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GERD - Key Points

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  • Suppose a patient presents with heartburn, regurgitation, and/or non-cardiac chest pain without alarming symptoms.

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  • The next best step is a 4 to 8 week trial of once-daily PPI dosing and consider testing for H. pylori (stool H. pylori antigen or urea breath test).

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  • If there is an adequate response, taper the PPI to the lowest effective dose.

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  • If there is no adequate response, switch to twice-daily dosing.

 

  • If there is still no adequate response, proceed with an upper endoscopy.

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  • Endoscopy should be done after 2 to 4 weeks off PPIs (to maximize the chance of documenting esophagitis).

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  • If the patient presents with GERD and exhibits alarm symptoms such as dysphagia or weight loss, an endoscopy should be recommended immediately to consider malignancy.​​

  • Ambulatory pH monitoring (off treatment) is the next step if endoscopy is normal.

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  • We recommend intermittent or “on-demand” (rather than indefinite) PPI therapy in patients with no history of high-grade esophagitis or Barrett's esophagus.

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  • A patient who requires ongoing PPI therapy for symptom control should use the lowest effective dose.

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  • Important - If a patient with no alarm symptoms and a good response to a PPI stops the drug after several months and symptoms relapse, primary care clinicians often resume PPI therapy without further evaluation.

    • For such patients, this guideline recommends endoscopy to identify complications that merit indefinite PPI therapy (i.e., erosive esophagitis or Barret's esophagus) and to identify alternative diagnoses (e.g., eosinophilic esophagitis).​​

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