Physicians
Dear Physician,
We hope that you will find the following information useful when caring for your patients with GERD.
On this site, I have strived to provide information that can be helpful in your diagnostic and therapeutic decision-making.
Please assist us with your suggestions in making this site more helpful and accessible, both to physicians and patients.
M. Farivar, MD, FACP, FACG
Introduction:
GERD is the most common condition encountered by pediatric and adult gastroenterologists. Millions of Americans suffer from daily heartburn, and millions more have other GERD related syndromes. The cost of relieving heartburn in the US is several billion dollars per year – a major public health expenditure. No wonder why drug companies allocate expensive resources to the development and marketing of newer anti-GERD medications.
Patients are often poorly informed about dietary restrictions and over-the-counter self-medication.
Primary Care Doctors treat most patients empirically with the strongest medication that they have been detailed about, and they are often not sure when to refer patients with GERD to specialist or when to stop or modify treatment.
Specialists, in turn have their own problem in dealing with GERD.
GERD can present itself in a variety of ways from esophageal to supra and peri-esophageal syndromes. Less than 50% of patients with GERD complain about heartburn. There is no “Gold Standard” test for diagnosis of GERD. Endoscopy indications are not well defined (Indications for Endoscopy in GERD). Not all endoscopist report the degree of damage that they see in a systematic way. (Endoscopy Slides) or Los Angeles classification. This grading is very important and should be adopted by endoscopists. It provides a blue print for comparison when further endoscopy follow-up is indicated, and it has important therapeutic implications (Grades C and D of EE according to the LA criteria rarely if ever heals without the use of PPIs). Upper GI endoscopy, the most common used diagnostic modality in GERD, is negative (NERD or non-erosive reflux disease) for erosive esophagitis in more than 50% of patients exhibiting GERD related chest pain, heartburn, regurgitation, as well as ENT and pulmonary symptoms.
Attention to the posterior larynx for evidence of erythema and edema (Reflux Laryngitis slides), as well as careful observation of lower esophagus for presence of patulous lower esophageal sphincter (LESC) and HH can enhance diagnostic capabilities of EGD and saves considerable costs (Increase the Diagnostic Yield of Upper G.I. endoscopy).
In patients with Barrett’s esophagus the frequency of surveillance endoscopies remain mostly specialist individual choice.(Link to Barrett's Surveillance)
In our experience, proper esophageal mucosal biopsy and proper histological study of endoscopic biopsies has confirmed the diagnosis of up to 82% of our GERD patients. However, due to its expense and considerable degree of false positive and false negative reporting if morphometric studies (Pathology Slide) are not done, biopsy should be done only when diagnosis is in doubt.
When heartburn, the most common presenting symptom, is present no further diagnostic testing is necessary before initiating empirical therapy for symptomatic relief. Recent studies suggest that proton pump inhibitors are the preferred form of medical therapy. In addition to symptomatic relief of heartburn, they heal esophageal mucosal injury and reduce the need for frequent dilatation in patients with peptic stricture. Grades III and IV according to the Savary-Miller classification of mucosal injury (C and D according to the Los Angeles criteria of erosive esophagitis) usually do not heal without the use of PPIs. Furthermore, at least for heartburn relief, not all the PPIs have the same therapeutic benefits on a mg-to-mg basis, hence knowing your PPIs becomes very important especially in this managed care era.
Occasionally, as in chest pain, chronic cough, asthma or dyspepsia due to GERD, therapeutic trials of PPIs may be our only diagnostic as well as therapeutic tool.
Unfortunately, if treatment is stopped symptoms will return. As for mucosal injury there is an 80% recurrence within six months of stopping PPI therapy. Since the basic mechanism of injury is reflux of acid gastric contents in to the esophagus via an incompetent lower esophageal sphincter (LES), continuous long-term medical treatment or surgical repair of the sphincter mechanism is recommended in severe cases.
Laparoscopic Nissen's Fundoplication must be reserved for patients that are surgical candidates and have responded favorably to the therapeutic dose of PPIs for their given condition.
For comprehensive information about GERD, refer to "Improving Diagnostic Accuracy of Upper GI Endoscopy in Patients with GERD". This body of clinical research was carried out in Caritas Norwood Hospital during 1993, parts of which were presented during the Digestive Disease Week (DDW) conference (San Diego, 1995) before the American Society of Gastrointestinal Endoscopy (ASGE). You can also view selected slides pertaining to this research: Selected slides