Gastroesophageal Reflux Disease: Adults

Summary of the Alberta Clinical Practice Guideline, July 2000 2005 Update

Exclusion • This guideline does not apply to pregnant or lactating women or patients <18 years of age

Etiology • Combination of conditions that increase the presence of gastric content in the esophagus, including:
- transient lower sphincter relaxation
- decreased lower esophageal sphincter tone
- impaired esophageal clearance
- delayed gastric emptying
- decreased salivation

Diagnosis • Diagnosis based on history (burning retrosternal pain or discomfort with or without regurgitation) and
physical examination
- typical uncomplicated GERD generally does not require further investigation
• GERD is not caused by H. pylori infection

Alarm • Alarm features:

Features - dysphagia (solid food, progressive)
- odynophagia
- bleeding/anemia
- weight loss
• Alarm features or complicated GERD (failure to respond to 4 to 8 weeks of therapy) require further
investigation and/or referral
- if further investigation warranted - endoscopy is preferred; however, barium examination is more
readily available

Management • Lifestyle modification (weight control, reduction of alcohol, tobacco and caffeine intake,elevation of
head of bed, eating smaller meals and avoidance of lying down within 2 hours of eating, avoidance of
spicy foods
• Over the counter antacid or antisecretory medications
- Assess response at 1 month
• If patient fails to respond to above, add antisecretory or promotility therapy as therapeutic trial (below)

Proton pump inhibitor (PPI)

Once daily for 4 - 8 weeks
or
H2 receptor antagonist (H2RA)
Full dose - BID for 4 weeks

Treatment Failure or Recurrence of Symptoms

If previous PPI given extend the therapy to 16 weeks
or
If previous PPI given consider double dose PPI for 4 weeks
or
If previous treatment did not use PPI then, PPI is recommended for 4 weeks

Follow-up • Follow- up at 2 to 4 weeks

For complete guideline refer to the TOP Web Site:

www.topalbertadoctors.org Administered
Guideline reviewed November 2001/ Revised January 2005 by the Alberta Medical Association
 Diagnosis and Management of GERD in Adults

• Patients with GERD and alarm features1 require prompt investigation

• GERD is NOT caused by H. pylori infection
• Diagnosis of GERD can usually be established on the basis of history and physical examination
GERD-like symptoms (heartburn, regurgitation)?

NO YES
6 6
Manage as appropriate Recommend lifestyle modification
and/or
over-the-counter medication (if not yet tried and failed)

6
Assess response in one month
Has there been a response to treatment?

Response No Response

6 6
• Discontinue medication As a therapeutic trial:
• Continue over-the-counter Response • PPI once daily for 4-8 weeks
6

medications and lifestyle or

modification • Full dose H2 receptor antagonist BID for 4 weeks

No Response

6
Re-treat:
• If previous H2RA, PPI is recommended for 4 weeks
- Follow up at 4 weeks
• If previous PPI given extend therapy to 16 weeks
or
If previous PPI given consider double dose PPI for 4 weeks
- Follow-up at 2-4 weeks
If failure
• Reassess for alarm symptoms
• Reassess working diagnosis
Note: • Complicated GERD
1. Alarm features:
• New onset of symptoms over age 50
• Further investigation2 and/or referral suggested for
• Dysphagia recurrent or persistent symptoms
• Odynophagia
• Bleeding/anemia
• Weight loss
Other Indications for further investigation:
• Non-cardiac angina-like chest pain
• Respiratory symptoms secondary to reflux
• Failure to respond to 4 to 8 weeks of medical therapy