "step-down" approach ensures more rapid symptom resolution, improved quality of life, and lower overall cost compared to starting with antacids 2

Step 2: Assess Response After 4-8 Weeks

• If symptoms resolve: Attempt to titrate down to lowest effective dose or intermittent therapy 2, 3
• If partial response: Escalate to twice-daily PPI dosing 1
• If no response: Proceed to diagnostic evaluation 1

When to Perform Endoscopy

Perform endoscopy immediately if alarm features present:

• Weight loss, dysphagia, or epigastric mass on examination (best predictors of malignancy) 1
• Gastrointestinal bleeding, odynophagia, or anorexia 3, 5
• Critical caveat: When evaluating dysphagia, obtain at least 5 esophageal mucosal biopsies to exclude eosinophilic esophagitis 1, 6

Perform endoscopy for treatment failures:

• Persistent symptoms despite twice-daily PPI therapy for adequate duration 1
• Need to identify complications (Barrett's metaplasia, stricture, alternative diagnoses) 1
• Do not perform routine endoscopy to monitor disease progression in uncomplicated GERD—this does not reduce cancer mortality 1

Management of PPI Treatment Failures

After normal endoscopy with persistent symptoms, follow this sequence:

1. Esophageal manometry (second test) to exclude motility disorders (achalasia, distal esophageal spasm) and confirm preserved peristaltic function if surgery is being considered 1, 6

2. pH monitoring off PPI therapy (third test) to document excessive esophageal acid exposure when PPI is withheld 1

   • Withhold PPI for 7 days before testing 7
   • Prolonged wireless pH monitoring (96-hour) is superior to catheter-based studies 7
   • Pathologic GERD confirmed by acid exposure time ≥6.0% on 2+ days 7

Maintenance Therapy

Long-term PPI therapy is appropriate for:

• Patients with erosive esophagitis or documented excessive acid exposure 1
• Those with rapid symptom recurrence during trial periods off medication 8
• Important: Approximately 70% of patients relapse within 6 months of stopping therapy 2

Titrate to lowest effective dose:

• After initial healing, attempt to reduce to maintenance doses or intermittent therapy 2, 3
• The need for maintenance therapy is determined by rapidity of symptom recurrence during trial periods off medication 8

Special Scenarios

Reflux Chest Pain Syndrome:

• First, carefully exclude cardiac etiology (mortality from ischemic heart disease far exceeds GERD) 1
• Once cardiac disease excluded, initiate twice-daily PPI therapy for 4 weeks (Grade A recommendation) 1

Extraesophageal GERD Syndromes (laryngitis, asthma, cough):

• Do not treat with PPIs unless concomitant esophageal GERD syndrome is present (Grade D recommendation against treating isolated extraesophageal symptoms) 1
• If concomitant esophageal symptoms exist, empirical twice-daily PPI therapy for 2 months is reasonable (Grade B) 1
• These syndromes are usually multifactorial; GERD rarely the sole cause 1

Surgical Management

Antireflux surgery indications:

• Patients responsive to but intolerant of PPI therapy (Grade A) 1
• Persistent troublesome symptoms (especially regurgitation) despite PPI therapy, with documented esophagitis and/or excessive acid exposure off PPI (Grade B) 1
• Requires preserved peristaltic function on manometry 1

Do not perform surgery for:

• Patients well-controlled on medical therapy (Grade D) 1
• As an antineoplastic measure in Barrett's esophagus (Grade D) 1

Critical consideration: Weigh benefits against new post-surgical symptoms (dysphagia, flatulence, inability to belch, bowel symptoms) 1

Barrett's Esophagus Screening

Do not perform routine endoscopic screening in adults ≥50 years with 5-10 years of heartburn to reduce mortality from esophageal adenocarcinoma (Grade D) 1

• Risk of adenocarcinoma in Barrett's esophagus is approximately 0.5% per year 1
• Endoscopic monitoring has not been shown to diminish cancer risk 1
• Likelihood of developing Barrett's, stricture, or adenocarcinoma over 7 years in patients with healed mucosa at index endoscopy is 0.0%, 1.9%, and 0.1% respectively 1

Common Pitfalls to Avoid

• Do not start with H2-receptor antagonists—PPIs are more cost-effective and provide faster symptom resolution 2, 3
• Do not perform endoscopy in every GERD patient—reserve for alarm symptoms or treatment failures 1, 5
• Do not continue escalating PPI doses indefinitely without objective testing—after twice-daily PPI failure, pursue diagnostic evaluation 1
• Do not diagnose extraesophageal GERD syndromes without concomitant esophageal symptoms—this leads to overdiagnosis and overtreatment 1