Gastroesophageal Reflux Disease (GERD) affects women and men of all ages. It is one of the most common gastrointestinal diseases worldwide (prevalence ~8-33%) and is the most prevalent acid-related disorder in Canada.

• GERD occurs when gastric contents reflux into the esophagus causing damage or worsening quality of life.
• Patients with GERD report poorer health-related quality of life than those with hypertension, mild diabetes, arthritis or mild heart disease.
• Symptoms are often worse after meals, when bending over, or when laying down.
• 70% of patients with GERD symptoms have normal endoscopy.
• Endoscopy is not required to make a diagnosis of GERD.
• Potential complications of chronic GERD include esophageal stricture, ulcers, Barrett’s esophagus, and esophageal cancer.

Diagnosed clinically:

• Heartburn ± regurgitation:
  • Burning pain in the chest that usually occurs after eating and may occur at night.
  • Pain that worsens when lying down or bending over.
  • Bitter or acidic taste in the mouth.
• Risk factors: family history of GERD, older age, hiatus hernia, obesity.
• Start PPI trial (once daily for 8 weeks) in patients with suspected GERD who have symptoms more than twice a week. See table below.

Red Flags For Further Investigations:

• Dysphagia, odynophagia, GI bleeding/anemia, recurrent vomiting, involuntary weight loss, chest pain, choking.
• Relapsing, persistent, or atypical symptoms.
• Persistent symptoms despite an adequate PPI trial (4-8 weeks).
• Investigations:
  • Consider/rule out cardiac causes.
  • Refer for endoscopy and if normal endoscopy, ambulatory pH monitoring.
• Screening for H. Pylori not recommended.

Mild or Infrequent GERD (symptoms less than 3 times per week)

• • Over-the-counter medications:
    • Alginates, antacids, and low dose H2RAs + lifestyle modification.
  • Lifestyle modification and education include:
    • Weight loss in patients who are overweight.
    • Avoid large meals 3h before sleep and elevate the head of the bed.
    • Identify and avoid triggers (ie. Smoking, mint, alcohol, carbonated beverages, spicy/acidic foods, chocolate, and caffeine).

Severe or Frequent GERD

• • • The above is not effective for the management of severe GERD.
    • PPIs are superior to H2Ras for the management of GERD.
    • 8-week trial of standard once-daily PPI therapy.

• If symptoms resolve, can attempt to discontinue or titrate to the lowest effective dose. Consider an on-demand acid suppression approach for some patients.
• If the inadequate response can try twice-daily PPI therapy for another 8 weeks or change to a different once-daily PPI.
• Not recommended to use prokinetic or promotility agents for initial treatment of GERD.

Created By Ella Barrett-Chan, MSI UBC

1. Canadian Consensus Conference on the management of gastroesophageal reflux disease in adults–update 2004. 
   Armstrong, D., Marshall, J. K., Chiba, N., Enns, R., Fallone, C. A., Fass, R., … & Moayyedi, P. (2005).
   – Canadian journal of gastroenterology, 19.

   
   

2.  Guidelines for the diagnosis and management of gastroesophageal reflux disease.
   Katz, P. O., Gerson, L. B., & Vela, M. F. (2013).
   – American Journal of Gastroenterology, 108(3), 308-328.

   
   

3.  Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. 
   ISBN: 978-1-4731-0717-5
   – National Institute for Health and Care Excellence (Great Britain). (2014).

   
   

4. Advances in the diagnosis of GERD.
   Săraru, E. R., Enciu, V., Peagu, R., & Fierbinţeanu-Braticevici, C. (2020).
   – Romanian Journal of Internal Medicine, 1(ahead-of-print).