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EnhancedPrimaryCarePathway:GERD

1.FocusedsummaryofGERDrelevanttoprimarycare

Therefluxofgastriccontentsintotheesophagusisanormalphysiologicalphenomenon.Refluxisdeemedpathologicalwhenitcausesesophagealinjuryorproducessymptomsthataretroublesometothepatient,typicallyheartburnandregurgitation,aconditionknownasgastroesophagealrefluxdisease.GERDisverycommoninprimarycarepracticeandeasytorecognizeinitstypicalform,generallyrequiringnoinitialinvestigations.TreatmentattheprimarycarelevelisfocusedonlifestyleanddietarymodificationstoavoidGERDtriggersandachievehealthybodyweight,andoptimaluseofprotonpumpinhibitor.Ifheartburnisadominantsymptom,thedifferentialdiagnosisincludesvariouscausesofesophagitis(infectious,pill-induced,eosinophilic),pepticulcerdisease,non-ulcerdyspepsia,coronaryarterydisease,biliaryandpancreaticdisease.Insomepatients,GERDhasawiderspectrumofsymptomsincludingchestpain,dysphagia,globussensation,odynophagia,nauseaandwaterbrash.Asrefluxtendstooccuraftereating,thereisoftenoverlapofGERDanddyspepsia,whichreferstopostprandialepigastricdiscomfort.ApresumptivediagnosisofGERDcanbemadeinpatientswithanyoftheclinicalsymptomsdescribedabove,andgenerallynoinvestigationsarerequiredaspartofinitialworkup.ScreeningforH.pyloriisnotrecommendedinGERD.MostpatientswithGERDwillhaveimprovementorresolutionofsymptomswhentreatedwithPPI.Endoscopyiswarrantedinpatientspresentingwithdysphagiaorotheralarmfeatures,andinthoserefractorytoadequateinitialandoptimizedPPItreatments.EsophagealpHorimpedence-pHrefluxmonitoringstudiesaresometimesarrangedbyGIafterendoscopy.GERDcanbecomplicatedbyBarrett’sesophagus,esophagealstrictureand,rarely,esophagealcancer.ScreeningforBarrett’sesophagusisanotherindicationforendoscopy,butspecificcriteriamustbemet:

o ChronicGERD(≥10years)plustwoormoreriskfactors:o >50yearsofageo Malegendero Caucasiano BMI≥30o Waistcircumference>35”forfemalesor>40”formaleso Hiatalhernia(demonstratedradiographically)o FamilyhistoryofesophagealcancerorBarrett’s

o GERDiswellcontrolledwithonceortwicedailyPPI

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2.Checklisttoguideyourin-clinicreviewofthispatientwithGERDsymptoms

o SymptomsofGERDwithoutalarmfeatures

o IfdyspepsiaoverlapswithGERD,followEnhancedPrimaryCarePathway:DYSPEPSIA,availableatwww.calgarygi.com

o LifestylefactorsthatcontributetoGERDhavebeenidentifiedanddiscussedwithyourpatient.Ifapplicable,weightlossisessentialtomanagementofGERD,andyourpatientshouldbeguidedandmonitoredtoachievespecificgoals.

o PatientadherenttoinitialtrialofPPIfor8weeks,followedbyreviewandoptimization3.LinkstoadditionalresourcesforphysiciansandpatientsCalgaryGIDivisionhttp://www.calgarygi.com

WeightManagementMyHealth.Alberta.cahttps://myhealth.alberta.ca/health/pages/conditions.aspx?Hwid=aa122915

WeightWiseAdultCommunityProgramhttp://www.albertahealthservices.ca/services.asp?pid=service&rid=1060802

AlbertaHealthyLivingProgramhttp://www.albertahealthservices.ca/services.asp?pid=service&rid=1005671

CanadianDigestiveHealthFoundationhttp://www.cdhf.ca/en/disorders/details/id/11

UpToDate®–BeyondtheBasicsPatientInformation(freelyaccessible)http://www.uptodate.com/contents/acid-reflux-gastroesophageal-reflux-disease-in-adults-beyond-the-basics?source=search_result&search=GERD+beyond+the+basics&selectedTitle=2~150

4.Clinicalflowdiagramwithexpandeddetail

This AHS Calgary Zone pathway incorporates the most current evidence-based clinical guidelines fordiagnosisandmanagementofGERDfrombothGastroenterologyandPrimaryCareliterature:Katzetal.Guidelinesforthediagnosisandmanagementofgastroesophagealrefluxdisease.AmJGastroenterol.108:308-28,2013Flooketal.Approachtogastroesophagealrefluxdiseaseinprimarycare:PuttingtheMontrealdefinitionintopractice.CanFamPhysician.54:701-5,2008Kahrilasetal.AmericanGastroenterologicalAssociationInstitutetechnicalreviewonthemanagementofgastroesophagealrefluxdisease.Gastroenterology135:1392-1413,2008.Armstrongetal.Canadianconsensusconferenceonthemanagementofgastroesophagealrefluxdiseaseinadults.CanJGastroenterol.19:15-35,2005TreatmentofGastroesophagealRefluxDiseaseinAdults.TowardOptimizedPracticehttp://www.topalbertadoctors.org/cpgs/3294128

The following is a best-practice clinical pathway formanagement of GERD in the primary caremedicalhome,whichincludesaflowdiagramandexpandedexplanationoftreatmentoptions:

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FlowDiagram:GERDDiagnosisandManagement-ExpandedDetail1. ApresumptivediagnosisofGERDcanbemadeinpatientswithtypicalsymptomsofheartburnandregurgitation.

ThepresenceofthesesymptomsisquitespecificforGERD.IfpatientswithsuspectedGERDhavechestpainasadominantfeature, cardiac causes should first be excluded. In the presence of any red flags, referral to Gastroenterology forconsideration of urgent endoscopic investigation is recommended, even though the predictive value of some of thesefeaturesissomewhatlimited.

2. Featuresofdyspepsiashouldbesought.Ifthepatient’sdominantsymptomispostprandialepigastricpainandbloating,pleaserefer to theEnhancedPrimaryCareDYSPEPSIApathway(availableatwww.calgarygi.com).GERDanddyspepsiaclinicalpathwaysaresufficientlydistinctand,inparticular,theinitialassessmentofdyspepsiainvolvestestingforH.pyloriandotherlaboratoryinvestigations,whicharenotrequiredinpatientswithGERD.

3. Non-pharmacologicalprinciplesofGERDmanagement.

• Weightlossinpatientswhoareoverweight,orinthosewhohaverecentlygainedweightevenifnormalbodymassindex

• Headofbedelevation(blocksorfoamwedges)andavoidmeals3hbeforebedtimeifnocturnalGERD• Elimination of prototypic GERD triggers (smoking, alcohol, caffeine, carbonated beverages,

spicy/fatty/acidic foods, chocolate andmint) is reasonable, but is not supported by clear evidence ofphysiologicalorclinicalimprovementofGERD.Ratherthanfoodtriggers,itislikelyhigheryieldtoprovidedietarycounselingtoGERDpatientstoaffectweightloss.

4. Trialofprotonpumpinhibitor

• AlthoughPPIsare themainstayofGERDtherapy, thereremainsa role forH2RAorantacids (alginates,Ca/Mg/Al salts) inpatientswithmild, infrequent, episodic symptoms.Theseprovide rapidon-demandreliefofheartburnandavoidprematurelycommittingsomepatientstolong-termuseofPPI.

• Forpatientswithmoretroublesomesymptoms,PPIprovidesmoreeffectivelong-termrelief.• An 8-week trial of standard once-daily PPI is recommended (omeprazole 20mg, rabeprazole 20mg,

lansoprazole30mg,pantoprazole40mg,esomeprazole40mg,dexlansoprazole30mg).Therearenomajordifferences in efficacy between these agents. All PPI should be administered 30-60 minutes beforebreakfastwiththeexceptionofdexlansoprazole,whichisadualdelayedreleaseformulationthatcanbetakenatanytimeofdayregardlessoffoodintake.

• If symptomsare resolved, PPI shouldbe titrated to lowest effectivemaintenancedose (there arehalf-standarddosesofmostPPIavailablee.g.lansoprazole15mg)orevenattempttodiscontinue,especiallyifweightreductionhasbeenachieved.

• Potential side effects of PPI include headache and diarrhea,whichmay not occurwhen switched to adifferentPPI.ThereissomeevidencethatPPIuseisassociatedwithC.difficilecolitisandotherentericinfections,andshouldbeusedwithcautionincertainpatientsatrisk.

5. OptimizePPI

• Itisestimatedthatone-thirdofpatientswithtypicalGERDwillnotadequatelyrespondtoPPI.FactorsthatpredictPPIfailureareobesityandpooradherencetoPPItreatment.

• Patientnon-adherencetotreatmentwithPPIiscommon.ConfirmthatthepatienthastakentheintendeddoseofPPIonadailybasis,30minutesbeforebreakfastfor8weeks.

• Ifsuboptimalresponse,switchtoanotheroncedailyPPI(e.g.esomeprazole)ortryhigh-dosePPI(standarddosePPItwicedaily30minutesbeforebreakfastandsupperordexlansoprazole60mgoncedaily)foranadditional 8 weeks. The clinical and pharmacodynamic data to support this is actually fairly limited,however.

6. RefractoryGERD.PatientswithpersistenttroublesomeGERDsymptomsshouldbereferredtoGICentralAccessandTriage

fordiagnosticevaluation(endoscopy±pH/impedancerefluxmonitoring)todiscernGERDfromnon-GERDetiologies.