Approach to the Evaluation and Medical Management of Reflux

Educational Objectives

The goal of this program is to improve the evaluation and management of acid reflux. After hearing and assimilating this program, the clinician will be better able to:

1. Review the different phenotypes of acid reflux.
2. Manage patients with reflux disease according to their phenotype.

Summary

Acid reflux: occurs when acidic fluid from the stomach enters the esophagus; it may be caused by defects in the gastrointestinal junction (GEJ), including the hiatus, or by issues with peristalsis; classic symptoms include heartburn and regurgitation; obesity, smoking, and alcohol consumption are risk factors; the global prevalence is 8% to 33% (15%-19% in North America, Canada, and Mexico); reflux disease occurs equally across sexes, but men tend to experience higher rates of erosive esophagitis, Barrett esophagus, and esophageal adenocarcinoma; diagnosis — give therapy for a few weeks; if unsuccessful, consider a pH impedance test (a 24-hr test) or a wireless pH test (measures reflux for 2-4 days)

The Lyon consensus updates: conclusive evidence of reflux now includes grade B along with grade C or D esophagitis on endoscopy; acid reflux is defined as >6% acid exposure time (AET) on pH testing; with 4-day testing, an AET >6% for ≥2 days is also considered conclusive evidence of reflux disease

Reflux phenotypes: indicate the severity of reflux and the potential to progress to complications; nonerosive reflux disease — affects 60% to 70% of patients; patients have troublesome symptoms, but endoscopy is typically normal; erosive esophagitis — affects 30%; mucosal breaks are present in the esophagus and are graded using the Los Angeles (LA) classification of esophagitis; Barrett esophagus — is least common; it is characterized by metaplastic columnar epithelium (a complication of reflux); atypical reflux — indicates extraesophageal symptoms

Erosive esophagitis: patients have LA grade B or higher esophagitis with symptoms and are more likely to develop complications; discuss the importance of therapy for preventing complications in, eg, 10 to 30 yr

The American College of Gastroenterology (ACG) clinical guidelines (2022): do not include the newest available medications but emphasize phenotypes; they recommend proton pump inhibitors (PPIs) over histamine (H2) blockers for patients with erosive esophagitis; ask patients to take PPIs 30 to 60 min before breakfast; consider on-demand or intermittent PPI therapy for patients with nonerosive reflux disease; unless patients are pregnant, sucralfate (Carafate) is not recommended

Management: lifestyle and weight management (ie, decreasing intra-abdominal pressure) are important; optimize PPI therapy (or whatever medication the patient is taking); ensure consistent medication use (especially for patients with erosive esophagitis); Kalaitzakis et al (2007) compared esomeprazole (Nexium) 20 mg vs pantoprazole (Protonix) 20 mg in patients with esophagitis who were in remission and found that esomeprazole performed significantly better than pantoprazole; Zheng et al (2009) found that high-dose esomeprazole performed better than pantoprazole for symptom scores

Adjuvant pharmacotherapy: alginate (Reflux Gourmet and Gaviscon Double Action) is a seaweed derivative that prevents acid reflux and can be used for breakthrough symptoms; famotidine (Pepcid) can be used for nocturnal symptoms; baclofen can be considered for regurgitation belching; prokinetics are not typically used for reflux but can be used for concomitant gastroparesis

Medication adherence: Dal-Paz et al (2012) reported that 60% of patients taking omeprazole for reflux did not know what it was treating, 47% reported low adherence, and 34% were not taking it correctly; most patients who reported continuing symptoms despite taking omeprazole had low adherence; ensure that patients understand how to take medication (especially non-English speaking patients)

Atypical reflux: occurs when retrograde gastric contents enter the pharynx and larynx, causing, eg, cough, sore throat, sinusitis, and ear congestion (≈50% of patients visiting an otolaryngologist have these symptoms); the American Gastroenterological Association clinical practice update suggests diagnostic testing instead of empirically starting acid reflux therapy to confirm the cause; consider alternative therapies, which are inexpensive and easy to take (eg, alginate)

Readings

Dal-Paz K, Moraes-Filho JP, Navarro-Rodriguez T, et al. Low levels of adherence with proton pump inhibitor therapy contribute to therapeutic failure in gastroesophageal reflux disease. Dis Esophagus. 2012;25(2):107-113; Fock KM, Poh CH. Gastroesophageal reflux disease. J Gastroenterol. 2010;45:808–815; Kalaitzakis E, Bjornsson E. A review of esomeprazole in the treatment of gastroesophageal reflux disease (GERD). Ther Clin Risk Manag. 2007;3(4):653–663; Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022;117(1):p27-p56; Kim YS, Kim N, Kim GH. Sex and gender differences in gastroesophageal reflux disease. J Neurogastroenterol Motil. 2016;22(4):575–588; Phillips WA, Lord RV, Nancarrow DJ, et al. Barrett's esophagus. J Gastroenterol Hepatol. 2011;26(4):639-648; Zheng RN. Comparative study of omeprazole, lansoprazole, pantoprazole and esomeprazole for symptom relief in patients with reflux esophagitis. World J Gastroenterol. 2009 28;15(8):990–995.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Kamal was recorded at the 2nd Annual Updates in Gastroenterology and Hepatology, held April 17-20, 2024, in Los Sonoma, CA, and presented by Stanford Medicine. For information on upcoming programs from this presenter, please visit Stanford.cloud-cme.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GE381701

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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