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Management of Gastroesophageal Reflux Disease

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Management of Gastroesophageal Reflux Disease Gastroenterology 2018;154:302–318 GERD Management of Gastroesophageal Reflux Disease C. Prakash Gyawali1 Ronnie Fass2 1Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri; and 2Division of Gastroenterology and Hepatology, Esophageal and Swallowing Center, Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio Management of gastroesophageal reflux disease (GERD) therapy. The presence of erosive esophagitis is associated commonly starts with an empiric trial of proton pump with response to antireflux therapy.6 Additionally, increased inhibitor (PPI) therapy and complementary lifestyle mea- distal esophageal acid exposure time (AET) predicts symp- sures, for patients without alarm symptoms. Optimization tom improvement following antireflux therapy; positive of therapy (improving compliance and timing of PPI doses), symptom association probability complements increased or increasing PPI dosage to twice daily in select circum- AET in this setting.6,7 Using these 2 parameters, GERD can stances, can reduce persistent symptoms. Patients with be characterized into distinct phenotypes that have continued symptoms can be evaluated with endoscopy and management implications.8 More than two-thirds of patients tests of esophageal physiology, to better determine their with increased AET have a symptomatic response to medi- disease phenotype and optimize treatment. Laparoscopic cal or surgical antireflux therapy.8 On the other hand, fundoplication, magnetic sphincter augmentation, and physiologic reflux metrics indicate a functional basis for endoscopic therapies can benefitpatientswithwell- symptoms,9,10 and fewer than 50% of patients with physi- characterized GERD. Patients with functional diseases that ologic reflux burden and negative symptom-reflux associa- overlap with or mimic GERD can be treated with tion report reduced symptoms. When symptoms associate neuromodulators (primarily antidepressants), or psycho- fl fl logical interventions (psychotherapy, hypnotherapy, with re ux episodes in patients with physiologic re ux fl cognitive behavioral therapy). Future approaches to treat- (re ux hypersensitivity), treatment outcomes vary. We ment of GERD include potassium-competitive acid blockers, review management strategies for GERD and approaches to reflux-reducing agents, bile acid binders, injection of inert GERD symptoms that persist despite seemingly adequate substances into the esophagogastric junction, and electrical disease management. stimulation of the lower esophageal sphincter. Management Keywords: Gastroesophageal Reflux Disease; Proton Pump Lifestyle Inhibitor; Histamine-2 Receptor Antagonist; Antireflux Surgery. Lifestyle measures designed to reduce reflux symptoms are typically initiated at presentation, and should be recommended for all patients with GERD. Unfortunately, astroesophageal reflux disease (GERD) is a common many physicians either do not provide clear instructions for fi diagnosis for all age groups and both sexes, with lifestyle modi cations or offer patients a printed list of G fi estimated prevalence rates of 8% to 33% worldwide.1 The activities and food items to avoid, which patients nd hard economic burden is $9 to $10 billion per year in direct costs in the United States alone, mainly related to use of proton 2 pump inhibitors (PPIs). PPIs are prescribed empirically as Abbreviations used in this paper: AET, acid exposure time; ARS, antireflux surgery; BE, Barrett’s esophagus; EGJ, esophagogastric junction; GERD, a pragmatic initial diagnostic approach for patients with fl 3,4 gastroesophageal re ux disease; H2RA, H2 receptor antagonists; LES, typical symptoms of GERD, as well as atypical symptoms lower esophageal sphincter; MSA, magnetic sphincter augmentation; (noncardiac chest pain, chronic cough, hoarseness, throat NERD, nonerosive reflux disease; P-CAB, potassium-competitive acid blocker; PPI, proton pump inhibitor; RFA, radiofrequency application; TIF, clearing, wheezing). Sometimes, patients are given double transoral incisionless fundoplication; TLESR, transient LES relaxation. the standard dose; overprescription and inappropriate use Most current article of PPIs is a widespread problem.5 © 2018 by the AGA Institute Esophageal testing can stratify patients with GERD into 0016-5085/$36.00 management categories for appropriate use of antireflux https://doi.org/10.1053/j.gastro.2017.07.049 January 2018 Management of Gastroesophageal Reflux Disease 303 to follow.11 Some patients report specific foods that induce erosive esophagitis or BE on upper endoscopy defines GERD symptoms, including citrus, spicy food, caffeine, proven GERD; GERD remains unproven when these have chocolate, and fatty foods. However, broad dietary restrictions not been demonstrated. Best practice recommendations 12 are of limited value in reducing esophageal symptoms. for proven GERD consist of long-term therapy with the GERD The association between weight gain and GERD symp- lowest dose of PPI that provides symptom control and/or toms is well established in population studies; weight gain healing of esophagitis.39 In contrast, patients with has also been associated with increased risk of erosive unproven GERD, or those with atypical esophageal symp- – esophagitis and Barrett’s esophagus (BE).13 15 Even modest toms and normal endoscopy, benefit from esophageal weight gain can exacerbate GERD symptoms in both non- reflux monitoring to define abnormal reflux burden before obese and obese individuals, particularly women.16 Conse- initiation of long-term PPI therapy. Therefore, the clinician quently, weight loss and reduction in waist circumference has managing GERD needs to address indication, consider been demonstrated to reduce symptoms of GERD, esophageal evidence of efficacy for the indication, and establish acid exposure, and post-prandial reflux events.17–20 benefit over risk before initiating long-term PPI therapy.40 Because nighttime breakthrough symptoms are commonly Typical symptoms of GERD are reduced with PPI reported by patients failing GERD therapy,21 emphasizing therapy. This led to the development of the PPI trial,41 in lifestyle modifications for nighttime hours is especially lieu of esophageal tests for patients with heartburn without important. Sleeping with the head end of the bed elevated, alarm symptoms. A meta-analysis showed that the sensi- using either blocks under bedposts or a wedge, reduces reflux tivity of a 7-day PPI trial in resolving heartburn was 71% in episodes, with faster acid clearance and fewer reflux symp- the presence of erosive esophagitis, and 78% when ambu- toms compared with sleeping flat.12 AET is longer, and acid latory pH monitoring was abnormal42; however, specificity clearance is slower when lying on the right side compared was suboptimal at 41% and 54%, respectively, implying a with the left, possibly because the esophagogastric junction mixture of GERD and non-GERD mechanisms underlying (EGJ) is above the level of pooled acid while lying on the left uninvestigated heartburn.43 side.22–24 Other measures include turning off bedroom lights Abnormal esophageal acid burden correlates with and minimizing disturbances to normal sleep.25 Despite response of symptoms to the PPI trial (odds ratio 4.11).44 associations between post-prandial reflux episodes and Meta-analyses have found that 72% of patients with GERD symptoms, there is no conclusive evidence that avoiding erosive esophagitis respond to PPI therapy, and 73.5% of late-night meals reduces esophageal acid burden.26 patients with nonerosive reflux disease (NERD) confirmed Although smokers have more reflux symptoms,27,28 by abnormal reflux monitoring.43 In contrast, fewer than there is no evidence that smoking cessation consistently 47% of patients with functional heartburn and reflux reduces esophageal acid exposure or GERD symptoms.29,30 hypersensitivity respond to PPI therapy.8,9,45 Symptom- Similarly, alcohol use can induce reflux symptoms,31,32 but reflux association alone has not been consistently associ- alcohol abstinence does not decrease esophageal reflux ated with treatment outcome, compared with the presence burden.33 Despite lack of conclusive evidence, there are of erosive esophagitis or abnormal AET.7,8,46–48 health benefits to cessation of smoking and alcohol use, Short-term PPI therapy heals esophagitis in 72% to 83% particularly in reducing neoplastic progression of BE and of patients (compared with 18% to 20% for placebo, see risk of esophageal adenocarcinoma.34,35 Table 1),43,49 but resolves heartburn in only 56% to 77% of patients with esophagitis (with 4–12 weeks of therapy).50–52 PPIs PPIs maintain healing of erosive esophagitis in 93% of PPIs are the mainstay of medical management of GERD, patients (compared with 29% of patients for placebo),53 and due to irreversible blockade of the activated Hþ Kþ ATPase lower doses may suffice. The standard dose of PPIs proton pump in the gastric parietal cells. Effects are not resolves heartburn in only 37% to 61% of patients without immediate because the PPI needs to concentrate in the erosive esophagitis or with uninvestigated heartburn acidic secretory canaliculi of the parietal cell before (Table 1).43,52,54 Thus, patients with a nonresponse or inhibiting the proton pump.36 Acid production is sup- incomplete response to PPIs should undergo esophageal pressed until new proton pumps regenerate, so the PPI is evaluation to confirm the presence or absence of GERD as a readministered each day, to ensure continued acid sup- cause of symptoms.6 The optimal indications
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