Clinical Evidence Handbook

A Publication of BMJ Publishing Group

GERD in Adults

Am Fam Physician. 2009 Jan 15;79(2):149-150.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See CME Quiz on page 99.

Up to 25 percent of persons have symptoms of gastroesophageal reflux disease (GERD), but only 25 to 40 percent of these persons have esophagitis visible on endoscopy.

  • Although obesity, smoking, alcohol use, or certain foods are considered risk factors, we do not know whether they are actually implicated in GERD.

  • About 80 percent of persons with GERD will have recurrent symptoms if they stop treatment, and severe esophagitis may result in esophageal stricture or Barrett esophagus.

Proton pump inhibitors (PPIs) increase healing in patients with esophagitis compared with placebo and histamine H2 receptor antagonists, but we do not know whether one specific PPI is more effective than the others.

  • H2 receptor antagonists increase the esophagitis healing rate compared with placebo, and may improve symptoms more than antacids.

We do not know whether antacids, alginates, motility stimulants, or lifestyle advice to lose weight or to raise the head of the bed are effective in improving symptoms of GERD or in preventing its recurrence.

  • The motility stimulant cisapride has been associated with heart rhythm problems.

Standard- and low-dose PPIs reduce relapse of esophagitis and reflux symptoms compared with placebo or H2 receptor antagonists, but we do not know which is the optimal drug regimen.

  • H2 receptor antagonists may reduce the risk of relapse of reflux symptoms compared with placebo, although they have not been shown to prevent recurrence of esophagitis.

Laparoscopic or open surgery (Nissen fundoplication) may improve endoscopic esophagitis compared with medical treatment, although studies have given conflicting results.

  • Laparoscopic surgery seems to be as effective as open surgery, with lower risks of operative morbidity and a shorter duration of admission, but both types of surgery may have serious complications.

Clinical Questions

What are the effects of initial treatment of GERD associated with esophagitis?

Beneficial

Histamine H2 receptor antagonists (increase healing of esophagitis compared with placebo, but not as effective as PPIs)

PPIs (increase healing of esophagitis compared with placebo and H2 receptor antagonists; insufficient evidence to compare effects of different PPIs)

Unknown effectiveness

Antacids or alginates

Lifestyle advice or modification

Motility stimulants (with the exception of cisapride)

What are the effects of maintenance treatment of GERD associated with esophagitis?

Beneficial

PPIs (reduce relapse of esophagitis and reflux symptoms at six to 12 months compared with placebo or H2 receptor antagonists)

Likely to be beneficial

H2 receptor antagonists (reduce relapse of esophagitis and reflux symptoms at six to 12 months compared with placebo, but not as effective as PPIs)

Trade-off between benefits and harms

Laparoscopic surgery

Open surgery

Unknown effectiveness

Antacids or alginates

Lifestyle advice or modification

Motility stimulants (with the exception of cisapride)


GERD = gastroesophageal reflux disease; PPIs = proton pump inhibitors.

Clinical Questions

View Table

Clinical Questions

What are the effects of initial treatment of GERD associated with esophagitis?

Beneficial

Histamine H2 receptor antagonists (increase healing of esophagitis compared with placebo, but not as effective as PPIs)

PPIs (increase healing of esophagitis compared with placebo and H2 receptor antagonists; insufficient evidence to compare effects of different PPIs)

Unknown effectiveness

Antacids or alginates

Lifestyle advice or modification

Motility stimulants (with the exception of cisapride)

What are the effects of maintenance treatment of GERD associated with esophagitis?

Beneficial

PPIs (reduce relapse of esophagitis and reflux symptoms at six to 12 months compared with placebo or H2 receptor antagonists)

Likely to be beneficial

H2 receptor antagonists (reduce relapse of esophagitis and reflux symptoms at six to 12 months compared with placebo, but not as effective as PPIs)

Trade-off between benefits and harms

Laparoscopic surgery

Open surgery

Unknown effectiveness

Antacids or alginates

Lifestyle advice or modification

Motility stimulants (with the exception of cisapride)


GERD = gastroesophageal reflux disease; PPIs = proton pump inhibitors.

Definition

GERD is defined as reflux of gastroduodenal contents into the esophagus, causing symptoms sufficient to interfere with quality of life. Persons with GERD often have symptoms of heartburn and acid regurgitation. GERD can be classified according to the results of upper gastrointestinal endoscopy. Currently, the most validated method is the Los Angeles classification, in which an endoscopy result showing mucosal breaks in the distal esophagus indicates the presence of esophagitis. The breaks are graded in severity from grade A (mucosal breaks of less than 5 mm in the esophagus) to grade D (circumferential breaks in the esophageal mucosa). Alternatively, severity may be graded according to the Savary–Miller classification, from grade I (linear, nonconfluent erosions) to grade IV (severe ulceration or stricture).

Incidence

Surveys from Europe and the United States suggest that 20 to 25 percent of persons have symptoms of GERD, and 7 percent have heartburn daily. In primary care settings, about 25 to 40 percent of persons with GERD have esophagitis on endoscopy, but most have endoscopy-negative reflux disease.

Etiology

We found no evidence of clear predictive factors for GERD. Obesity is reported to be a risk factor, but epidemiologic data are conflicting. Smoking and alcohol use are also thought to predispose to GERD, but observational data are limited. It has been suggested that some foods, such as coffee, mints, dietary fat, onions, citrus fruits, and tomatoes, may predispose to GERD. However, we found insufficient data on these factors. We found limited evidence that drugs that relax the lower esophageal sphincter, such as calcium channel blockers, may promote GERD. Studies of twins suggest that there may be a genetic predisposition to GERD.

Prognosis

GERD is a chronic condition, with about 80 percent of persons relapsing once medication is discontinued. Therefore, many persons require long-term medical treatment or surgery. Endoscopy-negative reflux disease remains stable, with a minority of persons developing esophagitis over time. However, persons with severe esophagitis may develop complications, such as esophageal stricture or Barrett esophagus.

Author disclosure: Paul Moayyedi has received fees for speaking and consulting.

Adapted with permission from Delaney B, Moayyedi P. GORD in adults. Clin Evid Handbook. June 2008:173–174. Please visit http://www.clinicalevidence.bmj.com for full text and references.

editor’s note: Cisapride is available in the United States only through a manufacturer research protocol or a compassionate use program.

search date: July 2007

 

This is one in a series of chapters excerpted from the Clinical Evidence Handbook, published by the BMJ Publishing Group, London, U.K. The medical information contained herein is the most accurate available at the date of publication. More updated and comprehensive information on this topic may be available in future print editions of the Clinical Evidence Handbook, as well as online at http://www.clinicalevidence.bmj.com (subscription required). Those who receive a complimentary print copy of the Clinical Evidence Handbook from United Health Foundation can gain complimentary online access by registering on the Web site using the ISBN number of their book.


Want to use this article elsewhere? Get Permissions


Article Tools

  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

Navigate this Article