The utility of maintenance therapy in patients with GERD depends on the manifestation of the disease being monitored, with the strongest data pertaining to erosive esophagitis. Subjects not maintained on continuous acid suppressive therapy have high rates of recurrence of erosive disease. Several randomized controlled trials have shown that the recurrence of erosive esophagitis in subjects with GERD is dramatically decreased by daily PPI treatment. Similarly strong are randomized controlled trials between H2RAs and either healing-dose or maintenance-dose (usually half) PPIs, with subjects randomized to H2RAs up to twice as likely to have recurrent esophagitis. The role of daily maintenance therapy in nonerosive disease is less clear. Patients with esophageal GERD syndrome without esophagitis who initially responded to PPI therapy are less likely to have recurrent symptoms when randomized to continuing PPI therapy than to H2RAs or placebo. Whether PPI dosing needs to be continuous as opposed to "on demand" has also been studied, and patients with uninvestigated GERD or patients with an esophageal GERD syndrome without esophagitis did well with on-demand regimens. On balance, the data suggest that on-demand therapy is a reasonable strategy in patients with an esophageal GERD syndrome without esophagitis, where symptom control is the primary objective. In contrast, in those with a known history of erosive esophagitis who are healed with continuous PPI therapy and then randomized to either continuous or on-demand therapy, the recurrence rates of erosive disease are high with on-demand compared with continuous therapy, and on-demand therapy cannot be recommended.
Chronic cough, laryngitis, and asthma have an established association with GERD on the basis of population-based studies. However, cough, laryngitis, and asthma have a multitude of potential etiologies other than GERD, making them nonspecific for GERD. Furthermore, the causal relationship of GERD with these nonspecific syndromes in the absence of a concomitant esophageal GERD syndrome remains controversial and unproven. The only randomized controlled trials showing a treatment effect for GERD therapies in these syndromes were in patients with esophageal GERD syndromes in addition to either laryngitis or asthma. Hence, existing evidence supports the following: (1) the association between these syndromes and GERD, (2) the rarity of extraesophageal GERD syndromes without concomitant esophageal symptoms or findings, (3) that suspected extraesophageal GERD syndromes are usually multifactorial, and (4) that data substantiating benefit from the treatment of reflux for the extraesophageal syndromes are very weak. Furthermore, clinical predictors implicating GERD in the extraesophageal syndromes have proven elusive, and the premature adoption of flawed diagnostic criteria has likely resulted in the overdiagnosis of extraesophageal GERD syndromes.
Acid reflux (gastroesophageal reflux disease ..
The other broad scenario under which diagnostic testing is performed is in the evaluation of troublesome symptoms that have not adequately responded to empirical twice-daily PPI therapy. Did therapy fail because of troublesome symptoms attributable to reflux that did not resolve with PPI therapy or because the symptoms under consideration are not attributable to reflux? Endoscopy is again the first diagnostic test to consider because it may demonstrate Barrett's metaplasia, stricture, or an alternative upper gastrointestinal diagnosis. After a normal endoscopy, priority should be given to identifying conditions for which an effective alternative therapy exists. In the case of GERD, the only alternative, potentially more effective, therapy is antireflux surgery. High-quality evidence on the efficacy of antireflux surgery exists only for esophagitis and/or excessive distal esophageal acid exposure when PPI therapy is withheld. Another requirement for antireflux surgery is that some peristaltic function be preserved. Finally, it is important to identify alternative diagnoses that may masquerade as GERD: functional heartburn, atypical cases of achalasia, or distal esophageal spasm. Given these priorities, the second diagnostic evaluation should be esophageal manometry and the third should then be to ascertain whether or not there is excessive esophageal acid exposure when PPI therapy is withheld. Whether this examination should be performed with the patient on acid suppressive therapy is debated. The unclear relevance of "normative" data for impedance-pH studies performed on PPI therapy makes it difficult to interpret such studies. If normal values are not adjusted, then such an on-PPI study could show an unequivocal PPI nonresponse. That, however, rarely occurs. At this point in the diagnostic algorithm, troublesome symptoms of heartburn, chest pain, regurgitation, or dysphagia persist despite normal findings on endoscopy (including mucosal biopsy in the case of dysphagia), normal esophageal acid exposure, and a manometry study that ruled out a major motor disorder. Current thinking is that the major remaining possibilities are a hypersensitivity syndrome or a functional syndrome, the distinction being that in the case of a hypersensitivity syndrome symptoms are attributable to reflux events, whereas in the case of a functional syndrome they are not. This is a subtle distinction and a domain in which there is currently no high-quality evidence supporting one management approach or another.
Gastroesophageal reflux disease (GERD) - Healthline
Broadly speaking, lifestyle modifications recommended for GERD fall into 3 categories: (1) avoidance of foods that may precipitate reflux (eg, coffee, alcohol, chocolate, fatty foods), (2) avoidance of acidic foods that may precipitate heartburn (eg, citrus, carbonated drinks, spicy foods), and (3) adoption of behaviors that may reduce esophageal acid exposure (weight loss, smoking cessation, raising the head of the bed, and avoiding recumbency for 2—3 hours after meals). The problem with these is that there are simply too many recommendations and each is too narrowly applicable to enforce the whole set on every patient. However, it is also clear that there are subsets of patients who may benefit from specific lifestyle modifications, and it is good practice to make those recommendations to those patients based on their specific history. A patient with symptoms of nighttime heartburn or regurgitation of sufficient severity to disturb his or her sleep despite acid suppressive therapy may benefit from elevation of the head of the bed. Similarly, a patient who consistently experiences troublesome heartburn after ingestion of alcohol, coffee, or spicy foods will benefit from avoidance of these. Finally, if a patient is overweight or obese, it is reasonable to suggest weight loss as an intervention that may prevent, or at least postpone, the need for acid suppression.