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TreatmentGERD patients should be assessed for alarm features,as these should prompt urgent endoscopic evaluation. If no alarm symptoms are present,initial management of GERD should be geared toward lifestyle modification. However,it is important to note that the majority of studies on lifestyle and dietary changes in GERD have not been well powered. Nevertheless,lifestyle changes remain first-line in management of GERD with a primary goal of symptom reduction and improvement in quality of life.,The only proven lifestyle modification for the management of GERD is head of bed (HOB) elevation. Head of bed elevation has been shown to decrease esophageal acid exposure and esophageal clearance time with subsequent reduction in symptoms in patients with supine GERD. In addition,is it advised that factors contributing to the incidence of TLESRs should also be minimized or avoided. These include smoking,heavy alcohol consumption,large evening meals,nighttime snacks,and high dietary fat intake. Weight loss is strongly encouraged in overweight GERD patients,but there is no documented benefit in those with normal weight. Although obesity is a risk factor for GERD,most bariatric surgeries exacerbate reflux. Additionally,all patients with GERD should avoid non-steroidal anti-inflammatory drugs (NSAIDs) because of their role in disrupting physiologic mucosal protection mechanisms.
Medication therapy for GERD is targeted at symptom reduction and minimizing mucosal damage from acid reflux. While acid suppression is successful in the treatment of GERD,there does not appear to be a clear relationship between GERD severity and high gastric acid levels with the exception being Zollinger-Ellison syndrome.
Many patients with heartburn try over-the-counter antacids prior to seeking medical attention. The primary acid suppressive medications include H2 blockers and proton pump inhibitors. H2 blockers decrease gastric acid secretion by inhibiting histamine stimulation of the parietal cell. Proton pump inhibitors work to decrease the amount of acid secreted from parietal cells into the gastric lumen. H2 blockers have been shown to have some symptomatic benefit above placebo,but in individuals without contraindication,PPIs are the most effective therapy. There is no clear role for prokinetic agents,such as metoclopramide,in the treatment of GERD.
Proton pump inhibitors are the most potent class of antacid medications. They are dosed once or twice daily and are most effective if taken 30 to 60 minutes prior to meals. Many patients will have relapse of symptoms after the cessation of PPI,therefore lifelong therapy is often required. Recently,there has been a rise in concern of PPIs contributing to the development of bone fractures,electrolyte deficiencies,infections (e.g.,Clostridium difficile,pneumonia),and renal insufficiency. Given the theoretical risk of side effect from PPI therapy,the lowest dose required for maintenance should be used and periodic trials of weaning should be attempted.
In GERD patients refractory to twice daily PPI dosing,there is some evidence to show that adding a nighttime H2 blocker can be beneficial.,In refractory cases,other disorders should be considered,notably: eosinophilic esophagitis,pill esophagitis,delayed gastric emptying,duodenogastric/bile reflux,irritable bowel syndrome,psychological disorders,achalasia,and Zollinger-Ellison syndrome.
The use of anti-reflux surgery (fundoplication) has been controversial. Studies show only minimal long-term symptomatic improvements with surgery over PPI therapy,paired with an increased incidence of dysphagia and dyspepsia. Patients who respond best to surgery are those who also respond well to PPIs and therefore may be managed medically. Conversely,PPI-refractory patients are unlikely to have benefit from surgery. Approximately half of all patients who undergo surgery eventually require surgical revision. Given the near-negligible difference in efficacy between surgery and PPI and the risk for postoperative complications and mortality,surgery should only be reserved for select patients. Choosing the best candidates for anti-reflux surgery remains a clinical challenge.","department":"
