A guide to GERD, H pylori infection, and Barrett esophagus

The Journal of Family Practice. 2022 June;71(5):E1-E7

June 13, 2022|Family Medicine

Megan Everson, MD;Alice M. Boshoven, MD;Allen Last, MD, MPH

How long should you treat GERD with a PPI? When should you order an endoscopy or test for Helicobacter pylori? How might H pylori treatment choices vary with a patient’s antibiotic history?

PRACTICE RECOMMENDATIONS

› Recommend endoscopy for patients with gastroesophageal reflux disease (GERD) and red flag symptoms: dysphagia, unintentional weight loss, or bleeding. B

› Recommend long-term use of a proton pump inhibitor at the lowest tolerated dose in patients with esophagitis or Barrett esophagus. C

› Test for Helicobacter pylori in patients with peptic ulcer disease, in those with past ulcers not investigated for H pylori, and in those starting chronic nonsteroidal anti-inflammatory drug therapy. A

› Use a urea breath test, stool antigen study, or endoscopically obtained biopsy to test for H pylori. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Additionally, adequate acid suppression is directly related to successful eradication. Thus, the likelihood of treatment success can be improved by using higher doses of PPIs and avoiding ones that are more likely to be metabolized quickly in some patients (lansoprazole, omeprazole). Patient adherence to the treatment regimen is an important determinant of effectiveness.^9,29 Adding vitamin C 400 to 1000 mg/d, vitamin E 100 to 400 mg/d, and probiotics may improve the effectiveness of treatment.^9,30

Duration of treatment is directly related to treatment effectiveness. Whenever possible, opt for 14 days of treatment instead of just 7.⁹

Test of cure. Patients treated for H pylori should be re-tested no sooner than 4 weeks after completion of therapy. Urea breath testing, stool antigen testing, and endoscopic biopsies (if endoscopy is indicated for some other reason) can all be used post treatment for test of cure.⁹

Barrett esophagus

Chronic reflux can lead to BE, in which metaplastic columnar epithelium replaces the normal squamous epithelium lining the distal esophagus. BE is linked to dysplasia and esophageal adenocarcinoma (EAC).¹¹ Endoscopic examination with biopsy is used to diagnosis BE. The global prevalence of histology-confirmed BE in people with GERD symptoms is 7.2%.¹⁰ Similar to GERD and H pylori infections, the prevalence of BE varies significantly with geographic location (14% in North America; 3% in the Middle East).¹⁰ BE is twice as likely to occur in men as in women, and it is rare in children.¹⁰

Whom to screen

The American College of Gastroenterology recommends consideration of screening with upper endoscopy for men with chronic GERD (> 5 years) or frequent GERD symptoms (once weekly or more often), plus 2 or more of the following risk factors: age > 50 years, Caucasian race, central obesity, smoking (current or past), or a family history of BE or EAC (TABLE 1^2,9-11). Screening for BE in women is not routinely recommended but can be considered in individuals with several of the risk factors just described.

Continue to: Not everyone with BE...

References

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