Management of Gastroesophageal Reflux Disease - American Family Physician

Diagnosis A careful history is essential to establish the diagnosis of GERD. If a patient has classic symptoms of heartburn and acid regurgitation, the diagnosis can be made with high specificity, yet the sensitivity remains low. GERD can be missed in patients with heartburn, and some patients with Barrett’s esophagus or adenocarcinoma of the esophagus do not complain of heartburn. Only 2 to 3 percent of acid reflux events reach the G astroesophageal reflux disease (GERD) is a common chronic, relapsing condition that is associated with a risk of significant morbidity and the possibility of mortality from complications. An estimated 44 percent of the U.S. adult population (61 million Americans) have heartburn, the hallmark of acid regurgitation, at least once a month. Approximately 14 percent of Americans have gastroesophageal symptoms weekly, and 7 percent have symptoms daily. Many patients self-diagnose and selftreat, and do not seek medical attention for their symptoms, while others have more severe disease, including erosive esophagitis. Patients who have GERD The primary treatment goals in patients with gastroesophageal reflux disease are relief of symptoms, prevention of symptom relapse, healing of erosive esophagitis, and prevention of complications of esophagitis. In patients with reflux esophagitis, treatment is directed at acid suppression through the use of lifestyle modifications (e.g., elevating the head of the bed, modifying the size and composition of meals) and pharmacologic agents (a histamine H2-receptor antagonist [H2RA] taken on demand or a proton pump inhibitor [PPI] taken 30 to 60 minutes before the first meal of the day). The preferred empiric approach is step-up therapy (treat initially with an H2RA for eight weeks; if symptoms do not improve, change to a PPI) or step-down therapy (treat initially with a PPI; then titrate to the lowest effective medication type and dosage). In patients with erosive esophagitis identified on endoscopy, a PPI is the initial treatment of choice. Diagnostic testing should be reserved for patients who exhibit warning signs (i.e., weight loss, dysphagia, gastrointestinal bleeding) and patients who are at risk for complications of esophagitis (i.e., esophageal stricture formation, Barrett’s esophagus, adenocarcinoma). Antireflux surgery, including open and laparoscopic versions of Nissen fundoplication, is an alternative treatment in patients who have chronic reflux with recalcitrant symptoms. Newer endoscopic modalities, including the Stretta and endocinch procedures, are less invasive and have fewer complications than antireflux surgery, but response rates are lower. (Am Fam Physician 2003;68:1311-8,1321-2. Copyright© 2003 American Academy of Family Physicians.) Management of Gastroesophageal Reflux Disease