Treatment

The initial management of GERD consists of implementing lifestyle changes and initiating acid suppression therapy, preferably with PPIs. Surgical therapy is not routinely indicated and should only be considered in select cases, e.g., patients who develop complications despite receiving optimal medical therapy.

• PPIs: standard dose of PPI for 8 weeks

  • Indications

    • Empiric PPI trial in patients with typical symptoms

    • After EGD: ERD or presumed NERD

  • Continuous management (based on the clinical response after 8 weeks)

    • Good response and no complications: Discontinue PPI.

    • Good response in patients with complications : Continue PPI at maintenance dose.

    • Partial response: Increase dose (to twice-daily therapy), adjust timing, or switch to a different PPI.

    • No response: further diagnostic evaluation

• H2 receptor antagonists: Consider as alternate maintenance therapy

• Maintenance therapy: lowest effective dose of acid suppression medication

A negative response to a PPI trial does not exclude GERD.

There is conflicting evidence as to which lifestyle modifications confer a significant benefit. The following recommendations are commonly mentioned in the literature but should be approached on a case-by-case basis, as they may offer relief only for some patients.

• Dietary recommendations

  • Small portions

  • Avoid eating at least 2–3 hours before bedtime.

  • Avoid foods and beverages that appear to trigger symptoms.

• Physical recommendations

  • Weight loss in patients with obesity

  • Elevate the head of the bed (10–20 cm) for patients with nighttime symptoms.

• Reduce or avoid triggering substances

  • Tobacco, alcohol, and/or caffeine if the patient experiences correlation with symptoms

  • Medications that may worsen symptoms (e.g., CCBs, diazepam)

Antireflux surgery may be considered for select patients after careful evaluation.

Indications

• Discontinuation of medical therapy (e.g., due to nonadherence or side effects)

• Symptoms refractory to medical therapy

• Complications despite optimal medical therapy, e.g., severe esophagitis, strictures, recurrent aspiration

• Large hiatal hernia

• Definition: an antireflux procedure in which the gastric fundus is wrapped around the lower esophagus and secured with stitches to form a cuff; results in a narrowing of the distal esophagus and the gastroesophageal junction (GEJ), preventing reflux

• Approach: Laparoscopic and open fundoplication are possible.

• Techniques

  • Partial fundoplication (fewer complications)

    • 180° (Dor fundoplication)

    • 270° (Toupet fundoplication)

  • Complete fundoplication (Nissen fundoplication): 360°

• Complications

  • Gas bloat syndrome: inability to belch, leading to bloating and an increase in flatulence

  • Dysphagia

  • Recurrence of reflux esophagitis

• Considerations for patients with comorbidities

  • Patients with obesity and reflux undergoing bariatric surgery: Consider Roux-en-Y.

  • Hiatal hernias: Combine fundoplication with hiatoplasty and, in some cases, gastropexy.