GPAC: Guidelines and Protocols Advisory Committee

Gastroesophageal Reflux Disease - Clinical Approach in Adults

Effective Date: January 30, 2010

Summary | Flow Sheet | Patient Guide | Full Guideline in PDF

Recommendations and Topics

Scope

Prevention and Risk Factors

Diagnosis/Investigation

Management

Rationale

References

Abbreviations

Appendices

Scope

This guideline outlines the clinical approach to the diagnosis and treatment of gastroesophageal reflux disease (GERD) in adult patients. Treatment of Helicobacter pylori (H. pylori) infection is not part of the management of GERD (see Dyspepsia with or without H. pylori Infection guideline).

Diagnostic Codes: 536 Dyspepsia; 535 or 537 Gastritis and Duodenitis

Prevention and Risk Factors

Obesity is a major risk factor.^1,2 Symptoms may be aggravated by spicy or fatty foods, caffeine, alcohol, citrus fruits, recumbency or bending forward.^3,4 GERD may also be provoked by certain medications such as calcium channel blockers and may be mimicked by other drugs such as bisphosphonates and non-steroidal anti-inflammatory drugs (NSAIDs).⁵ GERD is frequently worse during pregnancy (see Management of GERD in pregnancy).

Diagnosis/Investigation

GERD is usually diagnosed by history. Symptoms typically include retrosternal burning and may also include sour or bilious regurgitation, belching, hypersalivation, and epigastric or chest pain.⁶ Increasingly recognized are extraesophageal symptoms such as chronic cough, laryngeal irritation and wheezing, particularly when they occur at night.^7,4 Certain symptoms (‘alarm features’) require prompt endoscopy. These include dysphagia, weight loss, gastrointestinal blood loss (acute or chronic), persistent vomiting or failure to respond to an adequate trial of therapy.^6,8 Differential diagnoses to consider include cardiac and musculoskeletal disorders.

Management

Initial Management of GERD:

In the absence of alarm features, the initial management should consist of diet and lifestyle modifications, antacids, alginates or histamine₂ receptor antagonists (H₂RA) (see Appendix A.^6,9 Under these circumstances barium X-rays and endoscopy results are frequently normal and are generally not recommended.⁶ Antacids and alginates may be effective in patients with intermittent or sporadic symptoms.

Management of severe symptoms or poor response:

In the absence of improvement with the above management strategy, H₂RA or proton pump inhibitors (PPI) may be tried (see Appendix A). It may take 4-8 weeks to see a response. GERD is a chronic disease and patients may require prolonged or intermittent therapy.¹⁰ H₂RAs and PPIs are more effective in patients with chronic symptoms.

Management of refractory symptoms:

Absence of response to the above regimens justifies specialist consultation and/or further investigation. Endoscopy is the investigation of choice.

Management of GERD in pregnancy:

Traditional antacids and alginates are generally considered safe in pregnancy and lactation, and can be considered first-line in these settings. Studies on H₂RA and PPI in pregnancy do not demonstrate an increased risk of malformations; these are appropriate second line agents.^11,12 In lactation, cimetidine is recognized as safe whereas other H₂RA and PPI have not been adequately studied.¹³ For the latest information on drug safety in pregnancy and lactation, please refer to recognized database sources such as www.motherisk.org.

Rationale

GERD is a common chronic recurrent problem. Most individuals with GERD experience only occasional heartburn, which is usually responsive to simple measures. GERD and hiatus hernia are not synonymous and do not imply each other’s presence.

More severe reflux can cause esophageal mucosal injury (esophagitis) and its complications. Respiratory symptoms (chronic cough, hoarseness, bronchospasm, recurrent aspiration) may occur in the absence of typical heartburn. Patients with extraesophageal symptoms such as chronic cough may not respond well or quickly to standard antireflux therapy.⁴

Chronic longstanding GERD may be complicated by Barrett’s esophagus (intestinal metaplasia in the lower esophagus) in up to 10% of individuals.¹³ Barrett’s esophagus predisposes to adenocarcinoma, with an incidence of 0.5-1% per year.¹⁵ This risk for cancer is higher in caucasians, males, individuals aged > 50 years, smokers, and people with more than 10 years of symptoms occurring more than 3 times per week.⁴ Patients with the above risk factors may be offered endoscopy on one occasion to rule out Barrett’s esophagus; if not present, it will generally not develop later.

Endoscopy is not necessary or universally effective in making a diagnosis of GERD, but is considered the investigation of choice to identify esophagitis, assess its severity and rule out complications including strictures and Barrett’s esophagus. Barium studies are not adequate to assess the mucosa or diagnose reflux disease.⁴

Patients with complicated GERD (Barrett’s esophagus, ulceration, bleeding, peptic stricture) may require long-term PPI therapy.^10,16 The efficacy of prokinetic agents (domperidone and metaclopramide) has not been established.

Anti-reflux surgery could be considered in patients who respond well to PPI therapy, but who are intolerant or reluctant to take medications. Outcomes are highly dependent on individual factors.¹⁰

References

1. Hampel H, Abraham NS, El-Serag HB. Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications. Ann Intern Med 2005 Aug 2;143(3):199-211.
2. Jacobson BC, Somers SC, Fuchs CS, et al. Body-mass index and symptoms of gastroesophageal reflux in women. N Engl J Med 2006 Jun 1;354(22):2340-2348.
3. Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med 2006 May 8;166(9):965-971.
4. Richter JE. Gastrooesophageal reflux disease. Best Practice & Research Clinical Gastroenterology 2007;21(4):609-631.
5. Leong R, Chan F. Drug-induced side effects affecting the gastrointestinal tract. Expert Opin Drug Saf 2006;5(4):585.
6. Armstrong D, Marshall JK, Chiba N, et al. Canadian Consensus Conference on the management of gastroesophageal reflux disease in adults - update 2004. Can J Gastroenterol 2005 Jan;19(1):15-35.
7. Chang AB, Lasserson TJ, Kiljander TO, et al. Systematic review and meta-analysis of randomised controlled trials of gastro-oesophageal reflux interventions for chronic cough associated with gastro-oesophageal reflux. BMJ 2006 Jan 7;332(7532):11-17.
8. Jones R. Gastro-oesophageal reflux disease: a re-appraisal. Br J Gen Pract 2006 Oct;56(531):739-740.
9. Tran T, Lowry AM, El-Serag HB. Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease therapies. Aliment Pharmacol Ther 2007 Jan 15;25(2):143-153.
10. Fennerty MB. Review article: alternative approaches to the long-term management of GERD. Aliment Pharmacol Ther 2005 Dec;22 Suppl 3:39-44.
11. Magee L, Inocencion G, Kamboj L, et al. Safety of First Trimester Exposure to Histamine H2 Blockers. A Prospective Cohort Study. Digestive Diseases and Sciences 1996;41(6):1145.
12. Nikfar S, Mohammad D, Mula M, M., et al. Use of Proton Pump Inhibitors During Pregnancy and Rates of Major Malformations. A Meta-analysis. Digestive Diseases and Sciences 2002;47(7):1526.
13. Briggs GG, Freeman, RK, Yaffe, SJ. Drugs in Pregnancy and lactation. Lippincott Williams & Wilkins, 2005 PA USA.
14. Spechler S, Goyal R. The Columnar-Lined Esophagus, Intestinal Metaplasia, and Norman Barrett. Gastroenterology 1996;110:614.
15. Shaheen N, Ransohoff DF. Gastroesophageal reflux, barrett esophagus, and esophageal cancer: scientific review. JAMA 2002 Apr 17;287(15):1972-1981.
16. 16. Wang KK, Sampliner RE, Practice Parameters Committee of the American College of Gastroenterology. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol 2008 Mar;103(3):788-79.

Resources

www.motherisk.org

List of Abbreviations

Appendices

Appendix A – Prescription Medication Table for Gastroesophageal Reflux Disease (PDF 165K)

Revised Date: March 5, 2010

This guideline is based on scientific evidence current as of the effective date.

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.

Disclaimer

The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.

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