Gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD), gastric reflux disease, or acid reflux disease is a chronic symptom of mucosal damage caused by stomach acid coming up from the stomach into the esophagus. Gastroesophageal reflux disease (GERD) is common, occurring in 30 to 40% of adults.

Symptoms:

  • The most prominent symptom of GERD is heartburn, with or without regurgitation (backflow of blood through a defective heart valve.) of gastric contents into the mouth.
  • Infants present with vomiting, irritability, anorexia, and sometimes symptoms of chronic aspiration(drawing breath). Both adults and infants with chronic aspiration may have cough, hoarseness, or wheezing.

Diagnosis:

  • Typical symptoms are present
  • Clinical diagnosis
  • Endoscopy for those not responding to empiric treatment
  • 24-h pH testing for those with typical symptoms but normal endoscopy.

If Prescription Contains:

  • Proton pump inhibitors (Omeprazole etc)
  • H2 receptor blockers (Ranitidine)
  • antacids with or without alginic acid.

Drug and Dose:

  • Proton-pump inhibitors (omeprazole) are the most effective followed by H2 receptor blockers (ranitidine). If a once-daily PPI is only partially effective they may be used twice a day. They should be taken half to one hour before a meal.
  • When these medications are used long term, the lowest effective dose should be taken.  H2 receptor blockers lead to roughly a 40% improvement.
  • The evidence for antacids is weaker with a benefit of about 10% (NNT=13) while a combination of an antacid and alginic acid (such as Gaviscon) may improve symptoms 60% (NNT=4).
  • Sucralfate has similar effectiveness to H2 receptor blockers; however, sucralfate needs to be taken multiple times a day, thus limiting its use.
  • Adults can be given omeprazole  20 mg, lansoprazole 30 mg, or esomeprazole 40 mg 30 min before breakfast. In some cases, proton pump inhibitors may be given bid.
  • Infants and children may be given these drugs at an appropriate lower single daily dose (ie, omeprazole 20 mg in children > 3 yr, 10 mg in children < 3 yr; lansoprazole 15 mg in children ≤ 30 kg, 30 mg in children > 30 kg).
  • These drugs may be continued long-term, but the dose should be adjusted to the minimum required. H2 blockers (eg, ranitidine 150 mg at bedtime) or promotility agents (eg, metoclopramide 10 mg po 30 min before meals and at bedtime) are less effective.

Management of uncomplicated GERD: Consists of elevating the head of the bed about 15 cm (6 in).

Avoiding the following:

  • Eating within 2 to 3 h of bedtime, strong stimulants of acid secretion (eg, coffee, alcohol), certain drugs (eg: anticholinergics), specific foods (eg, fats, chocolate), and smoking.
  • Anti-reflux surgery (usually via laparoscopy) is done on patients with serious esophagitis, large Hiatal hernias, hemorrhage, stricture, or ulcers. Esophageal strictures are managed by repeated balloon dilation.

Pregnancy:

  • In pregnancy, dietary modifications and lifestyle changes may be attempted, but often have little effect. Calcium-based antacids are recommended if these changes are not effective. Aluminum- and magnesium-based antacids are also safe, as is ranitidine and PPIs.

Infants:

  • Infants may see relief with changes in feeding techniques, such as smaller, more frequent feedings, changes in position during feedings, or more frequent burping during feedings.
  • They may also be treated with medicines such as ranitidine or proton pump inhibitors. Proton pump inhibitors, however, have not been found to be effective in this population and there is a lack of evidence for safety.