Gastroesophageal reflux disease (gerd). _ national guideline clearinghouse

Note from the University of Michigan Health System (UMHS) and the National Guideline Clearinghouse (NGC): The following guidance was current as of May 2012. Heartburn acid reflux remedy Because UMHS occasionally releases minor revisions to its guidance based on new information, users may wish to consult the original guideline document for the most current version.

Note from NGC: The following key points summarize the content of the guideline. Lemon water for heartburn Refer to the full text for additional information, including detailed information on dosing, possible side effects, and cost of medications.


• History. Instant relief from heartburn If classic symptoms of heartburn and acid regurgitation dominate a patient’s history, then they can help establish the diagnosis of gastroesophageal reflux disease (GERD) with sufficiently high specificity, although sensitivity remains low compared to 24-hour pH monitoring. How to ease heartburn in pregnancy The presence of atypical symptoms (see table below), although common, cannot sufficiently support the clinical diagnosis of GERD [B].

• Testing. Alcohol heartburn No gold standard exists for the diagnosis of GERD [A]. How to get rid of heartburn fast at home Although pH probe is accepted as the standard with a sensitivity of 85% and specificity of 95%, false positives and false negatives still exist [II B]. Heartburn prescription Endoscopy lacks sensitivity in determining pathologic reflux but can identify complications (e.g., strictures, erosive esophagitis, Barrett’s esophagus) [I A]. Constant heartburn feeling Barium radiography has limited usefulness in the diagnosis of GERD and is not recommended [III B].

• Therapeutic trial. Heartburn acid reflux An empiric trial of anti-secretory therapy (AST) can identify patients with GERD who lack alarm/warning symptoms (see table below) [I A] and may be helpful in the evaluation of those with atypical manifestations of GERD, specifically non-cardiac chest pain (NCCP) [II B].

• Lifestyle modifications. Ease heartburn Lifestyle modifications (see table below) should be recommended throughout the treatment of GERD [II B], yet there is evidence-based data to support only weight loss and avoiding recumbency several hours after meals [II C].

Avoid medications that can potentiate symptoms: calcium channel blockers, β-agonists, α-adrenergic agonists, theophylline, nitrates, and some sedatives (benzodiazepines)

• Pharmacologic treatment. Heartburn after gastric sleeve H2-receptor antagonists (H2RAs), proton pump inhibitors (PPIs), and prokinetics have proven efficacy in the treatment of GERD [I A]. Get rid of heartburn fast Prokinetics are as effective as H2RAs but are currently unavailable [III A]. Acid reflux or heartburn Carafate and antacids are ineffective [III A], but may be used as supplemental acid-neutralizing agents for certain patients with GERD [II D].

• Non-erosive reflux disease (NERD): Step-up (H2RA then as followed by a PPI if no improvement) and step-down (PPI then followed by the lowest dose of acid suppression) therapy are equally effective for acute treatment and maintenance [I B]. Heartburn feeling in throat On demand (patient-directed) therapy is the most cost-effective strategy [I B].

• Take PPI’s 30-60 minutes prior to breakfast (and dinner if two times per day [BID]) to optimize effectiveness [I B]. Ways to get rid of heartburn fast Use generic and over-the-counter (OTC) formulations exclusively, eliminating need for prior authorizations.

• Surgery. How to avoid heartburn during pregnancy Anti-reflux surgery is an alternative modality in GERD treatment for patients with chronic reflux and recalcitrant symptoms [II A], yet has a significant complication rate (10-20%). Heartburn stomach pain Resumption of pre-operative medication treatment is common (>50%) and may increase over time.

• Other endoscopic modalities. Heartburn description While less invasive and with fewer complications, they have lower response rates than anti-reflux surgery [II C], and have not been shown to reduce acid exposure.

• Symptoms unchanged. Home remedy for indigestion and heartburn If symptoms remain unchanged in a patient with a prior normal endoscopy, repeating endoscopy has no benefit and is not recommended [III C].

• Risk for complications. Is heartburn a sign of labor Further diagnostic testing (e.g., EGD [esophagogastroduodenoscopy], pH monitoring) should be considered in patients who do not respond to acid suppression therapy [I C] and in patients with a chronic history of GERD who are at risk for complications. Heartburn nausea Chronic reflux has been suspected to play a major role in the development of Barrett’s esophagus, yet it is unknown if outcomes can be improved through surveillance and medical treatment [D].

The literature search began with the results of the literature searches performed through May 2006 for the previous versions of this guideline. Daily heartburn The results of three more recent literature searches were initially reviewed and accepted as adequate through the time they were performed:

• American Gastroenterological Association (AGA): Position statement on the management of gastroesophageal reflux disease, 2008, literature search through early 2007.

• Society of American Gastrointestinal and Endoscopic Surgeons: Guidelines for surgical treatment of gastroesophageal reflux disease, 2010, literature search through early 2006.

A search of more recent literature was conducted prospectively on Medline from January 2007 (end of AGA search) through March 2011, except January 2006 was the start date for endoscopy (since ASGE search) and January 2008 was the start date for surgical treatment (since SAGES search). What is heartburn in pregnancy The major keywords were: gastroesophageal reflux disease (or GERD, NERD [non-erosive reflux disease], NEED [non-erosive esophageal disease]), human adults, English language, guidelines, clinical trials, and cohort studies. Heartburn symptoms and treatment Terms used for specific topic searches within the major key words included: symptoms and classification (atypical symptoms, heartburn, retrosternal burning sensation precipitated by meals or a recumbent position, hoarseness, laryngitis, sore throat, chronic cough, chest pain, bronchospasm/asthma, dental erosions), eosinophile, lymphocytic esophagitis, non acid reflux and weekly acid reflux, nocturnal (or nocturnal breakthrough, night time), endoscopy, pH recording, manometry, provocative testing (Bernstein’s), video esophagography, empiric/therapeutic trial to acid suppression, lifestyle measures/treatment (avoiding fatty foods, chocolate, peppermints, ethanol-containing beverages; recumbency for 3 hours after a meal; elevating head of bed; weight loss), antacids, alginic acid (gaviscon), carafate, prokinetic agents (cisapride, metoclopramide, bethanechol, dromperidone), H2 receptor antagonists (nizatidine, ranitidine, famotidine, cimetidine), proton pump inhibitors (omeprazole, lansoprazole, rabeprazole, pantoprazole, esomeprazole) – toxicity and adverse reactions/events, proton pump inhibitors – other references, baclofen, fundoplication (open vs. Heartburn remedies during pregnancy laparoscopy; endoscopic antireflux procedures), Barrett’s esophagus (screening, surveillance). Heartburn drinking water Detailed search terms and strategy available upon request.

The search was conducted in components each keyed to a specific causal link in a formal problem structure (available upon request). Acid reflux heartburn The search was supplemented with very recent information available to expert members of the panel, including abstracts from recent meetings and results of clinical trials. Heartburn pain location Negative trials were specifically sought. Difference between acid reflux and heartburn The search was a single cycle. Quick home remedy for heartburn Number of Source Documents

• H2 receptor antagonists (H2RAs) have been associated with rare cytopenias, gynecomastia, liver function test abnormalities, and hypersensitivity reactions. Acid reflux and heartburn In the long-term, there have been no controlled trials with follow-up on the safety of chronic use of H2RAs. Acute heartburn Cimetidine may cause gynecomastia or androgenic side effects, and may interact with medications metabolized by cytochrome P450.

• The potential benefit of chronic proton pump inhibitor (PPI) therapy in patients with chronic or complicated gastroesophageal reflux disease (GERD) generally outweighs any theoretical risk of adverse events. How to stop heartburn immediately Risks associated with chronic PPI therapy include Clostridium-difficile-associated diarrhea (adjusted odds ratio [AOR] = 2.1 – 2.6); community-acquired pneumonia (AOR = 1.5 – 1.9); bone fracture (AOR = 1.4 – 1.6); vitamin B12 deficiency (AOR = 1.0 – 4.46); antiplatelet interactions (AOR = 1.25). Severe heartburn during pregnancy Data regarding risks of bone fracture and antiplatelet interactions are controversial. Child heartburn A recent U. Coffee heartburn S. Gas heartburn Food and Drug Administration (FDA) warning recommends periodic surveillance of serum magnesium levels due to potential hypomagnesiumia. Heartburn during pregnancy treatment Since all data were collected retrospectively, a definitive cause-and-effect relationship cannot be proven. Peppermint tea for heartburn All patients on long-term PPI therapy should be re-evaluated periodically to determine need and to weigh potential risks versus benefits of therapy.

• Controlled trials comparing open and laparoscopic approaches have shown similar efficacy and complications with lower morbidity and shorter hospital stays in the laparoscopic repair group. Pregnancy heartburn medication Post-surgical complications are common, but typically short term and manageable in most instances. Heartburn with back pain Short-term solid food dysphagia occurs in 10% of patients (2% to 3% have permanent symptoms) and gas bloating occurs in 7% to 10% of patients. Meaning of heartburn Diarrhea, nausea and early satiety occur more rarely. Severe heartburn relief While some complication occurs in up to 20% of patients, major complications occur in only 3% to 4% of patients.

The University of Michigan Health System endorses the Guidelines of the Association of American Medical Colleges and the Standards of the Accreditation Council for Continuing Medical Education that the individuals who present educational activities disclose significant relationships with commercial companies whose products or services are discussed. Heartburn cause chest pain Disclosure of a relationship is not intended to suggest bias in the information presented, but is made to provide readers with information that might be of potential importance to their evaluation of the information. Heartburn after eating Team Member

• Gastroesophageal reflux disease (GERD). Heartburn and gas University of Michigan Health System; 2012 May. Pregnancy heartburn remedies 3 p. Is apple cider vinegar good for heartburn Electronic copies: Available in Portable Document Format (PDF) from the University of Michigan Health System (UMHS) Web site .

• Gastroesophageal reflux disease (GERD) – patient instructions. How to get rid of heartburn instantly University of Michigan Health System; 2012 May. Avoid heartburn 2 p. Coffee cause heartburn Electronic copies: Available in PDF from the UMHS Web site .

• Understanding GERD. Why do you get heartburn in pregnancy A consumer education brochure about gastroesophageal reflux disease. Heartburn symptoms chest pain University of Michigan Health System; 10 p. Can smoking cause heartburn Electronic copies: Available in PDF from the UMHS Web site .

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. Heartburn at night only By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Constant heartburn symptoms Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. Heartburn and reflux This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. Heartburn coffee The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline’s content. Heartburn remedies milk NGC Status

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