SOAP. – Gastroesophageal Reflux Disease and Dyspepsia (GERD)

Kathy R. Reese and Cheryl A. Glass

Definition

A.The American College of Gastroenterology (ACG) defined gastroesophageal reflux disease (GERD) as symptoms or complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or lung.

B.GERD is considered a normal physiologic process in healthy infants, children, and adults. Most episodes last less than 3 minutes, and most often occur 30 to 60 minutes after meals and with reclining positions. GERD is present when the episodes, more than twice a week, cause troublesome symptoms or complications.

C.The ACG and Canadian Association of Gastroenterology (CAG) Clinical Guideline: Management of Dyspepsia was released in 2017. Dyspepsia is defined as predominant epigastric pain lasting at least a month. This can be associated with any other upper gastrointestinal (GI) symptoms such as epigastric fullness, nausea, vomiting, or heartburn, provided epigastric pain is the patient’s primary concern. Functional dyspepsia (FD) refers to patients with dyspepsia where endoscopy, and other tests where relevant, have ruled out organic pathology that explains the patients symptoms:

1.A very large population of patients will present after self-medicating with antacids, bicarbonate soda, and over-the-counter (OTC) medications. Proton pump inhibitors (PPIs) are currently available by prescription and OTC (see Table 14.12).

Incidence

A.GERD is very common; the estimated global presence is 8% to 33%. GERD affects all ages and both genders. Daily heartburn typically occurring postprandially has been estimated to affect 17% to 65% of the normal adult population. Reflux esophagitis affects over 50% of women at some time during pregnancy. It is estimated that 30% to 90% of asthmatics have GERD. Barrett’s esophagus, which affects fewer than 1% of adults, is commonly associated with GERD.

B.Approximately 40% of the population has symptoms of dyspepsia globally. Dyspepsia is more common in women, smokers, and those taking nonsteroidal anti-inflammatory drugs (NSAIDs).

Pathogenesis

A.GERD is relaxation or incompetence of the lower esophagus persisting beyond the newborn period. Relaxation of the lower esophageal sphincter (LES) allows reflux of gastric acid and pepsin into the distal esophagus. Heartburn occurs when reverse peristaltic waves cause regurgitation of acidic stomach contents into the esophagus. Anatomical abnormalities such as a hiatal hernia predispose persons to GERD. Improper diet and nervous tension are also precipitating factors.

B.GERD has been identified as a trigger for asthma, possibly by the activation of vagal reflexes and/or microaspiration. Asthma may promote GERD, and GERD may provoke asthma. Some asthma medications may reduce LES tone, further complicating the picture. Conversely, a patient with GERD may experience pulmonary disease as a response to the esophageal acid exposure.

Predisposing Factors

A.Obesity.

B.Consuming large meals.

C.Pregnancy.

D.Emotional stress.

E.Increased abdominal pressure from tight clothes, straining to lift or defecate, or swallowing air.

F.Ingesting drugs that promote LES relaxation; slow gastric emptying can directly affect the mucosal lining (see Table 14.12).

G.Foods that promote LES relaxation:

1.Alcohol.

2.Chocolate.

3.Peppermint.

H.Smoking: Increases stomach acid and LES pressure.

I.Ingestion of caustic agents such as lye.

TABLE 14.12 Proton Pump inhibitors (PPIs)

PPI	Available Dosages
Omeprazole (Prilosec)	Capsules: 10, 20, and 40 mg
Lansoprazole (Prevacid)	Capsules: 15, 20, and 30 mg delayed release Oral suspension, capsules, and Solu Tab
Rabeprazole (Aciphex)	Tablets: 20 mg delayed release Sprinkles 5 and 10 mg capsules
Pantoprazole (Protonix)	Capsules: 20 and 40 mg Oral suspension: 30 mg
Esomeprazole (Nexium)	Capsules: 20 and 40 mg Oral suspension: 20 and 40 mg
Dexlansoprazole (Dexilant)	Sustained-release tablets: 30 and 60 mg
Omeprazole + sodium bicarbonate (Zegerid)	Capsules: Omeprazole 20 and 20 mg plus 300 mg Na+ Oral suspension: Omeprazole 20 and 40 mg plus 460 mg Na+

J.Infection by agents, such as Candida, herpes simplex, or cytomegalovirus (CMV), which directly attack the esophageal mucosa.

K.Compromised immunity, from AIDS, diabetes, or chemotherapy.

L.Asthma.

Common Complaints

A.Heartburn.

B.Regurgitation of fluid or food.

C.Chest pain.

Other Signs and Symptoms

A.Retrosternal aching or burning.

B.Nocturnal aspiration, water or acid brash.

C.Harsh taste in the mouth upon awakening.

D.Chronic cough, especially at bedtime.

E.Hoarseness.

F.Globus sensation.

G.Nausea.

H.Dental erosion.

Subjective Data

A.Review onset, duration, and course of heartburn or other symptoms.

B.Review medication history, including OTC medication and herbals:

1.Has the patient been taking OTC antacids, H2 blockers, or OTC PPIs?

2.How long has the patient been using these OTCs?

3.Is the patient taking drugs that induce symptoms (refer to Table 14.13)?

C.Ask the patient about alleviating and aggravating factors.

D.Review the patient’s habits, including smoking and alcohol intake.

E.Inquire about other symptoms, such as weight loss, dysphagia, blood loss, regurgitation, and diarrhea.

F.Establish the patient’s usual weight to determine extent of problem.

G.Ask the patient about any history of asthma.

H.Ask the patient about any history of Crohn’s disease (CD; mucosal damage).

I.Review the patient’s dietary history for bulimia.

Physical Examination

A.Check pulse, respirations, blood pressure (BP), and measure height and weight to calculate the patient’s body mass index (BMI).

B.General observation of respiratory distress.

C.Inspect:

1.Examine throat and evaluate mouth for dental erosion.

2.Assess swallowing ability.

D.Auscultate:

1.Evaluate the presence of wheezing in the lungs.

2.Auscultate the heart.

3.Evaluate the abdomen in all four quadrants.

E.Palpate:

1.Palpate abdomen for the presence of hepatosplenomegaly and masses.

2.Assess the abdomen for tenderness or distension.

F.Perform rectal exam (if indicated for any history of hematemesis or melena).

Diagnostic Tests

A.Clinical findings and history alone usually confirm the diagnosis in the vast majority of reflux sufferers.

B.Helicobacter pylori testing.

C.The 2017 ACG and CAG clinical guidelines for dyspepsia related to endoscopy state:

1.Patients 60 years or over with dyspepsia should have an endoscopy to exclude upper GI neoplasia.

TABLE 14.13 Commonly Used Medications That Can Impede Esophageal Function, Retard Gastric Emptying, or Cause Direct Esophageal Mucosal Injury

NSAIDs, nonsteroidal anti-inflammatory drugs.

2.For patients under age 60, an endoscopy should not be done to investigate alarm features for dyspepsia to exclude upper GI neoplasia.

3.Patients younger than 60 years with dyspepsia should have a noninvasive H. pylori test and treatment if possible. (Refer to section Peptic Ulcer Disease in this chapter for H. pylori treatment.)

D.The 2013 American Gastroenterology Association (AGA) guidelines for GERD state:

1.Endoscopy is not required for the presence of typical GERD symptoms but is recommended for the presence of alarm symptoms or for screening patients at high risk for complications.

2.Endoscopy with biopsy is usually the first diagnostic tool in cases of caustic ingestion or suspected infectious etiology.

3.The ACG does not recommend an endoscopy to establish the diagnosis of GERD-related asthma, chronic cough, or laryngitis.

E.The Lyon Consensus statement related to endoscopy notes when GERD symptoms do not respond to empiric PPI an endoscopy is advised to both evaluate for GERD complications and to detect potential alternative diagnoses that might redirect therapy. Barrett’s esophagus or peptic stricturing are considered confirmatory evidence of GERD. Motility and pH monitoring:

1.The ACG and CAG guidelines on motility studies state:

a.Recommend against routine motility studies for patients with FD.

b.Suggest motility studies for selected patients with FD where gastroparesis is strongly suspected

2.The AGA states ambulatory 24-hour pH monitoring: Prolonged monitoring is the best clinical tool for diagnosing GERD in asthmatics. However, it is very expensive and not universally available.

3.The Lyon Consensus states reflux monitoring demonstrates GERD pathology, evident as either excessive esophageal acid exposure time (AET) or reflux episodes, rather than the mechanics. However wireless pH monitoring is expensive, limiting its availability.

F.Upper GI series or barium contrast radiography is not used to diagnose GERD but rules out anatomic abnormalities of the upper digestive tract.

G.Guaiac test for occult blood. Bleeding may accompany reflux esophagitis and be slow and chronic, resulting in iron deficiency anemia, or brisk, resulting in hematemesis. GERD may not be obvious to the clinician when obtaining a patient history, especially in an asthma patient with confounding respiratory symptoms.

A.GERD.

B.Dyspepsia.

C.Cancer—gastric or esophageal.

D.Peptic ulcer.

E.Eosinophilic esophagitis (EE).

F.Esophageal spasm.

G.Myocardial infarction (MI)/angina.

H.Gallbladder disease.

I.Infections: CMV, herpes simplex virus, and Candida.

J.Ingestion of caustic substance.

K.Self-induced vomiting/bulimia.

L.Pyloric stenosis.

M.Autoimmune skin disorders affecting the esophagus.

N.Food allergy.

Plan

A.General interventions: Management depends on cause and severity of symptoms.

B.See Section III: Patient Teaching Guide Gastroesophageal Reflux Disease (GERD).

C.Dietary management:

1.Weight loss is advised for overweight or obese patients with GERD symptoms.

2.At present, there is no supporting data for special dietary precautions; however, a dietary elimination of foods helps to identify triggers.

D.Medical and surgical management:

1.The Nissen fundoplication is a surgical procedure used to treat GERD in asthmatics. It improves the antireflux barrier and provides a lasting solution. Because it is not always successful, it is reserved for severe cases. The Nissen operation is often performed as a laparoscopic procedure.

2.Surgical therapy is not recommended for patients who do not respond to PPI therapy.

3.The ACG guidelines note that surgical therapy is as effective as medical therapy for carefully selected patients with chronic GERD when performed by an experienced surgeon.

4.Patients on NSAIDs who experience upper gastric pain including reflux need to be referred for endoscopy as soon as possible.

E.Pharmaceutical therapy:

PPIs are used for dyspepsia, GERD, and EE and are considered the gold standard of treatments.

1.Guidelines related to PPI therapy:

a.The AGA and CAG guidelines related to PPI therapy:

i.Dyspepsia patients under the age of 60 should have empirical PPI therapy if they are H. pyloric negative or remain symptomatic after H. pylori eradication therapy.

ii.Tricyclic antidepressants (TCA) or prokinetic therapies for patients younger than 60 with dyspepsia can be tried if a trial of PPI is ineffective or the patient did not respond to H. pylori eradication therapy.

iii.The ACG and CAG guidelines recommend PPI, TCA, and prokinetic therapy in that order for patients that fail therapy or are H. pylori negative.

b.The AGA guidelines state:

i.Histamine-2 receptor antagonists (H2 blockers) are effective in managing milder, infrequent GI symptoms. Tolerance occurs with chronic use of H2 blockers. Several H2 blockers are currently available as prescription and OTC: nizatidine (Axid), famotidine (Pepcid), cimetidine (Tagamet), and ranitidine (Zantac).

ii.Rule out cardiac/noncardiac chest pain before institution of PPI therapy (see section Chest Pain in Chapter 12).

iii.The target of pharmaceutical therapy is improvement in quality of life by the reduction/relief of symptoms and healing of erosive esophagitis.

iv.Initiation of a PPI should be prescribed once a day, before the first meal of the day. For maximal pH control, the traditional delayed-release PPI should be administered 30 to 60 minutes before a meal.

v.Management of GERD and dyspepsia should be tailored to the frequency, severity, and duration of symptoms. On-demand or self-directed therapy has been shown to be effective; however, a patient’s use and response should be evaluated.

vi.Long-term use of acid suppression therapy without a diagnosis is not advised.

vii.Long-term therapy should be titrated down to the lowest effective dose based on symptom control.

2.Adverse side effects of PPIs:

a.The potential adverse effects of acid suppression include the increased risk of community-acquired pneumonia, osteoporosis/osteopenia, vitamin B12 deficiency and hypomagnesium, and GI infections, including Clostridioides difficile–associated diarrhea.

b.Avoid the concomitant use of clopidogrel (Plavix) with PPIs because of the significant reduction of the antiplatelet activity of clopidogrel.

c.PPIs interact with warfarin, phenytoin, and diazepam:

i.Monitor the therapeutic effect of warfarin and phenytoin.

ii.Patients may experience a relapse in their GERD symptoms after discontinuance and therefore may need to be tapered off or use a stepdown approach with an antacid or an H2 blocker.

3.The ACG guidelines do not recommend the use of integrated and alternative medicines.

Follow-Up

A.Noncardiac chest pain due to GERD should have a diagnostic evaluation before institution of therapy.

B.Empiric treatment with a PPI may be attempted for a short period except for patients presenting with any alarm symptoms. Schedule a return visit in 1 to 2 weeks to evaluate the relief of symptoms.

C.Patients having frequent relapses and failure to adequately respond to long-term OTC H2 blockers and PPI use should have an endoscopic evaluation.

D.The need for prescribed long-term PPI treatment or the presence of alarm symptoms requires a gastroenterology consultation.

E.Consider bone density studies for patients with long-term PPI use.

Emergent Issues/Instructions

A.Alarm symptoms:

1.Dysphagia (difficulty swallowing).

2.Unintentional weight loss.

3.Predominant upper abdominal pain.

4.Hematemesis (vomiting blood).

5.Melena (black feces/blood stool).

6.Odynophagia (painful swallowing).

7.Severe symptoms.

B.Patients on NSAIDs who experience upper gastric pain including reflux need to be referred for endoscopy as soon as possible.

Consultations

A.Referral is necessary if the patient fails to improve after trying two different medications, or if the patient has dysphagia, recent weight loss, or blood loss.

B.PPI nonresponders need to be referred for evaluation.

Individual Considerations

A.Pregnancy:

1.Underlying causes in pregnancy are diminished gastric motility and displacement of stomach by enlarging uterus.

2.Rule out pregnancy-induced hypertension (PIH); evaluate the patient immediately for signs and symptoms of sudden onset discomfort with no relief from antacids (PIH or HELLP [hemolysis, elevated liver enzymes, and low platelets] syndrome).

B.Geriatrics:

1.GERD prevalence increases with age and may be associated with a hiatal hernia.

2.Prolonged reflux results in esophagitis and may lead to stricture development. Chronic recurrence may develop into Barrett’s syndrome.

3.Treatment of GERD is the same as for general adults; however, do diagnostic testing in short time sequence secondary to stricture and cancer in the elderly.

4.Atypical symptoms are common presentations in the elderly:

a.Vomiting.

b.Anorexia.

c.Dysphagia.

d.Respiratory symptoms.

e.Belching.

f.Hoarseness.

g.Postprandial fullness.

5.Beers Criteria cautions for PPIs:

a.Due to polypharmacy a full review of medications, herbals, and OTC drugs should be undertaken to identify medications that should be avoided in the geriatric population, duplicate medications, and medications that are able to be to be decreased or deprescribed. Evaluate if the patient has difficulties with chewing or if the patient is altering medications by crushing due to swallowing difficulties. Some medications should not be crushed because it alters the absorption or stability of the medication, causes an irritant effect, or has unacceptable taste. (Refer to section Deprescribing of Chapter 3.)

b.When prescribing to the elderly, use the lowest dose, for the shortest period of time.

c.PPIs interact with medications that are commonly taken in the older population, including warfarin, phenytoin, and diazepam. PPIs also reduce the antiplatelet effect of clopidogrel:

i.Monitor the therapeutic effect of warfarin and phenytoin.

d.PPIs are on the American Geriatrics Society 2015 Beers Criteria for potential inappropriate medication use in older adults. (Refer to Appendix C, Table C.1.) Avoid scheduled use of PPIs for greater than 8 weeks unless needed for high-risk patients. PPIs are associated with the following:

i.Osteoporosis/osteopenia, prolonged exposure may increase of fractures.

ii.Community-acquired pneumonia.

iii.C. difficile infections and diarrhea.

iv.Vitamin B12 deficiency and hypomagnesium.

e.See Appendix D for the PPI Deprescribing Algorithm from deprescribing.org.

Resources

AGS Beers Criteria for potentially inappropriate medication use in older adults. Printable Beers pocket card is available at http://www.ospdocs.com/resources/uploads/files/Pocket%20Guide%20to%202015%20Beers%20Criteria.pdf.

American Gastroenterological Association: www.gastro.org.

The 2013 guidelines for the diagnosis and management of gastroesophageal reflux disease are available online at gi.org/guideline/diagnosis-and-managemen-of-gastroesophageal-reflux-disease.

The 2017 ACG Clinical Guideline: Management of Dyspepsia is available online at gi.org/wp-content/uploads/2017/06/ajg2017154a.pdf.