Gastroesophageal Reflux Disease

[2012 update]

Introduction to this self-study CME activity

Purpose

Gastroesophageal reflux disease (GERD) is a common chronic, relapsing condition that carries a risk of significant morbidity and possible mortality from resultant complications.  The lack of a gold standard in the diagnosis of GERD presents a clinical dilemma in treating patients with reflux symptomatology.  This CME activity helps clinicians understand and implement a cost-effective and evidence-based strategy for the diagnosis and treatment of GERD reflux disease. The educational material provides useful summaries on practical aspects of care, including an algorithm for steps in diagnosis and treatment, atypical and warning signs, and information on pharmacologic therapy. 

New in this update are several aspects of treatment and evaluation:

Treatment

  • A response to a short (2 week) course of a proton-pump inhibitor (PPI) often supports a diagnosis of GERD.
  • On-demand therapy with PPIs is the most cost-effective method for GERD treatment, as generic omeprazole is currently the least expensive PPI.
  • Aggressive acid reduction using PPIs BID before meals for at least 2-3 months is the standard treatment for atypical GERD and can demonstrate a causal relationship between GERD and extra-esophageal symptoms.
  • Evidence is insufficient to conclude that PPI treatment benefits cough associated with GERD in adults.
  • Patients should not be left on anti-secretory therapy without symptom re-evaluation to minimize cost and potential adverse events (e.g., Clostridium difficile-associated diarrhea; community acquired pneumonia; osteoporotic fracture; vitamin B12, calcium, and magnesium deficiencies, interactions with clopidogrel).

Evaluation

  • Recent advances in “wireless” pH radiotelemetry capsule technology eliminates the need for the uncomfortable nasoesophageal tube for pH probe evaluation, and increases diagnostic yield by allowing for longer monitoring (e.g., 48-hour and 96-hour).
  • Intraluminal impedance monitoring can detect “nonacid” (e.g., liquid/gas) reflux, important in refractory patients with regurgitation who are being considered for surgery or in patients with atypical symptoms.

Key aspects of care include:

  • An empiric medication trial without diagnostic testing can identify GERD in most patients.
  • Treat with either PPIs or histamine-2 receptor antagonists (H2RAs), with drug selection depending upon clinical efficacy and cost-effectiveness.
  • Non-erosive reflux disease (NERD): step-up therapy (H2RA followed by PPI if no improvement) and step-down (PPI followed by the lowest dose of acid suppression) therapy are equally effective for both acute treatment and maintenance therapy.
  • Erosive esophagitis: PPI therapy is the treatment of choice in acute and maintenance therapy
  • PPIs should be taken 30–60 minutes before a meal (e.g., daily: breakfast, BID: breakfast & dinner), not at bedtime, to optimize effectiveness.  Increase single dose strength before increasing dosing frequency.
  • Warning signs, including non-response to treatment, require diagnostic testing and referral to a GERD specialist.  PPI therapy is treatment of choice in acute and maintenance therapy.

Objectives

Participants in this CME activity will understand and be able to implement evidence-based cost-effective clinical strategies for the diagnosis and treatment of GERD in adults.

Audience

This self-study activity is appropriate for primary care clinicians and other health care providers involved in the diagnosis and treatment of GERD in adults.

Authors

Team Leaders

  • Joel J. Heidelbaugh, MD
    Family Medicine

Team Members

  • R. Van Harrison, PhD
    Medical Education
  • Mark A McQuillan, MD
    Medical Education
  • Timothy T. Nostrant, MD
    Gastroenterology

Author Disclosures

Neither the team lead, the team members, nor the consultants have financial relationships with commercial companies whose products are discussed in this CME activity.
Joel J Heidelbaugh, MD
(None)
R Van Harrison, PhD
(None)
Mark A McQuillan, MD
Speakers Bureau
Tadeka, Pfizer, Astra Zeneca
Timothy Nostrant, MD
(None)

Other Acknowledgements

UMHS Guidelines Oversight Team

  • Karl T. Rew, MD
  • R. Van Harrison, PhD

Literature Search Services

  • Taubman Medical Library

Production of Internet Format and Website Maintenance

  • Ellen Patrick, MA

CME Accreditation and Credit Designation

The University of Michigan Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Michigan Medical School designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This CME activity was prepared for release in May 2012 with credit available through April 2015. The activity was reviewed for currency of content in March 2015 and availability of credit extended through March 2018. The activity was reviewed for currency of content in March 2018 and availability of credit extended through February 2021. Continuation of credit from that date depends on a thorough review of the content currency and accuracy.

Method of Participation

  1. View the web pages. You may print the self-study text to read off-line.
  2. Complete the on-line learning assessment test with a score of 70% or higher.  After you initially take the test, the test will be immediately electronically scored. 
    If fewer than 70% of the questions are answered correctly, the questions that were not answered correctly will be noted in red.  Review the CME content related to those topics and retake the test.
    If 70% or more of the questions are answered correctly, the correct and incorrect answers for all questions will be shown along with explanations of the basis for the correct answer.  The link to register and receive credit is shown at the end of the items and explanations. 
  3. Complete the electronic credit request and activity evaluation.  An electronic certificate of participation will be provided immediately.
  4. Print the certificate of participation for your personal records.