GERD Primary Care Pathway

See “Expanded Details” section for more information on the numbered boxes

1. Symptoms of GERD 2. Is it dyspepsia? Follow

Predominant Heartburn +/- regurgitation. No • Epigastric discomfort/pain Yes dyspepsia
If chest pain predominant, do cardiac workup. • Upper abdominal bloating pathway
Yes

3. Alarm features (one or more)

• GI bleeding (hematemesis or melena) or anemia (if yes, complete CBC,
INR, PTT as part of referral)
• Progressive dysphagia Refer for
• Odynophagia Yes consultation /
• Persistent vomiting (not associated with cannabis use) endoscopy
• Unintended weight loss (≥5-10% of body weight over 6 months)
• Abdominal mass
No

4. Consider need to screen for Barrett’s esophagus?

Screening for Barrett’s esophagus may be considered in males with chronic (>5 years)
poorly GERD symptoms AND two or more risk factors:
• Age >50 years Continue with
• Caucasian pathway while
• Presence of central obesity (waist circumference >102cm/40” or waist-hip ratio >0.9) Yes
awaiting
• Current or past history of smoking screening
• Confirmed family history of Barrett’s esophagus or esophageal cancer

Given the substantially lower risk in females with chronic GERD, screening for Barrett’s
esophagus in females is not recommended. It could be considered in individual cases
as determined by the presence of multiple risk factors per above.
Continue with pathway regardless of screening requirement
No

5. Non-pharmacological principles
• Smoking cessation
• Weight loss
• Elimination of food / drink triggers

Ineffective

6. Pharmacologic therapy
Mild, infrequentsymptoms H � RA or Antacids (PRN)
Yes
< 2 times / week

No

PPI trial
Symptoms Symptoms Discontinue or titrate down to
Yes Once daily for
≥ 2 times / week resolve lowest effective dose
4-8 weeks
Symptoms
Inadequate
return
response

PPI Maintenance
Optimize PPI • Lowest effective dose
Twice daily for • Consider annual trial of deprescribing
4-8 weeks

Inadequate response

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GERD Primer

 The reflux of gastric contents into the esophagus is a normal physiological phenomenon.
o Reflux is deemed pathological when it causes esophageal injury or produces symptoms that are troublesome to
the patient (typically heartburn and/or regurgitation) - a condition known as gastroesophageal reflux disease
(GERD).
 A diagnosis of GERD can be made in patients with any of the clinical symptoms described above (without alarm
features). Generally no investigations are required as part of the initial workup.
 Treatment at the primary care level is focused on lifestyle, smoking cessation, dietary modifications to avoid GERD
triggers and achieve a healthy body weight, and optimal use of proton pump inhibitors (PPI), if needed.
 Screening for H. pylori is not recommended in GERD. Most patients with GERD do not have H. pylori and will have
improvement or resolution of symptoms through lifestyle and dietary modifications or when treated with a PPI or
H₂RA.
 Endoscopy is warranted in patients presenting with dysphagia or other alarm features and in those refractory to
adequate initial and optimized PPI treatments. Esophageal pH or impedance-pH reflux monitoring studies are
sometimes arranged by GI after endoscopy.
 GERD can be complicated by Barrett’s esophagus, esophageal stricture, and, rarely, esophageal cancer.

Expanded Details – Assessment and Treatment

1. Symptoms of GERD
 A diagnosis of GERD can be made in patients with predominant symptoms of heartburn and/or regurgitation.
 In some patients, GERD has a wider spectrum of symptoms including chest pain, dysphagia, globus
sensation, odynophagia, nausea and water brash.
 If patients with suspected GERD have chest pain as a dominant feature, cardiac causes should first be
excluded. GERD treatment can be started while doing cardiac investigations.

2. Is it dyspepsia?
 If the patient’s predominant symptom is epigastric pain and/or upper abdominal bloating, please refer to the
dyspepsia pathway.

3. Alarm Features (warranting consideration of referral for consultation and/or endoscopy)

 GI bleeding (hematemesis or melena – see primer on black stool on page 3) or anemia (if yes, complete
CBC, INR, PTT as part of referral)
 Progressive dysphagia
 Odynophagia
 Persistent vomiting (not associated with cannabis use)
 Unintended weight loss (≥ 5-10% of body weight over 6 months)
 Abdominal mass

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 Primer on black stool
 Possible causes of black stool
o Upper GI bleeding
o Slow right-sided colonic bleeding
o Epistaxis or hemoptysis with swallowed blood
 Melena is dark/black, sticky, tarry, and has a distinct odour
 Patient history should include:
o Any prior GI bleeds or ulcer disease
o Taking ASA, NSAIDs, anticoagulants, Pepto Bismol, or iron supplements
o Significant consumption of black licorice
o Significant alcohol history or hepatitis risk factors
o Any other signs of bleeding (e.g. coffee ground emesis, hematemesis, hematochezia, or bright red blood
per rectum)
o Any dysphagia, abdominal pain, change in bowel movements, constitutional symptoms or signs/symptoms
of significant blood loss
 Physical exam should include vitals (including postural if worried about GI bleeding) and a digital rectal exam for
direct visualization of the stool to confirm, in addition to the remainder of the exam
 Initial labs to consider include CBC, BUN (may be elevated with upper GI bleeding), INR
 If the patient is actively bleeding, suggest calling GI on call and/or the ER for assessment, possible resuscitation,
and possible endoscopic procedure

4. Consider need to screen for Barrett’s esophagus

 Males with long-term (>5 years) poorly controlled GERD may be considered for a referral for screening for
Barrett’s esophagus, but only if at least two risk factors are present:
o Age >50 years
o Caucasian
o Presence of central obesity (waist circumference > 102cm/40” or waist-hip ratio > 0.9)
o Current or past history of smoking
o Confirmed family history of Barrett’s esophagus or esophageal cancer
 Females with chronic GERD have a substantially lower risk of esophageal cancer (when compared with
males), and therefore screening for Barrett’s esophagus in females is not recommended. Screening could
be considered in individual cases as determined by the presence of multiple risk factors as per above.
o For females, central obesity = waist circumference > 88cm/35” or waist-hip ratio > 0.8).
 Before screening is performed, the overall life expectancy of the patient should be considered, and
subsequent implications, such as the need for periodic endoscopic surveillance and therapy, if BE with
dysplasia is diagnosed, should be discussed with the patient.

5. Non-pharmacological principles of GERD management (see patient resources for more information)
 Smoking cessation is essential.
 Weight loss in patients who are overweight or who have recently gained weight (even if at a normal BMI).
 Elimination of GERD triggers including alcohol, caffeine, carbonated beverages, chocolate, mint, and
spicy/fatty/acidic foods, is reasonable but is not supported by clear evidence of physiological or clinical
improvement of GERD.
 Avoid meals three hours before bedtime for patients with nocturnal GERD.
 Consider elevating the head of bed 4-6 inches, using blocks or foam wedges. An extra pillow for sleeping is
not sufficient.

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6. Pharmacologic therapy
 If symptoms are mild and infrequent (<2 times per week), histamine H₂-receptor agonists or antacids
(Ca/Mg/Al salts) are recommended. These provide rapid on-demand relief of heartburn and avoid
prematurely committing some patients to long-term use of PPI.
 If symptoms are ≥ 2 times per week, a trial of PPI is recommended.
 Initial PPI therapy should be once daily, 30 minutes before breakfast on an empty stomach.
o If there is inadequate response after 4-8 weeks, step up to BID dosing for another 4-8 weeks.
o If symptoms are controlled, it is advisable for most patients to titrate the PPI down to the lowest effective
dose, and attempt once yearly to taper or stop PPI use. NOTE: patients with Barrett’s esophagus require
lifetime daily PPI, regardless of whether symptoms continue.
 PPI deprescribing resources are available on the Digestive Health Strategic Clinical Network (DHSCN)
website (poster, guideline, co-decision making tool for patients and health care providers)
 There are no major differences in efficacy between PPIs.

Estimated 90
PPI Dosage Coverage2
day cost (2018)1
Rabeprazole 20mg $25 Covered by Blue Cross/Non-insured health benefits
Pantoprazole 40mg $30 Covered by Blue Cross/Non-insured health benefits
Omeprazole 20mg $55 Covered by Blue Cross/Non-insured health benefits
Lansoprazole 30mg $60 Covered by Blue Cross/Non-insured health benefits
Dexlansoprazole 30mg $230 Not covered by Blue Cross/NIHB
Esomeprazole 40mg $230 Not covered by Blue Cross/NIHB

 It is estimated that 1/3 of patients with GERD will not adequately respond to PPI. Factors that predict PPI
failure include obesity, poor adherence to PPI treatment, and psychological factors.
o Patient non-adherence to treatment with PPI is common. Confirm that the patient has taken the intended
dose of PPI on a daily basis, 30 minutes before breakfast.
 Patients with persistent, troublesome GERD symptoms, in spite of optimized use of PPI, should be referred
for diagnostic evaluation (endoscopy ± pH/impedance reflux monitoring) to discern GERD from non-GERD
etiologies.

1
Maximum Allowable Cost pricing paid by Alberta government sponsored drug programs. Cost and coverage information as
reported in the Alberta College of Family Physicians publication “Price Comparison of Commonly Prescribed Pharmaceuticals in
Alberta in 2018” found at https://acfp.ca/wp-content/uploads/2018/03/ACFPPricingDoc2018.pdf
2
Drug plans will only pay the cost of rabeprazole 10mg for low dose PPI and will only pay the cost of pantoprazole for high dose
PPI.

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 Patient Resources - Information

Description Website
General information on GERD
https://myhealth.alberta.ca/health/pages/conditions.aspx?Hwid=hw99177
(MyHealth.Alberta.ca)
General information on GERD
(Canadian Digestive Health https://cdhf.ca/digestive-disorders/gerd/what-is-gastroesophageal-reflux-disease-gerd/
Foundation)
General information on GERD
http://www.uptodate.com/contents/acid-reflux-gastroesophageal-reflux-disease-in-adults-beyond-
(UpToDate® – Beyond the Basics thebasics?source=search_result&search=GERD+beyond+the+basics&selectedTitle=2~150
Patient information)
General information on weight
management https://myhealth.alberta.ca/health/pages/conditions.aspx?Hwid=aa122915
(MyHealth.Alberta.ca)
Online learning module on
weight management https://myhealth.alberta.ca/learning/modules/Weight-Management
(MyHealth.Alberta.ca)
Resources on healthy eating
https://www.albertahealthservices.ca/nutrition/Page11115.aspx
(Alberta Health Services)

Patient Resources – Services Available

Description Website
Services for patients with chronic
conditions, including how to achieve a https://www.albertahealthservices.ca/info/page13984.aspx
healthy weight
(Alberta Healthy Living Program - AHS)
Supports to quit smoking https://www.albertaquits.ca/
(Alberta Quits)
Supports for working towards healthy
lifestyle goals and weight management https://www.albertahealthservices.ca/info/Page15163.aspx
(Weight Management – AHS)

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 Physician Resources and References
Non-urgent advice is available to support family physicians.
 Gastroenterology advice is available across the province via Alberta Netcare eReferral Advice Request
(responses are received within five calendar days). Visit http://www.albertanetcare.ca/documents/Getting-
Started-Advice-Requests-FAQs.pdf for more information.
 In the Calgary Zone, family physicians and specialists can be connected through Specialist LINK, a real-time
tele-advice line. Visit www.specialistlink.ca to request tele-advice from a gastroenterologist. Calls are returned
within one hour.
 Family physicians in the Edmonton Zone can request tele-advice via ConnectMD.(1-844-633-2263)

Physician Resources and References

Katz PO, Gerson, LB, Vela, MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J
Gastroenterol. 108:308-28, 2013.
https://journals.lww.com/ajg/Fulltext/2013/03000/Guidelines_for_the_Diagnosis_and_Management_of.6.aspx
Flook N, Jones R, Vakil N. Approach to gastroesophageal reflux disease in primary care: Putting the Montreal definition
into practice. Can Fam Physician. 2008;54(5):701-5. http://www.cfp.ca/content/54/5/701
Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association Institute technical review on the
management of gastroesophageal reflux disease. Gastroenterology 135:1392-1413, 2008.
https://www.gastrojournal.org/article/S0016-5085(08)01605-3/pdf
Armstrong D, Marshall JK, Chiba N et al. Canadian consensus conference on the management of gastroesophageal
reflux disease in adults. Can J Gastroenterol. 19:15-35, 2005. https://www.hindawi.com/journals/cjgh/2005/836030/abs/
Shaheen NJ, Falk GW, Iyer PG, Gerson LB. ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus.
Am J Gastroenterol. 111:30-50, 2016
Farrell B, Pottie K, Thompson W et al. Deprescribing proton pump inhibitors – Evidence-based clinical practice guideline.
Can Fam Physician. 2017:63(5):354-364. https://www.cfp.ca/content/63/5/354
Resources for appropriate PPI prescribing. Alberta Health Services – Digestive Health Strategic Clinical Network website.
 PPI guideline https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-dh-ppi-guideline.pdf
 PPI co-decision making tool https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-dh-ppi-decision-tool.pdf
 PPI patient poster https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-dh-ppi-patient-poster.pdf

Background on Primary Care Pathways

 Digestive health primary care pathways were originally co-developed in 2015 by gastroenterologists from the
Cumming School of Medicine at the University of Calgary and family physicians representing Primary Care
Networks in the Calgary Zone.
 The pathways were intended to provide evidence-based guidance to support primary care providers in caring for
patients with common digestive health conditions within the medical home.
 Based on the successful adoption of the primary care pathways within the Calgary Zone, and their impact on timely
access to quality care, the Digestive Health Strategic Clinical Network made the decision in 2017 to lead an
initiative to validate the applicability of the pathways for all of Alberta and to spread availability and foster adoption
of the pathways across Alberta.

Authors and Conflict of Interest Declaration

 Prior to provincial spread of this primary care pathway, it was reviewed and revised under the auspices of the
Digestive Health Strategic Clinical Network in 2018, by a multi-disciplinary team led by family physicians and

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 gastroenterologists. Names of participating reviewers and their conflict of interest declarations are available on
request.

Pathway Review Process and Timelines

 Primary care pathways undergo scheduled review every three years, or earlier if there is a clinically significant
change in knowledge or practice. The next scheduled review is April 2022, however we welcome feedback at any
time. Please submit your comments to the Digestive Health Strategic Clinical Network at
Digestivehealth.SCN@ahs.ca.

DISCLAIMER
This pathway represents evidence-based best practice but does not override the individual responsibility of health care professionals to
make decisions appropriate to their patients using their own clinical judgment given their patients’ specific clinical conditions, in
consultation with patients/alternate decision makers. The pathway is not a substitute for clinical judgment or advice of a qualified health
care professional. It is expected that all users will seek advice of other appropriately qualified and regulated health care providers with
any issues transcending their specific knowledge, scope of regulated practice or professional competence.

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