Cruz, Joshua R Webinar 3

Joshua R.
Cruz Output-based Webinar

MD17-0188 SY 21-22
Webinar 3 | Revisiting GERD Management

by Dr. Therese C. Macatula, Gastroenterologist (Word count: 769)
The lecturer started with her objectives such as the following: (1) To refresh
information on GERD epidemiology, pathophysiology and its manifestations, (2) To
present evidence and guideline-based strategies in the diagnosis and pharmacologic
treatment of GERD, and lastly, (3) to emphasize on nonpharmacologic aspect of GERD
management.
In East Asia, the prevalence of the disease is around 2.5% to 7.8% while 6.3% of
Filipinos are burdened with this. The Montreal definition of GERD states that the
disease is a spectrum with most mild being called a Non-Erosive Reflux Disease to
Erosive Esophagitis and to its most severe form called Stricture Barrett’s Esophagus.
The most common manifestation of GERD in the Asia-Pacific region is Non-erosive
reflux disease (NERD). Diagnosis of GERD is independent of diagnostic employed
which implies that the disease is diagnosed through its typical symptoms alone. In
addition, investigations in demonstrating the reflux of stomach content can also be done
through pH or impedance monitoring to prove the reflux of an acid, bile, or air; lastly,
endoscopy and histology can also be used in documenting the injurious effects of the
reflux.
Several factors has been identified in contributing to GERD such as the following:
transient lower esophageal sphincter (LES) relaxation, acid pocket development due to
poor mixing of acid with chyme in the proximal stomach, increased gastroesophageal
junction distensibility, delayed gastric emptying, sliding hiatal hernia, low LES pressure,
and obesity; with being obesity has the strongest relation to the increase in GERD
prevalence.
GERD can be handled in the primary care level on the basis of troublesome
symptoms alone even without additional diagnostic testing. At that level, the approach is
definitely patient-centered and cost-effective as it does not use unnecessary resources.
According to the Philippine Society of Gastroenterology 2014 GERD Guidelines, a
clinical diagnosis of GERD can be made if the typical symptoms of acid regurgitation
and/or heartburn are present. Further diagnostics such as upper endoscopy is not
necessary for diagnosis, however, empiric acid suppressive therapy can already be
started even if the patient does not present with alarming features. In practice, a 1-2
week course of high dose PPI (proton pump inhibitors) treatment is being done.
However, a formal course of 8-week PPI therapy is the adequate regimen which is
required in order to assess the treatment response in GERD patients.
If any of the alarm features are present in a patient, an endoscopy should be
recommended to them. Examples of alarm features are as follows: GI bleeding,
unintentional weight loss, epigastric mass, anemia, frequent vomiting, persistence
symptoms despite adequate medications, dysphagia, odynophagia, early satiety, etc.
Endoscopy for GERD should be considered in patients greater than 45-50 years old.
However, preference for EGD among Asiang countries is driven by the risk of
malignancy at an early age.
PPI-start strategy is highly preferred due to its sustained effect of heartburn relief
in comparison to the H2 receptor blocker, which are less effective. In addition, PPIs are
effective in healing severe forms of esophagitis and also in prevention of relapse and
other complications of GERD. According to studies, Pantoprazole 40mg has shown the
greatest effectiveness amongst the other PPIs (72% symptom relief at 4 weeks, 89%
esophageal healing at 8 weeks, and 78% relapse prevention). Some other medications
also act as an adjunct to PPI. These medications are prokinetics (dopamine antagonists
such as metoclopramide and domperidone) which are designed to correct defects in the
GI neuromuscular activity that causes the pathologic reflux.
With regards to the non-pharmacologic approach to GERD, lifestyle modification
is highly important especially on weight loss. According to studies, weight loss helps
reduce and eliminate GERD symptoms. Another thing that can help GERD is sleeping
position. It is recommended that the head of the bed of the patient is elevated and the
patient is on his left decubitus position while sleeping. Moreover, it is recommended that
the patient should avoid meals 2-3 hours before bedtime. Interestingly, no food has
been conclusively linked with increased GERD symptoms.
Lessons/ Reflections
GERD is a common disease that is to be managed in the clinics which causes
significant burdens to the patients. Empiric treatment approach via PPI is still the way to
manage them. I learned from this lecture that there are other PPIs other than
Omeprazole such as Pantoprazole which is highly recommended during the talk.
Endoscopy may give a more definitive diagnosis, however, it is not routinely
recommended as an initial management because of its cost and limited availability. Last
cool learning that I got is that complementary treatment with lifestyle change impacts
success of GERD management particularly regarding the diet. Trigger factor of food
varies from patient to another.
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Joshua R.

Cruz Output-based Webinar

Webinar 3 | Revisiting GERD Management

Proof of Attendance/ Slides

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