Thursday, September 24, 2015
GERD - When to Treat and When to Scope
By: Brent Barranco M.D. with Gastroenterology Associates, N.A. P.C.
Gastroesophageal Reflux Disease (GERD) is a very common problem facing both primary care physicians and gastroenterologist a like. It is estimated that 20 percent of American adults are affected by GERD, which means that we will likely be faced with diagnosing and treating this on a daily basis. And while the symptoms of GERD can be bothersome, it is estimated that 10-15 percent of these patients will go on to develop more serious complications from reflux.
I think it is helpful to define exactly what GERD is. When you talk about gastroesophageal reflux (GER - not disease), it is defined as the passage of gastric contents into the esophagus and is considered a normal physiologic process. Most episodes are brief and do not cause any clinical symptoms or even injury. However, when patients do have symptoms and they present to their primary care physician, they are labeled as having GERD. Gastroesophageal reflux (GER) does not becomes a disease (GERD) until it either causes damage to the esophagus as seen on EGD or it causes symptoms that significantly reduce the patients quality of life. So please keep in mind that every patient who presents to your office with heartburn does not necessarily have GERD.
GERD can be classified into 2 varieties based on the appearance of the esophageal mucosa at the time of upper endoscopy:
Erosive esophagitis that is characterized by endoscopically visible breaks in the esophageal mucosa.
Nonerosive reflux disease which is characterized by the presence of troublesome symptoms of GERD without breaks in the esophageal mucosa.
The most common symptoms that patients will present to the office with will be heartburn, regurgitation, or dysphagia. While these are the 3 most common symptoms, there are several other less common symptoms that health care providers need to be aware, as they may be a manifestation of more serious acid reflux disease. These include dysphagia, odynophagia (pain with swallowing), globus sensation (there is a lump in the throat), chest pain, chronic cough, asthma, nausea, and dyspepsia. Some of these symptoms are more serious than others, and it is the more serious symptoms that we call alarm symptoms of reflux disease. The alarm symptoms of reflux disease warrant a more aggressive means of work up and treatment. They include: dysphagia, odynophagia, non-cardiac chest pain, gastrointestinal bleeding, anemia, weight loss, and recurrent vomiting.
So the most common challenge facing the primary care physician is whom do you treat with medicine only and who do you send for endoscopic evaluation. Below is a guide to how to approach and manage these people who present to you with what you may think is gastroesophageal reflux.
In patients with mild and intermittent symptoms (fewer than two episodes per week) begin these patients on a combination of lifestyle and dietary modifications for reflux disease and either an H2 Blocker (i.e. Pepcid, Zantac, ect..) or an OTC PPI. This therapy should be continued for 8 weeks. If after 2 weeks of therapy the symptoms are still present, then change the patient over to a prescription strength PPI either once or twice a day, whichever is required to achieve good symptom control. If they are asymptomatic at 8 weeks, then give them a trial off of the medication. If the symptoms recur within 3 months, then refer them for endoscopic evaluation.
In patients with more frequent symptoms (two or more episodes per week) and/or severe symptoms that impair quality of life, a more aggressive approach needs to be taken. In these patients start them out on lifestyle and dietary modifications as well as once daily prescription strength PPI therapy. If after 2 weeks of therapy their symptoms still persist, then increase the dose of PPI to twice a day. This therapy should be continued for 8 weeks. If they are asymptomatic at 8 weeks, then give them a trial off of the medication. If symptoms recur within 3 months, then refer them for endoscopic evaluation.
If patients with typical GERD continue to have symptoms after 8 weeks of therapy, then they need to be referred for endoscopic evaluation. In patients who present with heartburn and alarm symptoms of reflux disease (see above), begin lifestyle and dietary modifications for reflux disease and start them on acid suppression therapy with a proton pump inhibitor once daily. These patients need to be referred for endoscopic evaluation immediately.
In Men over age 50 with chronic GERD symptoms (symptoms for more than five years) and additional risk factors for Barrett's esophagus (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, and tobacco use), refer these patients for endoscopic evaluation.
In patients with severe erosive esophagitis (Los Angeles classification Grade C and D) on initial endoscopy, a gastroenterologist should be managing their care and they should undergo a follow-up endoscopy after a two-month course of proton pump inhibitor (PPI) therapy to assess healing and rule out Barrett's esophagus.
Gastroenterology Associates, N.A. P.C. (www.gastrodocs.info) has 3 locations (Brookwood Medical Center, Shelby Baptist Medical Center, and St. Vincent’s East Medical Center) and is comprised of 13 board certified gastroenterologists and 9 nurse practitioners. We will gladly partner with you to help manage and care for your patients.