The possible extraesophageal symptoms of GERD are a common problem seen by gastroenterologists, internists, and family practitioners. Unfortunately, a strong evidence-based medicine approach for the diagnosis and treatment of these diseases is lacking because the true prevalence and predictors of GERD-related causes have not been identified. Nevertheless, I believe an empirical trial (see Figure 11-2) with twice daily dosing of PPIs (Table 11-1) is the most practical, cost effective, and humane approach for these patients. Symptom resolution or improvement suggests that GERD

TABLE 11-1. Suggested Treatment Regimens for Extraesophageal Presentations of Gastroesophageal Reflex Disease Based on the Medical Literature

Chest Pain

Omeprazole 40 mg in the am, 20 mg before dinner for 7 days Any PPI bid X 4 weeks


Omeprazole 20 mg bid x 3 months Lansoprazole 30 mg bid x 3 months Omeprazole 40 mg in the am x 2 months


Any PPI in the am x 1-2 months Omeprazole 40 mg bid x 2 weeks Esomeprazole 40 mg bid x 2 weeks

ENT syndromes*

Omeprazole 40 mg am or 20 mg bid x 4 months Lansoprazole 30 mg bid x 4 months Esomeprazole 40 mg bid x 4 months bid = twice daily; ENT = ear, nose, and throat; PPI = proton pump inhibitor. *Adding H2 receptor antagonists at bedtime is no better than bid PPI.

is causing their complaints, although a placebo response cannot be excluded. However, asymptomatic patients do not really care. Patients should be stepped down to the lowest dose of medication or lifestyle changes that will control their symptoms. Esophageal pH testing is limited to those patients not responding to this aggressive trial and is performed on PPI therapy. If pH testing and a prolonged therapeutic trial are negative, then I believe we have confidently excluded acid-related GERD as a cause of the extraesophageal complaints. I do not believe that nonacid reflux, except for obvious aspiration, causes these complaints and would not send patients for antireflux surgery unless they showed evidence of prior response to medical treatment.

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