Understanding GERD

GERD Overview

• GERD (Gastroesophageal Reflux Disease) is characterized by the recurrent backflow of gastric contents into the esophagus, leading to symptoms and potential tissue damage.
• Typical GERD symptoms include acid regurgitation and heartburn.
• Upper endoscopy is not essential for initial diagnosis; empiric acid suppressive therapy can commence in patients without alarm features.

Symptoms and Management

• Heartburn is a burning sensation located behind the breastbone.
• Regurgitation involves the experience of gastric contents flowing into the mouth or hypopharynx.
• Higher incidence of heartburn and hoarseness observed in men with erosive esophagitis.

Diagnosis Criteria

• NERD (Non-Erosive Reflux Disease) is diagnosed when there are no esophageal mucosal lesions noted during upper endoscopy despite typical symptoms.
• Upper endoscopy is necessary for confirming NERD.
• Common GERD questionnaires in the Philippines include the Frequency Scale for the Severity of GERD (FSSG) and the Gastoesophageal Reflux Disease Questionnaire (GerdQ).

Treatment Protocols

• Standard dose PPIs (Proton Pump Inhibitors) are foundational treatment for erosive esophagitis, recommended once daily for eight weeks prior to breakfast.
• Obesity significantly raises the risks of GERD symptoms, erosive esophagitis, and esophageal adenocarcinoma.
• Head elevation during sleep and using left lateral decubitus position can improve esophageal pH levels.

Therapy Adjustments

• If there is only partial symptom relief after eight weeks of standard PPI treatment, the same PPI should be given twice daily or switched to a different PPI.
• Upon symptom relapse after initial GERD treatment, NERD patients may use on-demand PPI therapy, while continuous PPI therapy is suggested for those with moderate to severe erosive esophagitis.

Additional Treatments

• Alginate-antacid combinations are recommended for relief of episodic and postprandial reflux symptoms.
• Refractory GERD is characterized by inadequate symptom improvement despite diligent PPI adherence for at least eight weeks.
• Ambulatory reflux studies are suggested for patients with refractory GERD displaying normal upper endoscopy results.

Monitoring and Alternative Medications

• Ambulatory reflux monitoring is the sole test for assessing abnormal esophageal acid exposure and symptom association.
• H2-receptor blockers, pain modulators, and TLESR (Transient Lower Esophageal Sphincter Relaxations) reducers may serve as adjunctive treatments for refractory GERD.
• Baclofen is effective in reducing TLESRs, decreasing upright reflux and regurgitation, and improving overall symptom scores.
• Citalopram, a selective serotonin reuptake inhibitor, benefits patients with a hypersensitive esophagus that are unresponsive to PPI therapy.

Extraesophageal Manifestations

• Chronic cough, laryngitis, and asthma may indicate extraesophageal manifestations of GERD.
• For patients with extraesophageal GERD without alarm features, standard-dose PPI treatment (twice daily) for at least 12 weeks is recommended.

Barrett’s Esophagus (BE)

• Barrett's esophagus is the replacement of squamous epithelium in the distal esophagus with abnormal columnar epithelium above the gastroesophageal junction, associated with specialized intestinal metaplasia.
• Barrett's esophagus is a risk factor for distal esophageal adenocarcinoma.
• The Prague Criteria is used during endoscopy to assess the extent of Barrett’s esophagus across different populations.

Long-term considerations

• PPI treatment can regress Barrett’s esophagus and lower the risk of high-grade dysplasia and adenocarcinoma.
• Chronic GERD may contribute to the development of Barrett's metaplastic epithelium, progressing to dysplasia and adenocarcinoma.
• Long-term PPI use can lead to complications like vitamin B12 deficiency, iron deficiency, and increased risk of infections and fractures.

Pregnancy Management

• Short-term PPI treatment is limited to the last two trimesters for pregnant women with GERD.
• H2RAs and antacids (excluding sodium bicarbonate) are well-studied for safety and efficacy in pregnancy.

Diagnostic Approaches

• Routine screening and treatment of Helicobacter pylori infection in GERD management is not standard.
• Upper endoscopy is unnecessary for diagnosing GERD.
• Endoscopy is recommended when alarm features are present or in cases of new onset alarm symptoms, post-treatment complications, or after inadequate symptom response to therapy.

Surgical Options

• Surgery, particularly laparoscopic fundoplication, may be considered for patients whose symptoms improve with PPI therapy but who are unsuitable for long-term medical management.
• Pre-surgical evaluation with esophageal manometry and ambulatory reflux studies is essential to rule out other disorders.