Management Guidelines for Acid Reflux Disease, as provided for doctors, but also helpful and informative for patients.
Medical management guidelines are written and published for doctors to assist them in providing optimal care for their patients. Patients are much better informed than 20 years ago, in large part due to the advent of the internet and easy access to huge amounts of information. This can only be a positive step forward. This article explains the medical management of GERD which has been prepared by gastroenterologists. The guidelines are based on and adapted from the Canadian Consensus Conference on the Management of Patients with GERD and the Montreal definition and classification of GERD.
Acid reflux disease is defined as a medical condition that begins when the acidic stomach contents reflux up into the lower esophagus and lead to problematic symptoms with or without complications.
These guidelines do not apply to people under 18 years of age, or to pregnant women or women who are breast feeding.
The diagnosis of GERD can usually be made by taking a detailed, careful medical history, and physical examination. Further investigation is not usually required, if the symptoms are typical, and there are no red flag (warning) symptoms. Those individuals who have alarm symptoms in addition to their acid reflux disease symptom, should be promptly investigated by upper gastrointestinal endoscopy (gastroscopy).
Acid reflux disease is not caused by Helicobacter pylori and treatment aimed eradicating Helicobacter pylori does not effect acid reflux disease or its management.
Red Flag (Alarm) Features
- Dysphagia, particularly for solid food and if progressive. Dysphagia means food getting stuck as it passes down the esophagus.
- Odynophagia which means painful swallowing.
- Weight loss
- Anaemia (low blood count) or bleeding.
- Persistent vomiting
Other factors that mean further investigation is required:
- Failure to respond to 8 weeks of medical therapy (usually with a PPI). Though some patients may take 16 weeks to respond.
- Respiratory symptoms, such as cough, wheeze, asthma, recurrent chest infections and aspiration pneumonia, that are secondary to acid reflux.
- If the symptoms could be cardiac in origin (due to heart disease eg angina)
The first step is to advise on lifestyle modification and emphasise healthy strategies that have additional health benefits.
- Weight control
- Reduce consumption of tobacco, alcohol and caffeine
- Avoid lying down within 2-3 hours of eating
- Recommend elevation of the head of the bed
- Advise about the avoidance of foods that are likely to trigger symptoms such as: fatty and fried foods spicy food citrus fruit and drinks chocolate
Recommend the use of over-the-counter medications such as antacids or histamine2 receptor antagonists (H2RA's), if they have not already been tried.
These treatments are especially useful for those who have infrequent and mild symptoms.
If the symptoms are relieved by modification of diet and lifestyle with or without medication bought over-the-counter, then continue as required. If there is no response to lifestyle modification and/or over-the-counter medication then add in treatment with the most effective medication, which is a proton pump inhibitor (PPI) e.g. omeprazole, lansoprazole, esomeprazole or pantoprazole.
Prescribe a PPI once a day for 4-8 weeks. If symptoms are still not resolved with this treatment or if the symptoms recur then consider:
- Continuing with proton pump inhibitor for 16 weeks, after carrying out a careful and thorough review of the patient to decide on the accuracy of the diagnosis, or:
- Consider treatment with PPI twice a day for 4 weeks, or:
- If the previous treatment did not use a PPI, then prescribe a PPI for 4-8 weeks.
Arrange to follow up and reassess the patient at 2-4 weeks to determine progress and review the diagnosis.
If the patient does not respond to treatment with a proton pump inhibitor after 16 weeks, then they require a thorough reassessment and further investigation by endoscopy.
Those patients who need ongoing prescription of PPI, or other acid suppression medication, for many years, should have an endoscopy within 10 years of the start of their symptoms to exclude Barrett's esophagus.
Medical evidence has found that up to about 36% of otherwise healthy individuals experience an episode of heartburn at least once a month. Also, about 7% have uncomplicated acid reflux disease and heartburn symptoms as frequently as every day. Research suggests that about 2% of the adult population suffers from complicated GERD, associated with histological (shown on analysis of tissue biopsy samples of the mucosal lining) or macroscopic (shown on direct examination through an endoscope) evidence of damage to the esophageal lining.
The incidence of acid reflux disease increases after the age of 40, and it is not unusual for heartburn sufferers to not consult a doctor until they have had symptoms for many years.
GERD is thought to be caused by a combination of factors that increase the occupation of the distal esophagus by the acidic stomach contents. These factors include decreased lower esophageal sphincter (LES) tone, frequent and prolonged transient LES relaxations, delayed gastric emptying, reduced saliva production and impaired esophageal acid clearance.
Other medical conditions and lifestyle behaviours also lead to an increased risk of acid reflux disease. These include:
- Large meals,
- fatty foods,
- fried food,
- alcohol consumption,
- body position,
- hormones and
A hiatus hernia often occurs in association with acid reflux disease, and a hiatus hernia may contribute to prolonged gastric content exposure time following reflux. However, patients with acid reflux disease do not necessarily have a hiatus hernia, and conversely individuals with a hiatus hernia do not invariably have acid reflux disease.
The excessive acid reflux endured by GERD sufferers is thought to overwhelm the intrinsic defence mechanisms of their esophageal lining, leading to symptoms and sometimes esophageal damage and esophagitis. The most frequent symptom of acid reflux disease is heartburn. In addition to heartburn, reflux may result in the sensation of sour liquid rising effortlessly into the mouth or throat.
Other symptoms include:
- dysphagia (sensation of food getting stuck),
- odynophagia (painful swallowing).
The acid reflux may sometimes cause respiratory symptoms such as
- recurrent chest infections or
- aspiration pneumonia.
The reflux can lead to symptoms affecting the mouth such as:
- tooth enamel decay and
- water-brash (excessive reflex salivation) and
throat symptoms that include:
- throat soreness,
- hoarseness and
- a globus sensation (feeling of a lump in the throat).
It is known that only a small number of patients with diagnostic GERD have reflux esophagitis.
Investigation of Acid Reflux Disease
Investigation is unnecessary for the typical patient who has typical symptoms of gastroesophageal reflux disease, providing they do not have worrying alarm symptoms such as weight loss or dysphagia. If treatment with a proton pump inhibitor, as a therapeutic trial, effectively relieves symptoms then further treatment may be prescribed as needed.
If there are red flag (alarm) symptoms, and /or symptoms of GERD do not improve, then further investigation is needed. Upper gastro-intestinal endoscopy (gastroscopy) is the preferred investigation. This is because endoscopy is highly sensitive in identifying esophageal strictures, ulcers, erosions and cancer. Barrett's esophagus can also be identified and confirmed by biopsy by endoscopy. During endoscopy it is possible to take biopsies of suspicious looking areas of mucosa.
Prolonged and severe exposure of the lower esophagus to reflux of acidic stomach contents leads to the development of Barrett's esophagus. About 2-4 percent of patients with GERD are thought to develop Barrett's esophagus. There is a risk of adenocarcinoma of the esophagus developing in Barrett's esophagus. This risk is about 0.5 percent annually. Therefore patients with Barrett's esophagus require regular examinations by endoscopy. Those patients with long segment Barrett's esophagus have a greater risk of esophageal adenocarcinoma.
The gastroenterologist will normally have a detailed discussion with the patient about the need for and risk of upper gastrointestinal endoscopy, particularly with those patients who have recurrent and persistent symptoms of GERD.
Barium examinations (barium meal) of the esophagus and stomach are easy to perform and widely available. Barium studies are also well tolerated and have little morbidity. The disadvantage of barium studies is that they have significant limitations in the evaluation of acid reflux disease. A barium examination is excellent at diagnosing a stricture, but is poor at showing up pathological acid reflux or damage to the mucosal lining of the esophagus. A barium study will not identify Barrett's esophagus, because this requires a biopsy and confirmation by histology.
Esophageal manometry is a useful investigation for assessing peristalsis (the muscular waves of contraction that move food down the gullet) and for assessing the functioning of the lower esophageal sphincter (LES). Esophageal manometry is a useful investigation in those patients who may require anti-reflux surgery or those who have atypical chest pain.
Ambulatory esophageal pH monitoring is best used in the investigation of complicated acid reflux disease. Ambulatory esophageal pH monitoring enables an assesment of the length of time the pH in the esophagus is low (acidic). This indicates the persistent presence of acid above the lower esophageal sphincter. Ambulatory pH monitoring is especially useful in GERD sufferers with atypical symptoms such as asthma, cough, hoarsness and chest pain. In these patients it may be the only investigation that is able to confirm the diagnosis with objective evidence. Ambulatory esophageal pH monitoring is also useful for further investigating those acid reflux patients who do not respond fully to treatment with medication. This is a useful test to confirm that their GERD- like symptoms are definitely due to acid reflux.
Specialists divide GERD Syndomes into extra esophageal and esophageal syndromes. The esophageal syndromes include those with injury and symptomatic syndromes. The symptomatic syndromes are:
- Reflux Chest Pain Syndrome and
- Typical Reflux Syndrome.
The esophageal injury syndromes include:
- Barrett's Esophagus,
- Reflux Stricture,
- Reflux Esophagitis and
- Esophageal Adenocarcinoma.
The established extra-esophageal syndromes include:
- Reflux associated asthma,
- laryngitis and
- dental erosions.
There is no difference in the treatment of the reflux associated extra-esophageal syndromes and symptomatic esophageal syndromes, at the present time.
Lifestyle modifications such as an acid reflux diet, elevating the head of the bed and avoiding lying down after eating are helpful. Patients should be advised to avoid bedtime snacks, to eat low fat foods, reduce alcohol consumption and to stop smoking. Following this advice will have other health benefits in addition to helping ease the heartburn. Those individuals whose symptoms are not relieved completely with lifestyle modifications may be advised to buy over-the-counter medications including antacids and antisecretory agents (histamine2 receptor antagonists e.g. ranitidine - Zantac).
The therapeutic response should be reassessed at intervals. If the patient's symptoms are not controlled by these measures, then treatment with a proton pump inhibitor (PPI) should be started. The PPI should be taken once daily for 4 weeks.
Many medical studies have shown that short-term treatment with acid suppression medication can effectively relieve the symptoms of uncomplicated GERD. Following an appropriate acid reflux diet is also important. Those individuals whose symptoms resolve with a course of therapy require no further tests or medication. Medication may be repeated if the acid reflux symptoms recur. In those patients who do not respond to a PPI taken once daily for 8 weeks, then a trial of PPI twice a day for 4 weeks may be tried. If the patient fails to respond then further investigation is indicated.