A guide to GERD, H pylori infection, and Barrett esophagus
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
Keep in mind that the safety of long-term PPI use has not been fully established. While observational studies have shown that long-term PPI use may be associated with adverse events, including kidney damage, Clostridioides difficile infection, osteoporosis, and gastric cancer, subsequent prospective studies have not shown any significant risks with long-term PPI use.2,13,14,16,18,19 If a decision is made to discontinue PPIs after long-term use, the patient should be advised that rebound acid hypersecretion may occur, although this possibility can be mitigated by gradually tapering the PPI dose.
Another maintenance therapy option. Histamine-2 receptor antagonists (H2RAs) are a reasonable alternative to PPIs as maintenance therapy, but they are ineffective in healing esophagitis6,13 and may be best used as adjunctive therapy at bedtime for breakthrough symptoms while a patient is on maintenance PPIs.6,19 Antacids (eg, calcium carbonate, aluminum hydroxide, or magnesium hydroxide) and alginate may provide some symptomatic relief, as well.
When PPIs don’t work. If initial lifestyle changes and PPI treatment do not provide adequate relief, consider the possibility of nonadherence with medication or lifestyle directives. If nonadherence does not appear to be an issue, twice-daily PPI dosing is also an option. Recognize, though, that PPI treatment failure occurs in as many as 40% of patients and is much more common in those with atypical symptoms.6
Consider upper gastrointestinal (GI) endoscopy—and perhaps esophageal manometry or pH testing—if a patient does not respond to empiric treatment with a PPI for 4 to 8 weeks at a standard, once-daily dose.2,4,13 (Alternative diagnoses may also need to be considered.) Upper endoscopy is also appropriate for patients who have symptoms concerning for malignancy (progressive dysphagia, unintentional weight loss, or bleeding).
Esophagitis detected on endoscopy confirms GERD, although it is seen in only 18% to 25% of patients with GERD symptoms.2,4 (The absence of esophagitis only indicates a lack of mucosal injury and not the absence of GERD.4) Acid exposure can cause fibrotic scarring and, in turn, strictures visible on endoscopy.2 BE, the precursor to esophageal adenocarcinoma, is also a complication of GERD and is defined by columnar metaplasia replacing the normal squamous cell esophageal epithelium; it is detected on pathology review of biopsies.2
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