GI Conditions
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      Gastroesophageal Reflux Disease

      Condition: Gastroesophageal Reflux Disease (GERD)

      Brief Overview: According to NIDDK, “Gastroesophageal reflux (GER) happens when your stomach contents come back up into your esophagus. Many people have GER occasionally, and GER often happens without causing symptoms. Gastroesophageal reflux disease (GERD) is a more severe and long-lasting condition in which GER causes repeated symptoms that are bothersome or leads to complications over time.”

      Prevalence: The prevalence of GERD is estimated to be 15-30% in Western countries.

      Etiology: GERD develops when your lower esophageal sphincter becomes weak or relaxes when it shouldn’t. When this happens, the lower esophageal sphincter allows acid/stomach contents to pass back up into the esophagus.

      Risk Factors:

      • Obesity
      • Pregnancy
      • Estrogen replacement therapy in postmenopausal women
      • Specific diet and medications
      • Stress, sleep deprivation
      • Hiatal hernia
      • Tobacco use

      Commonly Associated Conditions:

      • Hiatal hernia
      • Barrett’s esophagus
      • Obesity
      • Scleroderma
      • Asthma
      • Esophagitis

      Common Medications:

      • Proton Pump Inhibitors (PPIs) – omeprazole, lansoprazole, pantoprazole, esomeprazole
      • Antacids – Maalox, Tums, Mylanta
      • Histamine blockers – Pepcid, Tagamet

      Dosing of Common Medications

      1. Antacids (OTC, quick relief)
      • Calcium carbonate (Tums, Rolaids)
        • Common dose: 500–1000 mg orally, as needed, up to several times daily.
        • See label on package. Ask healthcare provider for safe dosing.
      • Calcium carbonate/magnesium hydroxide/simethicone (Mylanta)
        • Common dose: 10–20 mL orally PRN; Max 60mL/24h up to 2wk
      1. H2 Receptor Blockers (H2RAs)
      • Famotidine (Pepcid)
        • Typical dose: 20 mg BID up to 6wks
        • Note: Sometimes up to 40 mg twice daily up to 12wks
      • Cimetidine (Tagamet)
        • OTC: 1600mg/day PO divided BID-QID x 12 wks
        • Note: give with food
      • Nizatidine
        • 150 mg twice daily
      • Ranitidine (Zantac) — withdrawn from market (NDMA contamination).
      1. Proton Pump Inhibitors (PPIs) (most effective for frequent symptoms)
      • Omeprazole (Prilosec)
        • 20 mg once daily before breakfast (up to 40 mg daily if prescribed).
      • Esomeprazole (Nexium)
        • 20–40 mg once daily before breakfast.
        • Note: take 1 hour before meals
      • Lansoprazole (Prevacid)
        • 15–30 mg once daily before breakfast.
      • Pantoprazole (Protonix)
        • 40 mg once daily before breakfast.
      • Rabeprazole (Aciphex)
        • 20 mg once daily before breakfast.
      • Dexlansoprazole (Dexilant)
        • 30–60 mg once daily.
      1. Prokinetic Agents (less common, used if motility issues contribute)
      • Metoclopramide (Reglan)
        • 5-15 mg up to 4 times daily up to 12wks, 30 minutes before meals and at bedtime.
        • ⚠️ Caution: Black Box Warning - risk of side effects (tardive dyskinesia with long-term use, especially elderly females).

      ⚠️ Key Points for Coordinators & Patients:

      • **Please do not advise the patient to take any medications, even OTC. This is just a guide for your reference if the patient reports they are taking/have been prescribed any of these medications.**
      • PPIs are usually taken 30–60 minutes before breakfast.
      • Medication adjustments (dose, timing, duration) should always be guided by the patient’s healthcare provider.

      Common Labs, Imaging, and Tests:

      • The diagnosis is typically made based on symptoms, but an upper endoscopy with biopsy, prolonged esophageal pH study, or esophageal manometry may be indicated for some patients

      Common Symptoms:

      • Heartburn
      • Regurgitation
      • Dysphagia – difficulty swallowing
      • GERD-related chest pain
      • Globus sensation – feeling like there is a lump in the throat
      • Chronic cough, hoarseness, wheezing, sore throat

      Common Treatments:

      • Medications (see above)
      • Lifestyle changes
        • Weight loss if indicated
        • Raising the head of the bed 6-8 inches
        • Wait 3 hours after eating before going to bed
        • Sleep on left side
        • Avoid triggering foods
        • Smoking cessation
        • Wear loose, comfortable clothing

      Physical Findings:

      • Typically, normal physical exam
      • Possible dental enamel erosion
      • Epigastric tenderness may be present

      Potential Complications and Contraindications:

      • Erosive esophagitis
      • Esophageal stricture
      • Barrett’s Esophagus
      • Pneumonia
      • Asthma symptoms or asthma exacerbations
      • Permanent lung damage
      • Dental problems – enamel erosion

      General Health and Lifestyle Guidance:

      • Keep a food/symptom log to identify any trigger foods
      • Eat smaller, more frequent meals
      • Generally, it is recommended to avoid: acidic foods (citrus, tomatoes), alcohol, chocolate, coffee, caffeine, high-fat foods, peppermint, spicy foods
      • You can elevate the head of your bed by putting wood blocks under the legs or adding a foam wedge over the mattress. You may be able to buy a commercial product for this purpose
      • Smoking cessation
      • See lifestyle changes listed above

      Suggested Questions to Ask Patients:

      • How often do you experience heartburn or regurgitation?
      • Do symptoms worsen after meals or at night?
      • Are you currently using any over-the-counter or prescription medications for reflux?
      • Have you had difficulty swallowing or unexplained weight loss?
      • Do you wake up with coughing, choking, or sore throat?

      Potential Questions to Ask if Patient Reports A Symptom

      • How long has this been going on? Or, when did this start?
      • Is it constant, or does it come and go?
      • How would you rate the severity? Mild, moderate, or severe?
      • Can you describe the symptom?
      • How often does this happen? Multiple times per day, daily, weekly, occasionally, etc.
      • How long does each episode last?
      • Is it getting better, worse, or staying the same?
      • What seems to make it better, worse?
      • Have you tried anything that helps the symptom?
      • Have you noticed anything specific that brings the symptom on?
      • Does it interfere with your daily life, activities?
      • Have you noticed any other symptoms that happen at the same time?
      • Have you ever experienced this before in the past?
      • Any recent changes in medications, lifestyle, diet, etc.?
      • Have you reported this to your healthcare provider yet?
      • If the answer is yes – what did your healthcare provider say?
      • If the answer is no – advise to call to report this to healthcare provider

      Common Trigger Foods

      • Beverages
        • Coffee (regular and decaf, due to acidity/caffeine)
        • Tea (especially black tea)
        • Alcohol (beer, wine, liquor)
        • Carbonated beverages (soda, sparkling water)
        • Citrus juices (orange, grapefruit, lemonade)
      • Fruits & Vegetables
        • Citrus fruits (oranges, grapefruits, lemons, limes)
        • Tomatoes and tomato-based foods (sauce, ketchup, salsa)
        • Onions (especially raw)
        • Garlic (particularly raw)
      • High-Fat / Fried Foods
        • Fried foods (french fries, fried chicken, doughnuts)
        • Fast food
        • High-fat meats (sausage, bacon, pepperoni)
        • Full-fat dairy (cheese, whole milk, cream, ice cream)
      • Spicy or Strongly Flavored Foods
        • Chili powder, hot peppers, hot sauce
        • Spicy dishes (curries, Mexican, Szechuan)
        • Strong spices (black pepper, mint, peppermint, spearmint)
      • Other
        • Chocolate (contains both caffeine and fat)
        • Peppermint/candy canes/mint tea
        • Large or heavy meals (not a food type, but a major trigger)

      ⚠️ Note for patients: Not every person reacts to the same foods. It’s best to keep a food and symptom diary to identify personal triggers.

      Suggested Talking Points:

      • Your PCP may manage your condition, or you may be referred to a GI specialist
      • Make sure to report any new, worsening, or persistent symptoms to your healthcare provider

      Suggested SMART Goal Examples

      1. Meal Timing: “I will stop eating at least 3 hours before bedtime every night for the next 4 weeks.”
      2. Meal Size: “I will replace one large dinner with two smaller meals three days per week for the next month.”
      3. Trigger Foods: “I will avoid spicy foods at dinner and keep a food diary to track symptoms for the next 2 weeks.”
      4. Caffeine Intake: “I will reduce coffee intake from 2-3 cups to 1 cup per day for the next 30 days.”
      5. Bed Elevation: “I will elevate the head of my bed by 6-8 inches by the end of this week to help reduce nighttime reflux. I will keep a log of my symptoms for the next 30 days.”
      6. Weight Management: “I will walk for 10-20 minutes at least 5 days per week for the next 4 weeks to support weight management and reduce reflux risk.”
      7. Medication Adherence: “I will take my reflux medication 30 minutes before breakfast every morning (or specifically as directed by healthcare provider) for the next 30 days.”
      8. Alcohol Reduction: “I will limit alcohol to no more than 1 drink per week for the next month.”
      9. Carbonated Beverages: “I will substitute water for soda at least 5 days per week for the next 4 weeks.”
      10. Symptom Tracking: “I will record my meals and reflux symptoms daily (or x days per week if daily is overwhelming/unattainable) in a diary for the next 4 weeks to identify triggers.”

       

      Sources:

      This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.