Gastroesophageal reflux disease (GERD) affects over 60 million Americans and is commonly diagnosed and treated by family physicians. GERD is defined as reflux of stomach contents into the esophagus, causing symptoms like heartburn and acid regurgitation. Proton pump inhibitors (PPIs) are highly effective at relieving GERD symptoms and different PPIs provide similar relief. Long-term PPI use may be associated with complications like hypomagnesemia, hip fractures, and pneumonia. Endoscopy is useful for diagnosing GERD complications but not sensitive for diagnosing GERD itself. Surgery should be reserved for severe cases that are poorly controlled by lifestyle changes and high doses

1. Gloria Monsalve M.D.
GERD

2. More than 60 million persons in the United States report
symptoms of GERD at least weekly, and a typical full-time
family physician can expect to diagnose and treat 40 to 60
patients with this condition each month.

3. GERD is defined as reflux of
gastroduodenal contents into the
esophagus, causing symptoms
sufficient to interfere with quality of
life.
Heartburn and acid regurgitation.
Acidez y/o la regurgitación or ardor en la
boca del estomago.

4. Common Questions About the
Management of Gastroesophageal Reflux
Disease
Am Fam Physician. 2015 May 15;91(10):692-697.

5. Are All PPIs Equally Effective in Relieving
GERD Symptoms?

6. All over-the-counter and prescription PPIs offer similar
relief of GERD symptoms.*
* Dean L. Comparing proton pump inhibitors. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004954/. Accessed June 10, 2014.

7. A recent Cochrane review identified three trials of treatments for nonerosiveGERD.
These trials compared equivalent doses of four PPIs:
Esomeprazole (Nexium) 20 mg
Omeprazole 20 mg
Pantoprazole (Protonix) 20 mg
Rabeprazole (Aciphex) 10 mg.
All had similar times to initial relief of symptoms and complete relief of symptoms at four weeks.

9. Although a meta-analysis concluded that high doses of esomeprazole wereslightly superior to other PPIs in healing erosive GERD at eight weeks.
❖ PPIs vs H2 antagonists
A Cochrane review found that PPIs are more effective at relieving GERDsymptoms than H2 antagonists.
RCT supported the cost- and clinical effectiveness of starting with a PPI ratherthan step therapy with an H2 antagonist when treating reflux esophagitis.

10. Adding prokinetic medications to PPI?
One RCT comparing
Omeprazole 20 mg BID/day + domperidone 10 mg three times daily vs.omeprazole 20 mg twice daily found decreased symptoms with a meanimprovement using a validated symptom score.
However, a meta-analysis of 12 RCTs found that the combination of a prokineticand PPI did not improve symptoms and was associated with more adverseeffects than a PPI alone.
Katz PO, et al. Guidelines for the diagnosis and management of gastroesophageal reflux disease [published correction
appears in Am J Gastroenterol. 2013;108(10): 1672]. Am J Gastroenterol. 2013;108(3):308–328.

11. What Are the
Complications
Associated with Long-
Term PPI Use?

12. Hypomagnesemia. increased incidence of hypomagnesemia and identified cases of severehypomagnesemia in patients who had been treated with a PPI in the four months
Hip Fracture. Several studies found an association between long-term PPI use and increased risk ofhip fractures.
C. difficile Infection. PPI use may increase susceptibility to C. difficile.
Vitamin B12 Deficiency. Thus, patients with suggestive symptoms should be tested for vitamin B12deficiency.
Community-acquired Pneumonia. Two studies found an increased risk of community-acquiredpneumonia in patients currently using PPIs, ranging from 29% to 39%.

13. How Should GERD be
Diagnosed?

14. GERD is based on typical symptoms such
as heartburn or regurgitation.
Diagnosis of GERD can be improved using validated diagnostic tools such as the GerdQ
questionnaire.

16. ENDOSCOPY?
When?
Who?

17. ● Endoscopy is useful for diagnosing the complications of GERD, such as Barrett's
esophagus, esophagitis and strictures.
● Endoscopy is not sensitive for diagnosis of GERD, Only 50 percent of patients with
GERD manifest macroscopic evidence on endoscopy
ENDOSCOPY

18. Screening for Barrett
esophagus is cost-effective
in white men 50 years or
older who have had GERD
symptoms for at least five
years.

19. AMBULATORY PH
MONITORING

20. A pH monitor is placed in the esophagus above the lower
esophageal sphincter, and the pH is recorded at given moments in
time.
Over the 24-hour test period, the patient writes down the time and
situation in which symptoms occur, in the hope that symptoms can
be correlated with the lowering of esophageal pH that occurs with
reflux.

21. When Should a Patient with
GERD Be Referred for
Surgery?

22. Surgery should be reserved for patients with contraindications to PPI
therapy. Poorly controlled symptoms despite lifestyle changes and
maximal PPI doses.
Surgical intervention has been shown to provide long-term relief of
symptoms in patients with GERD.

23. Should Patients with GERD Be
Tested for H. pylori?

24. There is insufficient evidence to routinely test for
Helicobacter pylori in patients with GERD.

25. Practice points

27. Gracias.