Treatment of Hyperacidity
Start with a therapeutic trial of a full-dose proton pump inhibitor (PPI) twice daily for 4 weeks as the initial treatment approach for hyperacidity symptoms. 1
Initial Management Strategy
The British Society of Gastroenterology strongly recommends that patients with symptoms suspected to be due to gastro-oesophageal reflux disease (the primary cause of hyperacidity symptoms) should undergo a therapeutic trial of a PPI as the initial diagnostic and therapeutic approach. 1 This strategy is:
- More cost-effective than initial diagnostic testing with reflux monitoring 1
- Less invasive and more widely available than pH monitoring 1
- Highly sensitive when using twice daily dosing compared to once daily regimens 1
Specific Treatment Protocol
Prescribe a full-dose PPI twice daily for 4 weeks. 1 The treatment should be considered successful if there is at least a 75% reduction in symptom frequency. 1
- High-dose, twice daily PPI trials are more sensitive compared with pH monitoring for diagnosing and treating acid-related symptoms 1
- This approach has high sensitivity but relatively low specificity for gastro-oesophageal reflux disease 1
When Initial Treatment Fails
For Persistent Typical Symptoms (Heartburn, Acid Regurgitation)
If symptoms persist despite once daily PPI, increase to twice daily dosing before pursuing further investigations. 1 Only 7% of patients with heartburn or acid regurgitation have persistent acid exposure when taking twice daily PPIs. 1
If symptoms continue despite twice daily PPI therapy, perform pH/impedance monitoring rather than pH monitoring alone. 1 This allows:
- Diagnosis of increased acid exposure 1
- Detection of association between symptoms and acid or non-acid reflux 1
- Identification of specific phenotypes: non-erosive reflux disease, hypersensitive oesophagus, or functional heartburn 1
Approximately 60% of non-erosive reflux disease patients refractory to PPIs have a positive reflux/symptom association, primarily due to non-acid reflux. 1
For Atypical Symptoms (Chest Pain, Throat, Respiratory Symptoms)
For chest pain, throat, or respiratory symptoms not responding to twice daily PPIs, perform pH/impedance monitoring. 1 This enables:
- Diagnosis or exclusion of pathological acid gastro-oesophageal reflux 1
- Detection of association between symptoms and acid or non-acid reflux 1
- Recognition of patients with hypersensitivity to non-acid reflux and oesophageal distension 1
Role of Helicobacter pylori Testing
Consider testing for Helicobacter pylori infection, particularly if symptoms persist despite PPI therapy. 1 If present, eradication requires:
- Clarithromycin-based triple therapy (clarithromycin + amoxicillin or metronidazole + PPI) in areas with low clarithromycin resistance 1
- Alternative regimens (bismuth-based or non-bismuth-based quadruple therapies) if clarithromycin resistance is suspected or confirmed 1
Surgical Considerations
Before considering antireflux surgery in patients responsive to PPIs, perform oesophageal pH monitoring off PPIs to confirm excess acid exposure. 1 Patients with abnormal acid exposure on preoperative pH monitoring have:
- Better long-term patient satisfaction 1
- Fewer gastro-oesophageal reflux or dysphagia symptoms post-surgery 1
Common Pitfalls to Avoid
- Do not perform reflux monitoring in patients whose symptoms respond well to PPI therapy unless antireflux surgery is planned 1
- Do not continue once-daily PPI dosing if symptoms persist—escalate to twice daily before pursuing diagnostic testing 1
- Do not use pH monitoring alone in PPI-refractory patients—pH/impedance monitoring is superior for detecting non-acid reflux 1
- Do not assume all hyperacidity is acid-related—approximately 60% of refractory cases involve non-acid reflux requiring different management 1