Gastroesophageal Reflux Disease

Mark Feldman, M.D.
University of Texas Southwestern Medical School at Dallas

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References

Definition/Key Clinical Features

• Heartburn that radiates up chest and is readily relieved by antacids
• Regurgitation of small quantities of sour- or bitter-tasting gastric contents
• Atypical (extraesophageal presentations)
  • Chest pain
  • Hoarseness
  • Sore throat
  • Asthma
  • Chronic cough

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Differential Diagnosis

• Angina pectoris
• Myocardial infarction
• Esophagitis due to infection
• Esophageal motor disorder
• Scleroderma
• Aortic dissection (rare)

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Best Tests

• Therapeutic trial of antacids, H₂ blockers, or proton pump inhibitors (PPIs)
  • Initial test in patients with mild symptoms or symptoms of recent onset
• Endoscopy
  • High specificity (> 95%), but low sensitivity (50%)
  • Reserve for the following:
    • Uncomplicated gastroesophageal reflux disease (GERD) that does not respond to empirical therapy
    • Patients with symptoms of complicated GERD
      • Dysphagia
      • Weight loss/anorexia
      • Bleeding/anemia
    • Patients with long-standing symptoms (particularly if age > 50 yr) to rule out Barrett esophagus
• Esophageal pH monitoring
  • High sensitivity and specificity (both > 95%)
  • Useful for atypical or unresponsive symptoms
• Esophageal manometry
  • Useful for motor disorders and for evaluation before antireflux surgery

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Best Therapy

• Elimination of fatty foods and chocolate from diet
• Avoidance of tight, binding clothing
• Avoidance of late (bedtime) snacks
• Cessation of alcohol consumption
• Cessation of smoking
• Elevation of head of bed

• Efficacy of antireflux drug therapy inversely related to underlying GERD severity

• Treatment of choice for severe GERD (often in double the usual daily dose)
• Usually first choice for treatment of mild to moderate GERD (in typical daily doses)
• Efficacy rating 80%–100%
• Omeprazole
  • Dose: 20–40 mg q.d.
  • Cost/mo: $40 (nonprescription)
• Esomeprazole
  • Dose: 40 mg q.d.
  • Cost/mo: $124
• Lansoprazole
  • Dose: 30–60 mg q.d.
  • Cost/mo: $248
• Pantoprazole
  • Dose: 40–80 mg q.d.
  • Cost/mo: $222

• Efficacy rating ~ 50%
• Cimetidine
  • Dose: 400 mg q.i.d.
  • Cost/mo: $34 (nonprescription)
• Ranitidine
  • Dose: 150 mg b.i.d.–q.i.d.
  • Cost/mo: $22 (nonprescription)
• Famotidine
  • Dose: 20–40 mg b.i.d.
  • Cost/mo: $40–$52 (nonprescription)
• Nizatidine
  • Dose: 150 mg b.i.d.–q.i.d.
  • Cost/mo: $61–$122 (prescription)

• Efficacy satisfactory for mild and intermittent symptoms, but not for healing
• Use as needed
  • Liquid dose: 15 ml q.i.d. (1 hr after meals and at bedtime)
  • Tablet dose: 2–4 tablets q.i.d. (1 hr after meals and at bedtime)

• Metoclopramide
  • Efficacy satisfactory for mild and intermittent symptoms
    • Dose: 10–20 mg before meals
    • Cost/mo: $30

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Best References

Emerenziani S, et al: Curr Opin Gastroenterol 21:450, 2005 [PMID 15930987]

Halstead LA: Drugs Today (Barc) 41(suppl B):19, 2005 [PMID 16200228]

Locke GR 3rd: Thorac Surg Clin 15:369, 2005 [PMID 16104127]

Pessaux P, et al: Arch Surg 140:946, 2005 [PMID 16230543]