Heartburn / GORD – when to investigate

A trial of treatment with omeprazole 20 mg once or twice daily for 1 week settles 75% of symptomatic patients. But given the high prevalence of gastroesophageal reflux disease (GERD) and the various complications which can result from inadequate treatment, it is important to have a proper understanding of the current approach to its diagnosis and management.¹ Gastroesophageal reflux is primarily a disorder of the lower esophageal sphincter (LES) but there are several factors, both physiologic and pathologic, that may contribute to its development. While transient lower esophageal sphincter relaxations—brief moments of lower esophageal sphincter tone inhibition that are independent of a swallow—are physiologic in nature, there is an increase in frequency in the postprandial phase and they contribute greatly to acid reflux in patients with GERD.²

Investigate where there is:

• atypical chest pain
• paroxysmal nocturnal asthma
• poor response to treatment
• continuous treatment needed
• before surgery
• dysphagia

Endoscopy (FN 50%)

• nevertheless, still appropriate because it identifies coincidental and not insignificant pathologies, such as:
  • Barrett’s oesophagus
  • H. pylori infection – always causes macroscopic gastritis and affects gastric acid secretion³
  • peptic ulcer disease
  • neoplasia

The Maastricht IV/Florence Consensus Report¹⁹ mentioned that H. pylori status has no effect on symptom severity, symptom recurrence, and treatment efficacy in GORD. Moreover, the Report mentioned that H. pylori eradication does not exacerbate pre-existing GORD or affect treatment efficacy.²⁰ Previously, although H. pylori eradication in patients with GORD was considered to induce unfavourable effects that worsen the symptoms of GORD, recent reports indicate that it can have favourable consequences by reducing symptoms and therefore improving QOL.³

24-hour Ambulatory pH Monitoring

• negative endoscopy and failed treatment

PPls are more effective than H₂ antagonists for relieving symptoms of GORD and healing oesophagitis. PPls are slower to take effect than H₂ antagonists but the effect on gastric acid suppression is stronger and lasts longer.

Reference

1. Badillo, Raul, and Dawn Francis. “Diagnosis and treatment of gastroesophageal reflux disease.” World journal of gastrointestinal pharmacology and therapeutics vol. 5,3 (2014): 105-12. doi:10.4292/wjgpt.v5.i3.105
2. Clarrett, Danisa M, and Christine Hachem. “Gastroesophageal Reflux Disease (GERD).” Missouri medicine vol. 115,3 (2018): 214-218.
3. Masaoka, Tatsuhiro, and Hidekazu Suzuki. “Do we need to eradicate Helicobacter pylori in patients with GORD?.” United European gastroenterology journal vol. 1,4 (2013): 223-5. doi:10.1177/2050640613497713