2005 Update

Guideline for Administered by the Alberta Medical Association

Treatment of Gastroesophageal
Reflux Disease (GERD) in Adults
This guideline has been adapted from the Canadian
Consensus Conference on the Management of Patients Table 1
with Gastroesophageal Reflux Disease.1
Alarm Features for GERD
• Dysphagia (solid food, progressive)
GOALS • Odynophagia
• Bleeding/anemia
To position health care professionals in Alberta to
• Weight loss
optimize the management of Gastroesophageal
Reflux Disease (GERD) in Adults.
Other Indications for Further Investigation
• Non-cardiac angina-like chest pain
DEFINITION • Respiratory symptoms secondary
to reflux
GERD is a symptom complex that is often • Consider if failure to respond to 8 weeks
characterized by burning retrosternal pain or of medical therapy (some may take 16
discomfort with or without regurgitation. when weeks to respond)1
the symptoms are sufficient to disturb quality of
life.1
Management of Uncomplicated GERD
(see Algorithm)
EXCLUSIONS
♦ Lifestyle modification has limited
The recommendations contained in this guideline
do not apply to: effectiveness for GERD1
• Pregnant or lactating women ♦ Emphasize strategies that have added health
• Patients under the age of 18 years benefits (Table 2)

RECOMMENDATIONS Table 2
Lifestyle Modification
Investigation • Weight control
• Reduction of alcohol, tobacco and
♦ Diagnosis of GERD can usually be caffeine intake
established on the basis of a careful history • Avoid lying down within 2 hours of
and physical examination. Further eating
investigation is generally not required1 • Elevation of the head of the bed
• Avoidance of foods that trigger
♦ Patients with GERD and alarm features symptoms:
(Table 1) require prompt investigation: - spices
endoscopy is preferred.1 - peppermint
- chocolate
♦ GERD is not caused by H. pylori infection - citrus juices
and eradication of H. pylori is not known to
effect the disease or its management.1

The above recommendations are systematically developed statements to assist practitioner and
patient decisions about appropriate health care for specific clinical circumstances. They should be
used as an adjunct to sound clinical decision making.
RECOMMENDATIONS cont. a month, and that 7% experience uncomplicated
GERD and symptoms of heartburn as often as
once a day. It has been estimated that
♦ Over-the-counter antacid or H2RA’s can be approximately 2% of the adult population suffers
recommended if they have not already been from complicated GERD, associated with
tried. These treatments are useful for mild or macroscopic or histologic damage to the
infrequent symptoms.1 esophagus. The incidence of GERD increases after
the age of 40, and it is not uncommon for patients
♦ If symptoms are relieved by lifestyle experiencing symptoms to wait years before
modification and/or over-the-counter seeking medical treatment.2,3
medication; continue as necessary
GERD is believed to be caused by a combination
♦ If patient fails to respond to lifestyle of conditions that increase the presence of gastric
modification and/or over-the-counter medication content in the esophagus. These conditions include
add antisecretory therapy as a therapeutic trial: transient lower esophageal sphincter relaxation,
decreased lower esophageal sphincter tone,
1. Proton pump inhibitor (PPI) once daily impaired esophageal clearance, delayed gastric
for 4- 8 weeks emptying, and decreased salivation.

♦ If symptoms are not resolved by treatment or if Lifestyle factors can also cause increased risk
symptoms recur consider: of reflux. Smoking, large meals, fatty foods,
caffeine, pregnancy, obesity, body position, drugs,
1. Extending therapy to 16 weeks if the and hormones may all exacerbate GERD. Hiatus
diagnosis seems accurate1 hernia frequently accompanies GERD and may
or contribute to prolonged gastric content exposure
2. Consider double dose PPI for 4 weeks time following reflux. Patients with GERD do not
or necessarily have a hiatus hernia and, conversely,
3. If previous treatment did not use PPI then, those with hiatus hernia do not invariably have
PPI is recommended for 4-8 weeks GERD. The excessive reflux experienced by
patients with GERD overwhelms their intrinsic
♦ Follow-up at 2 to 4 weeks to review the mucosal defense mechanisms, resulting in
diagnosis and reassess management. symptoms and sometimes damage.

♦ Failure to respond to 16 weeks of PPI therapy The most common symptom of GERD is
warrants a careful reassessment of diagnosis heartburn. Besides the discomfort of heartburn,
and usually further investigaiton preferably by reflux may result in regurgitation. This is a sense of
endoscopy. sour fluid rising effortlessly into the throat or
mouth. There can be other symptoms such as
♦ Patients whose symptoms continue for many odynophagia (pain on swallowing) and dysphagia
years requiring ongoing use of acid suppression (difficult swallowing). The reflux may also cause
medication should have an endoscopy by 10 pulmonary symptoms such as coughing, wheezing,
years into their condition to search for Barrett’s asthma, or aspiration pneumonia. Oral symptoms
esophagitis.1 may also occur such as tooth enamel decay,
gingivitis, halitosis, and water-brash; throat
BACKGROUND symptoms such as a soreness, laryngitis,
hoarseness, and a globus sensation.
Introduction Investigation of GERD
Evidence indicates that up to 36% of otherwise The patient who presents with typical
healthy persons suffer from heartburn at least once uncomplicated GERD symptoms, should be

2
diagnosed by history and generally does not sphincter. Ambulatory pH monitoring is most
1
require other investigations. If a therapeutictrial useful in patients with atypical reflux symptoms
results in resolution of symptoms, therapy can such as chest pain, asthma, cough or
4
be prescribed as necessary. If symptoms are hoarseness. In these patients it may be the only
not resolved, or there are alarm symptoms diagnostic test that can provide objective
1
investigation and/or referral is recommended. evidence of the problem.

Endoscopy is highly sensitive in identifying Ambulatory esophageal pH monitoring is also

cancer, strictures, ulcers and erosions. useful in evaluating patients with an incomplete
Endoscopy will also demonstrate the presence response to medical therapy to document that
of Barrett’s epithelium (where normal their GERD-like symptoms are indeed reflux
epithelium is replaced by abnormal metaplastic related.
columnar cells).
Therapy for GERD
Barrett’s epithelial changes are a consequence
of prolonged and severe acid reflux in about 2- Lifestyle modifications such as elevating the
4% of cases of persistent reflux. As 0.5% of head of the bed can be helpful.1 Patients should
patients with Barrett’s develop adenocarcinoma also be advised to avoid bedtime snacks, eat
of the esophagus each year, patients with low fat foods, quit smoking, and reduce alcohol
consumption. These strategies may have other
Barrett’s epithelium require biopsy and ongoing
1,5 health benefits in addition to any improvement
surveillance.
sin GERD. Patients whose symptoms are not
completely controlled by lifestyle modification
For patients with persistent and recurrent may be advised to use over-the-counter
symptoms, the physician should engage in medications including antacids or antisecretory
thoughtful discussion regarding the risks and agents. Response to medication should be
benefits of further investigation. reassessed periodically.

Barium studies of the esophagus are widely If symptoms occur more than 3 times in a week
available and well tolerated (with little and are not controlled by over-the-counter
morbidity). However, barium studies have therapy and lifestyle modification, therapy may
significant limitations in the evaluation of be initiated with a regular dose of a PPI once a
GERD. While a barium examination of the day for 4 weeks.1
esophagus will detect strictures it is very
insensitive in its ability to detect reflux, mucosal Numerous trials have shown that short term
inflammation, and it cannot detect the presence treatment with acid suppression agents can
of Barrett’s epithelial changes (which requires effectively relieve the symptoms of
obtaining a biopsy specimen and histologic uncomplicated GERD.
confirmation).
Patients whose symptoms are resolved after
Esophageal manometry can be used to evaluate a course of therapy need no further
peristalsis and to assess the function of the investigation or therapy. Therapy may be
lower esophageal sphincter. Therefore, it may repeated if symptoms recur. For those few
be useful in patients who have atypical chest patients who fail therapy with a PPI for 8
6
pain or are to undergo anti-reflux surgery. weeks, a trial of twice-daily PPI for 4 weeks
may be tried. 1 Subsequent treatment failures
Ambulatory esophageal pH monitoring is may require further investigation and referral.
reserved for the investigation of complicated
GERD and provides a quantitative determination
of the amount of time the esophageal pH is low,
indicating persistent acid presence above the
3
REFERENCES Toward Optimized Practice (TOP)
Program
1. Armstrong D, Marshall J, Chiba N, et al.
Canadian Consensus Conference on the
Management of Gastroesophageal Reflux Arising out of the 2003 Master Agreement, TOP
Disease in Adults: Update 2004. Canadian succeeds the former Alberta Clinical Practice
Journal of Gastroenterology, Jan 2005; 19(1). Guidelines program, and maintains and distributes
2. Nebel OT, Fornes MF, Castell DO. Symptomatic Alberta CPGs. TOP is a health quality improvement
gastroesophageal reflux: Incidence and initiative that fits within the broader health system
precipitating factors. American Journal of focus on quality and complements other strategies such
Digestive Disease. 1976;21(11):953-956. as Primary Care Initiative and the Physician Office
3 Spechler SJ. Epidemiology and natural history System Program.
of gastro-oesophageal reflux disease. Digestion.
1992;51(Suppl 1):24-29. The TOP program supports physician practices, and the
4. DaCosta L. Value of a therapeutic trial to teams they work with, by fostering the use of evidence-
diagnose gastroesophageal reflux disease: step based best practices and quality initiatives in medical
up versus step down therapy. Canadian Journal care in Alberta. The program offers a variety of tools
of Gastroenterology, Sept 1997;11(Suppl B): and out-reach services to help physicians and their
78B-81B colleagues meet the challenge of keeping practices
5. MacPherson A, Bjarnason I. Colonocytes in current in an environment of continually emerging
Barrett’s metaplasia? Lancet, 1994;344: evidence.
903-904
6. Fennerty B, Castell D, Fendrick M, et al. The To Provide Feedback
diagnosis and treatment of gastroesphageal
The Alberta CPG Working Group for Dyspepsia is a
reflux disease in a managed care environment.
Archives of Internal Medicine, March 1996; multidisciplinary team composed of family physicians,
156:477-484 general practitioners, gastroenterologists, pediatric
gastroenterologists, a pathologist, radiologist, radiation
oncologist, an infectious disease specialist, and
representatives from the public and the Alberta
Pharmaceutical Association. The team encourages
your feedback. If you have difficulty applying this
guideline, if you find the recommendations problematic,
or if you need more information on this guideline, please
contact:

Toward Optimized Practice Program

12230 - 106 Avenue NW
EDMONTON, AB T5N 3Z1
T 780. 482.0319
TF 1-866.505.3302
F 780.482.5445
E-mail: [email protected]

GERD - July 2000

Reviewed November 2001
Reviewed 2005

4
 Algorithm:
Management of Uncomplicated GERD

Recommend
lifestyle modification
and/or
over-the-counter medication
(if not yet tried and failed)

Assess response
in one month

Response No response

↓
As a therapeutic trial:
• PPI once daily for 4 weeks
Response
← or
• Full dose H2 receptor antagonist
BID for 4 weeks

No response

↓ ↓
• Discontinue medication Re-treat:
• Continue over-the-counter ♦ If previous H2RA, PPI is recommended for
medications and lifestyle 4 weeks
modification • Follow-up at 4 weeks

♦ If previous PPI given consider double dose

PPI for 4 weeks
• Follow-up at 4 weeks
If failure
• Reassess for alarm symptoms
• Reassess working diagnosis
• Complicated GERD
• Further investigation and/or referral
suggested for recurrent or persistent
symptoms