The document summarizes key points about the diagnosis and management of GERD. It finds that the prevalence of GERD is 10-20% in Western countries and less than 5% in Asia. A therapeutic trial using a high-dose PPI is the standard initial approach to diagnosis. Lifestyle modifications like weight loss and elevating the head of the bed can help symptoms. Endoscopy is recommended when symptoms persist despite PPI treatment or if there are alarm features to rule out complications. The take home message is that GERD diagnosis is typically symptom-based initially with a PPI trial, while endoscopy is used when necessary to investigate atypical symptoms or risk factors for Barrett's esophagus.

1. GERD
in every day practice
“Journey pre-diagnosis”
Hossam GHONEIM, MD

2. Epidemiology
• A systematic review identified 15 epidemiological
studies of GERD that fulfilled strict quality criteria and
also met criteria concerning sample size, response rate,
and recall period)
• GERD prevalence was found to be 10 to 20% in the
Western world and less than 5% in Asia.
• The incidence in the Western world was approximately
5 per 1000 person-years or 0.5% per year
Dent J, El-Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-oesophageal
reflux disease: a systematic review. Gut 2005; 54:710.

3. Trait or disease?
• Some degree of reflux is physiologic
• Physiologic reflux episodes typically
– occur postprandially
– are short-lived
– asymptomatic (apart from heart burn)
– and rarely occur during sleep

4. Trait or disease?
• Montreal Consensus statement defines GERD
as a condition that develops when the reflux
of stomach contents causes troublesome
symptoms and/or complications
• According to the Montreal working grourp,
heartburn is considered troublesome if mild
symp occur 2 or more days a week, or mod to
severe symp occur more than 1 day a week
Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification
of gastroesophageal reflux disease: a global evidence-based consensus. Am J
Gastroenterol 2006; 101:1900.

5. Definition
“The term gastroesophageal reflux disease
should be used to include all individuals who are
exposed to the risk of physical complications
from gastroesophageal reflux, or who
experience clinically significant impairment of
the health-related well being (quality of life),
due to reflux related symptoms, after adequate
assurance of the benign nature of the
symptoms.”
Geneva consensus statement 1, 2001

6. In clinical practice
“This is what happens in the community, most
patients have a trial of therapy, so I think we
have to accept that as the standard approach
today; if it is successful, you have a diagnosis”
D. Castle, DDW 2003

7. Diagnostic Approach
• Symptom analysis
• PPI therapeutic trial
• GI Endoscopy
• Ambulatory PH monitoring, preferably
Multichannel intraluminal impedance MII

8. Clinical manifestations
Oesophageal
• Heart burn (pyrosis)
• Regurgitation
• Water brush
• dysphagia
• Globus sensation
• Odynophagia (rare)
Extra-oesophageal
Need concrete diagnosis
• Chest pain (NCCP)
• Bronchospasm
• Laryngitis
• Chronic cough
• Tooth decay
• Neck pain

9. Pre-diagnosis
Therapeutic trial of acid suppressiion
• “PPI’s are the agents of choice for a therapeutic
trial”
Geneva cnsesus statement 35, 2001
• “Trials of PPI therapy are most sensetive when a
high dose is used”
Geneva consensus statement 36, 2001
• However, A meta-analysis of diagnostic test
characteristics found that a response to PPIs did
NOT correlate well with objective measures of
GERD such as ambulatory pH monitoring
Numans ME, Lau J, de Wit NJ, Bonis PA. Short-term treatment with proton-
pump inhibitors as a test for gastroesophageal reflux disease: a meta-analysis
of diagnostic test characteristics. Ann Intern Med 2004; 140:518.

10. OTC medications
• Antacids
– role is limited to intermittent (on-demand) use for relief of mild
GERD symptoms that occur less than once a week
• Surface agents and alginates
– given the short duration of action and limited efficacy as
compared with PPIs, their use is limited to the management of
GERD in pregnancy Chiu CT, Hsu CM, Wang CC, et al. Randomised clinical trial: sodium
alginate oral suspension is non-inferior to omeprazole in the treatment of patients with non-erosive
gastroesophageal disease. Aliment Pharmacol Ther 2013; 38:1054.
• H-2receptor antagonists
– development of tachyphylaxis within two to six weeks of
initiation of H2RAs limits their use as maintenance therapy for
GERD
Komazawa Y, Adachi K, Mihara T, et al. Tolerance to famotidine and ranitidine treatment after 14 days of
administration in healthy subjects without Helicobacter pylori infection. J Gastroenterol Hepatol 2003; 18:678.

11. Life style modifications
• Although several lifestyle and dietary
modifications have been used in clinical practice,
a systematic review of 16 randomized trials that
evaluated the impact of these measures on GERD
concluded that only weight loss and elevation of
the head end of the bed improved esophageal
pH-metry and/or GERD symptoms
Ness-Jensen E, Lindam A, Lagergren J, Hveem K. Weight loss and reduction in
gastroesophageal reflux. A prospective population-based cohort study: the HUNT
study. Am J Gastroenterol 2013; 108:376.

12. Life style modifications
• Obesity
– Increase intra-abdominal pressure
• Smoking
– Lowers LES pressure and the acid-neutralizing
effect of saliva
• Physical activity
– Increases the TLERs thus provoking GERD

13. Dietary modification
• Dietary modification should not be routinely recommended in all
patients with GERD
• Selective elimination of dietary triggers in patients who note
correlation with GERD symptoms and an improvement in symptoms
with elimination.
– fatty foods
– caffeine
– chocolate
– spicy foods
– food with high fat content
– carbonated beverages
– peppermint
– Alcohol
Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An
evidence-based approach. Arch Intern Med 2006; 166:965.

14. Medications that may aggrevate GERD
Impair LES Function
• Beta-adrenergic agents
• Theophylline
• Anticholinergics
• Ticyclic antidepressant
• Progesteron
• Alpha-adrenergic agents
• Ca channel blockers
Damage oesophageal mucosa
• Acetylsalicylic acid
• NSAID’s
• Tetracycline
• Quinidine
• Bisphosphonates
Moayyedi P, Talley NJ. Gastro-oesophageal reflux disease. Lancet 2006; 367:2086
Katzka & Castle, 2005.

15. When to do Endoscopy
• Patients with typical GERD symptoms that
persist despite a therapeutic trial of 4 to 8 wks
of twice daily PPI therapy.
• Pts with HB & alarm features to rule out
complications of GERD and other diagnoses.
• Pts with LA Grade C and D on initial endoscopy
should undergo a f/up endoscopy after a 2 m.
course of PPI therapy to assess healing and
rule out Barrett's esophagus.

16. When to do Endoscopy
• Men > 50 yrs with chronic GERD symptoms (>
5yrs) and additional risk factors for Barrett's
esophagus and esophageal adenocarcinoma.
• Chronic pts who report unusual disappearance
of HB without treatment to look for BE.
Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association
Institute technical review on the management of gastroesophageal reflux
disease. Gastroenterology 2008; 135:1392.

17. Take Home Message
• Symptom-based diagnosis
– Only for typical Oesophageal symptoms
• Therapeutic trial using high dose PPI
• Limited role for antacids, alginates & H-2RA
• Lifestyle, dietary and medication modifications
• Endoscopy when necessary
– DD
– ? BE
– Alarming symptoms &/or History

18. THANK YOU