Approach to the evaluation and management of adults with refractory gastroesophageal reflux symptoms

BMI: body mass index; CYP2C19: cytochrome P450 2C19; GERD: gastroesophageal reflux disease; GI: gastrointestinal; H2RA: histamine 2 receptor antagonist; IBS: irritable bowel syndrome; NERD: nonerosive reflux disease; PCAB: potassium-competitive acid blocker; PPI: proton pump inhibitor.

* Documented GERD refers to patients with objective evidence of GERD on upper endoscopy or any type of pH testing.

¶ Some UpToDate contributors would perform an upper endoscopy in any patient with alarm symptoms, even if the patient had a normal endoscopy in the preceding 6 months. Targeted diagnostic workup might include abdominal imaging for pancreatic cancer or gallstones, or cardiopulmonary testing for those with heartburn symptoms suggestive of cardiac ischemia.

Δ Refer to UpToDate content on the management of GERD for details.

◊ Patients should take H2RAs at a different time than PPIs (eg, at bedtime if PPI is taken in the morning). Aluminum hydroxide-magnesium carbonate is an alginate-containing liquid antacid.

§ Patients on a PPI can switch to a different once-daily PPI (preferred) or a PCAB. Some UpToDate contributors preferentially switch to rabeprazole or esomeprazole because they are less susceptible to the effect of "rapid" or "ultrarapid" CYP2C19 metabolizer phenotypes.

¥ Baclofen 5 to 20 mg at bedtime.

‡ Twice-daily PPI doses include rabeprazole 20 mg twice daily, omeprazole 20 or 40 mg twice daily, esomeprazole or pantoprazole 40 mg twice daily, and lansoprazole 30 mg twice daily.

† Some experts perform esophageal manometry only in those with normal pH testing or with symptoms concerning for an esophageal motility disorder (eg, dysphagia).

** Start low initial dose (eg, nortriptyline 10 mg, citalopram 10 mg, fluoxetine 10 mg) and gradually increase to the lowest effective dose, based on symptom response and patient tolerance.

¶¶ Patients with supragastric belching have spikes of increased esophageal impedance that migrate proximally on impedance pH testing. Symptoms of postprandial fullness and epigastric pain may indicate dyspepsia. Gastroparesis is suggested by symptoms of nausea, vomiting, early satiety, postprandial fullness, and bloating; diagnosis is confirmed by gastric emptying studies. Predominant lower GI symptoms are suggestive of IBS.

ΔΔ Refer to UpToDate content on the management of esophageal motility disorders.