What is a reasonable approach to the management of GERD?

There are several ways to approach the evaluation and management of GERD. The approach depends primarily on the frequency and severity of symptoms, the adequacy of the response to treatment, and the presence of complications.

For infrequent heartburn, the most common symptom of GERD, life-style changes and an occasional antacid may be all that is necessary. If heartburn is frequent, daily non-prescription-strength (over-the-counter) H2 antagonists may be necessary. A foam barrier also can be used with the antacid or H2 antagonist.

If life-style changes and antacids, non-prescription H2 antagonists, and a foam barrier do not adequately relieve heartburn, it is time to see a physician for further evaluation and to consider prescription-strength drugs. The evaluation by the physician should include an assessment for possible complications of GERD based on the presence of such symptoms or findings as:

cough,


asthma,


hoarseness,


sore throat,


difficulty swallowing,


unexplained lung infections, or


anemia (due to bleeding from esophageal inflammation or ulceration).
Clues to the presence of diseases that may mimic GERD, such as gastric or duodenal ulcers and esophageal motility disorders, should be sought.

If there are no symptoms or signs of complications and no suspicion of other diseases, a therapeutic trial of acid suppression with H2 antagonists often is used. If H2 antagonists are not adequately effective, a second trial, with the more potent PPIs, can be given. Sometimes, a trial of treatment begins with a PPI and skips the H2 antagonist. If treatment relieves the symptoms completely, no further evaluation may be necessary and the effective drug, the H2 antagonist or PPI, is continued. As discussed previously, however, there are potential problems with this commonly used approach, and some physicians would recommend a further evaluation for almost all patients they see.

If at the time of evaluation, there are symptoms or signs that suggest complicated GERD or a disease other than GERD or if the relief of symptoms with H2 antagonists or PPIs is not satisfactory, a further evaluation by endoscopy (EGD) definitely should be done.

There are several possible results of endoscopy and each requires a different approach to treatment. If the esophagus is normal and no other diseases are found, the goal of treatment simply is to relieve symptoms. Therefore, prescription strength H2 antagonists or PPIs are appropriate. If damage to the esophagus (esophagitis or ulceration) is found, the goal of treatment is healing the damage. In this case, PPIs are preferred over H2 antagonists because they are more effective for healing.

If complications of GERD, such as stricture or Barrett's esophagus are found, treatment with PPIs also is more appropriate. However, the adequacy of the PPI treatment probably should be evaluated with a 24-hour pH study during treatment with the PPI. (With PPIs, although the amount of acid reflux may be reduced enough to control symptoms, it may still be abnormally high. Therefore, judging the adequacy of suppression of acid reflux by only the response of symptoms to treatment is not satisfactory.) Strictures may also need to be treated by endoscopic dilatation (widening) of the esophageal narrowing. With Barrett's esophagus, periodic endoscopic examination should be done to identify pre-malignant changes in the esophagus.

If symptoms of GERD do not respond to maximum doses of PPI, there are two options for management. The first is to perform 24-hour pH testing to determine whether the PPI is ineffective or if a disease other than GERD is likely to be present. If the PPI is ineffective, a higher dose of PPI may be tried. The second option is to go ahead without 24 hour pH testing and to increase the dose of PPI. Another alternative is to add another drug to the PPI that works in a way that is different from the PPI, for example, a pro-motility drug or a foam barrier. If necessary, all three types of drugs can be used. If there is not a satisfactory response to this maximal treatment, 24 hour pH testing should be done.

Who should consider surgery or, perhaps, an endoscopic treatment trial for GERD? (As mentioned previously, the effectiveness of the recently developed endoscopic treatments remains to be determined.) Patients should consider surgery if they have regurgitation that cannot be controlled with drugs. This recommendation is particularly important if the regurgitation results in infections in the lungs or occurs at night when aspiration into the lungs is more likely. Patients also should consider surgery if they require large doses of PPI or multiple drugs to control their reflux. Still, it is debated whether or not a desire to be free of the need to take life-long drugs to prevent symptoms of GERD is by itself a satisfactory reason for having surgery.

Some physicians—primarily surgeons—recommend that all patients with Barrett's esophagus should have surgery. This recommendation is based on the belief that surgery is more effective than treatment with drugs in preventing both the reflux and the cancerous changes in the esophagus. There are no studies, however, demonstrating the superiority of surgery over drugs for the treatment of GERD and its complications. Moreover, the effectiveness of drug treatment can be monitored with 24 hour pH testing.