GERD Chalk Talk

 GERD

Causes: weak lower esophageal sphincter tone, H pylori

HPI: Eating habits, types of foods and beverages, medications: anticholinergics, opioids, positional symptoms, body habitus, extra esophageal, esophageal, Red Flag symptoms (dyspepsia, GI bleed, IDA, wt. loss)

Diagnostics: Endoscopy w/ bx, manometry, barium swallow (esophagram), pH impedence (avoid in pts w/ transphenoidal fractures, pituitary surgery, nasal fractures)

Txtmt: 

lifestyle modification: avoidance of foods and meals 2-3 hours before bed

Medications: PPI: 8wk PPI trial before eating, split PPI pantoprazole 40mg (20mg 20mg) or 40mg BID, lansoprazole 30mg, famotidine 40mg

Surgery: Laparoscopic fundoplication (LES tone), bariatric surgery

Specialists: gastroenterologist, pulmonologist, otolaryngologist

Adverse effects of PPI: 

The DeMeester score is a composite scoring system used during ambulatory pH monitoring to quantify esophageal acid exposure and help diagnose GERD. A score of ≥14.7 indicates abnormal acid reflux. [1-2] The score incorporates six parameters measured during 24-48 hours of pH monitoring: percentage of time pH <4 (total, upright, and supine), total number of reflux episodes, number of episodes lasting >5 minutes, and duration of the longest episode. [2]

More recent guidelines suggest that extreme acid exposure (DeMeester score >50 or acid exposure time >12%) represents severe GERD and may warrant more aggressive management. [3] While the DeMeester score remains a reliable diagnostic tool, current practice increasingly emphasizes acid exposure time (AET) as a simpler metric, with AET >6% confirming GERD and <4% suggesting GERD is unlikely. [4-5] A 2025 study found the DeMeester score demonstrated superior discriminatory ability (AUC 0.90) compared to other metrics when using a cutoff of 15.6. [6]

Voquezna (vonoprazan) is a potassium-competitive acid blocker (PCAB), a newer class of acid suppression medication that differs from traditional PPIs. [7] It was FDA-approved in the U.S. for healing erosive esophagitis, maintenance therapy, relief of heartburn in non-erosive GERD, and H. pylori eradication. [8-9] Key advantages include faster onset of action (2-3 hours), no requirement for meal timing, and more consistent acid suppression compared to PPIs. [7-8]

For erosive esophagitis, vonoprazan 20 mg daily demonstrated non-inferiority to lansoprazole 30 mg for healing (92.9% vs 84.6% at 8 weeks) and superiority for maintenance of healing (79.2% vs 72.0% at 24 weeks). [7][10] It appears particularly effective in severe erosive esophagitis. [11] However, current evidence suggests no clear advantage over less expensive PPIs for most patients, except potentially in clarithromycin-resistant H. pylori infection. [10]

High-resolution manometry (HRM) is indicated in several GERD-related scenarios but does not diagnose GERD itself. [4] Primary indications include: (1) Pre-operative evaluation before any antireflux surgery or endoscopic therapy to rule out achalasia and assess for absent contractility, which would be contraindications to fundoplication; [4][12] (2) Refractory GERD evaluation when symptoms persist despite PPI therapy and other testing is negative, to identify alternative diagnoses like achalasia (found in 1-3% of refractory cases), esophageal spasm, or rumination syndrome; and [4][12] (3) Non-cardiac chest pain unresponsive to PPI therapy to assess for esophageal dysmotility. [12]

HRM also helps position pH monitoring catheters by locating the lower esophageal sphincter and can identify ineffective esophageal motility, which may predict post-operative dysphagia risk. 

Patients with refractory symptoms — We reserve fundoplication for patients with symptoms refractory to medical therapy in whom we can document ongoing (non)acid reflux being associated with symptoms. Fundoplication has the potential to reduce non-acid reflux by strengthening anatomic antireflux mechanisms [23-25]. In one study of 15 patients off PPI therapy before and seven months after laparoscopic Nissen-Rossetti fundoplication found that laparoscopic fundoplication improved acid reflux parameters (percent time pH <4 and DeMeester score) and the total number of impedance-detected episodes of both acid and non-acid reflux (figure 4) [23]. In a randomized trial that included 366 patients with persistent reflux symptoms on PPI therapy [26], 78 patients with documented reflux-related heartburn were randomized to undergo antireflux surgery (laparoscopic Nissen fundoplication) or receive active treatment (twice daily PPI plus baclofen with desipramine based on the symptoms) or control treatment (twice daily PPI). Treatment success in the surgery group was significantly higher compared with active medical treatment and control groups (67, 28, and 12 percent, respectively), suggesting that a highly selected group of patients with documented reflux-related heartburn refractory to PPI therapy benefits from laparoscopic Nissen fundoplication. However, patients must also be counseled on the existing data supporting laparoscopic Nissen fundoplication, which show that response rates are not as high as those published in surgery versus PPI trials [27,28]. In addition, predicting which patients will respond to fundoplication is also challenging. A retrospective review of 34 pediatric patients having fundoplication concluded that none of the reflux parameters detected on preoperative MII-pH testing predicted the outcome of antireflux surgery [29]. (See "Surgical treatment of gastroesophageal reflux in adults", section on 'Complete fundoplications' and "Approach to refractory gastroesophageal reflux symptoms in adults".)
[4][13]