Key practice point

Tests that quantify the amount of acid refluxing into the esophagus are often inaccurate in classifying abnormal from normal (physiological) reflux. For this reason, a classic symptom of heartburn, especially with response to acid suppression with a proton pump inhibitor, is as reliable a test as pH monitoring. Esophageal manometry does not improve the accuracy since substantial variation in the frequency of TLESRs occurs between asymptomatic individuals, and 30–50% of patients with documented GERD have normal LES pressures.

Management

The course of GERD is highly variable; most patients require medical therapy continuously but some respond to intermittent (medication used continuously for a predetermined duration) or on-demand (medication taken when symptoms occur) strategies of medication and others can discontinue medical therapy altogether.

Lifestyle modification

The modification of lifestyle is an integral part of the initial management of GERD. The head of the bed should be elevated to enhance nocturnal esophageal acid clearance. Smoking and alcohol, which have deleterious effects on LES pressure, acid clearance, and epithelial function, should be avoided. Reducing meal size and limiting the intake of fat, carminatives, and chocolate limit gastric distension, lower TLESR incidence, and prevent LES pressure reductions. Caffeinated and decaffeinated coffee, tea, and carbonated beverages should be avoided because they stimulate acid production. Tomato juice and citrus products may exacerbate symptoms because of osmotic effects. Medications that reduce LES pressure should be limited whenever possible.

Key practice points: lifestyle modifications for patients with gastroesophageal reflux

Elevate the head of the bed 6 inches
Stop smoking
Stop excessive ethanol consumption
Reduce dietary fat
Reduce meal size
Avoid bedtime snacks
Reduce weight (if overweight)
Avoid specific foods
    Chocolate
    Carminatives (e.g. spearmint, peppermint)
    Coffee (caffeinated, decaffeinated)
    Tea
    Cola beverages
    Tomato juice
    Citrus fruit juices
Avoid specific medications (if possible)
    Anticholinergics
    Theophylline
    Benzodiazepines
    Opiates
    Calcium channel antagonists
    β-Adrenergic agonists
    Progesterone (some contraceptives)
    α-Adrenergic antagonists

Medication therapy

Proton pump inhibitors are the drugs of choice for endoscopically proven erosive esophagitis and symptomatic GERD. These agents, which are H⁺, K⁺-adenosine triphosphatase antagonists, produce superior acid suppression compared with H₂ receptor antagonists. Recent concerns about adverse events associated with PPIs (C. difficile infection, pneumonia, bone fracture, drug interaction, magnesium deficiency) illustrate the need to use the lowest dose necessary to achieve therapeutic goals; however, the risk of adverse events is very low so appropriate use of PPIs to treat GERD is encouraged.

For patients with intermittent, mild symptoms, antacids and H₂

Only gold members can continue reading. Log In or Register to continue