> Summary Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, improvements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising questions about the safety of long-term use and raising concerns about overprescription of PPIs. New data have emerged regarding the potential of surgical and endoscopic interventions. In this new document, we provide updated evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacological, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and strength of the recommendations. Key concepts and suggestions are also provided that, as of this writing, do not have sufficient evidence to qualify. |
| > Background This document updates a 2013 ACG guideline (NEJM JW Gastroenterol May 2013 and Am J Gastroenterol 2013; 108:308). The guide spans 30 pages and includes 39 recommendations that cover all aspects of diagnosis and treatment. In this summary, I have chosen to highlight several points of particular relevance to primary care physicians. |
> Key points • An 8-week empirical trial with a proton pump inhibitor (PPI), given once daily, is recommended for a patient who has classic heartburn and regurgitation but no warning symptoms. A good clinical response to PPIs is considered an adequate (although not perfect) diagnostic test for gastroesophageal reflux disease (GERD). • The authors emphasize that many people who do not respond to PPIs have not taken the medications correctly: PPIs should be taken 30 to 60 minutes before a meal, because they bind to proton pumps that have been stimulated by meals. • PPI nonresponders and PPI responders whose symptoms recur after an 8-week course of PPIs should be evaluated for objective evidence of GERD. • Endoscopy should be performed after 2 to 4 weeks without PPI (to maximize the chance of documenting esophagitis). If the endoscopy is normal, the next step is ambulatory pH monitoring (without treatment). • The authors recommend intermittent or “as needed” (rather than indefinite) PPI therapy in patients without a history of high-grade esophagitis or Barrett’s esophagus. • A patient who requires continued PPI treatment for symptom control should use the lowest effective dose. • Although there are statistical associations between long-term PPI therapy and several putative “complications,” the causal relationship is doubtful for most of them. • Although scientific evidence supporting the favorable effects of diet and lifestyle modification on GERD is generally weak, the authors recommend several, particularly weight loss, smoking cessation, and avoiding eating before bedtime. It is also recommended to raise the head of the bed or sleep on a wedge, and sleep preferably on the left side. |
GERD is thought to contribute to several extraesophageal symptoms, such as chronic cough, hoarseness, and laryngitis; however, a causal relationship is often unclear in a given patient. For patients with extraesophageal symptoms but without heartburn or regurgitation, the authors argue against empiric PPI therapy unless reflux is documented by objective testing.
For refractory GERD, recommendations vary depending on the extent of prior diagnostic evaluation. Some patients will respond to proton pump inhibitors twice daily or as needed to a histamine-2 (H2) receptor antagonist at bedtime. However, clinicians should be alert to alternative conditions with symptoms that could be confused with GERD (e.g., achalasia). The pros and cons of surgical approaches for GERD are also discussed.
Much of this guide is worthwhile for non-gastroenterologists. A notable discrepancy between these recommendations and typical primary care practice is: If a patient without warning symptoms and responding well to a PPI discontinues the medication after several months and symptoms relapse, primary care physicians often resume treatment. PPI therapy, without further evaluation. For such patients, this guideline recommends endoscopy to identify complications that warrant indefinite PPI therapy (i.e., erosive esophagitis or Barrett’s esophagitis) and to identify alternative diagnoses (e.g., eosinophilic esophagitis).
| ? Diagnosis of GERD |
> Recommendations
1. For patients with classic GERD symptoms of heartburn and regurgitation who do not have alarm symptoms, we recommend an 8-week trial of empiric PPIs once daily before a meal (strong recommendation, moderate level of evidence).
2. We recommend attempting to discontinue PPIs in patients whose classic GERD symptoms respond to an 8-week empirical trial of PPIs (conditional recommendation, low level of evidence).
3 . We recommend diagnostic endoscopy, ideally after discontinuing PPIs for 2 to 4 weeks, in patients whose classic GERD symptoms do not respond adequately to an 8-week empirical trial of PPIs or whose symptoms return when PPIs are discontinued (strong recommendation, low ). level of evidence).
4. In patients who have chest pain without heartburn and who have had adequate evaluation to exclude cardiac disease, objective testing for GERD (endoscopy and/or reflux monitoring) is recommended (conditional recommendation, low level of evidence).
5. We do not recommend the use of a barium swallow alone as a diagnostic test for GERD (conditional recommendation, low level of evidence).
6. We recommend endoscopy as the first test for the evaluation of patients presenting with dysphagia or other alarm symptoms (weight loss and GI bleeding) and for patients with multiple risk factors for Barrett’s esophagus (strong recommendation, low level of evidence ).
7. In patients in whom the diagnosis of GERD is suspected but unclear, and endoscopy shows no objective evidence of GERD, we recommend that off-treatment reflux monitoring be performed to establish the diagnosis (strong recommendation, level of evidence low).
8. We recommend against performing off-therapy reflux monitoring solely as a diagnostic test for GERD in patients known to have endoscopic evidence of Los Angeles (LA) grade C or D reflux esophagitis or in patients with Barrett’s esophagus. long segment (strong, low recommendation). level of evidence).
| ? Medical management of GERD |
> Recommendations
1. We recommend weight loss in overweight and obese patients to improve GERD symptoms (strong recommendation, moderate level of evidence).
2. We suggest avoiding meals within 2-3 hours before bedtime (conditional recommendation, low level of evidence).
3. We suggest avoiding tobacco products/smoking in patients with GERD symptoms (conditional recommendation, low level of evidence).
4. We suggest avoiding “trigger foods” to control GERD symptoms (conditional recommendation, low level of evidence).
5. We suggest elevating the head of the bed for nocturnal GERD symptoms (conditional recommendation, low level of evidence).
6. We recommend PPI treatment versus histamine 2 receptor antagonist (H2RA) treatment for the cure of EoE (strong recommendation, high level of evidence).
7. We recommend PPI treatment over H2RA for maintenance of EoE healing (strong recommendation, moderate level of evidence).
8. We recommend administering PPIs 30 to 60 minutes before a meal rather than at bedtime for the control of GERD symptoms (strong recommendation, moderate level of evidence).
9. For patients with GERD who do not have EoE or Barrett’s esophagus, and whose symptoms have resolved with PPI therapy, an attempt should be made to discontinue PPIs or switch to on-demand therapy in which PPIs are taken only when symptoms occur and discontinue when they are relieved (conditional recommendation, low level of evidence).
10. . For patients with GERD who require PPI maintenance therapy, PPIs should be administered at the lowest dose that effectively controls GERD symptoms and maintains healing of reflux esophagitis (conditional recommendation, low level of evidence).
eleven . ? We do not recommend the routine addition of medical therapies in patients who do not respond to PPIs (conditional recommendation, moderate level of evidence).
12. We recommend indefinite PPI maintenance therapy or antireflux surgery for patients with grade C or D LA esophagitis (strong recommendation, moderate level of evidence).
13. We do not recommend baclofen in the absence of objective evidence of GERD (strong recommendation, moderate level of evidence).
14. We do not recommend treatment with a prokinetic agent of any type for GERD therapy unless there is objective evidence of gastroparesis (strong recommendation, low level of evidence).
15. We do not recommend sucralfate for the treatment of GERD except during pregnancy (strong recommendation, low level of evidence).
16. Do we suggest on-demand or intermittent PPI therapy to control heartburn symptoms in patients with NERD (conditional recommendation, low level of evidence).?
> Key concepts
1. There is a conceptual rationale for a PPI switch trial for patients who have not responded to a PPI. For patients who have not responded to a PPI, more than one change to another PPI is not permitted.
2. The use of the lowest effective dose of PPI is recommended and logical, but must be individualized. One area of controversy relates to abrupt discontinuation of PPIs and possible rebound acid hypersecretion, resulting in increased reflux symptoms. Although this has been shown to occur in healthy controls, strong evidence for an increase in symptoms after abrupt discontinuation of PPIs is lacking.
| ? Extraesophageal symptoms of GERD |
> Recommendations
1. We recommend evaluation of non-GERD causes in patients with possible extraesophageal manifestations before attributing symptoms to GERD (strong recommendation, moderate level of evidence).
2. We recommend that patients who have extraesophageal manifestations of GERD without typical GERD symptoms (e.g., heartburn and regurgitation) undergo reflux testing for evaluation prior to PPI therapy (strong recommendation, level of moderate evidence).
3. For patients who have both extraesophageal and typical GERD symptoms, we suggest considering a trial of twice-daily PPI therapy for 8 to 12 weeks before further testing (conditional recommendation, low level of evidence).
4. We suggest that upper gastrointestinal endoscopy should not be used as a method to establish a diagnosis of GERD-related asthma, chronic cough, or laryngopharyngeal reflux (LPR) (conditional recommendation, low level of evidence).
5. We do not suggest a diagnosis of LPR based on laryngoscopy findings alone and recommend that additional testing be considered (conditional recommendation, low level of evidence).
6. In patients treated for extraesophageal reflux disease, surgical or endoscopic antireflux procedures are only recommended in patients with objective evidence of reflux (conditional recommendation, low level of evidence).
> Key concepts
1. Although GERD may contribute to extraesophageal symptoms in some patients, careful evaluation for other causes should be considered for patients with laryngeal symptoms, chronic cough, and asthma.
2. Diagnosis, evaluation, and treatment of possible extraesophageal symptoms of GERD are limited by the lack of a gold standard test, variable symptoms, and other disorders that may cause similar symptoms.
3. Due to the difficulty in distinguishing between patients with laryngeal symptoms and normal controls, salivary pepsin testing is not recommended for the evaluation of patients with extraesophageal reflux symptoms.
4. For patients whose extraesophageal symptoms have not responded to a twice-daily PPI trial, we recommend an upper gastrointestinal endoscopy, ideally without PPI for 2 to 4 weeks. If endoscopy is normal, consider reflux monitoring. Demonstration of EE by endoscopy establishes a diagnosis of GERD, but does not confirm that GERD is the cause of extraesophageal symptoms. Confirmation may require pH/impedance testing.
5. For patients with extraesophageal symptoms, we do not routinely recommend oropharyngeal or pharyngeal pH monitoring.
| ? refractory GERD |
> Recommendations
1. We recommend optimization of PPI therapy as a first step in the management of refractory GERD (strong recommendation, moderate level of evidence).
2. We suggest esophageal pH monitoring (Bravo, catheter-based, or combined impedance-pH monitoring) performed without PPI if the diagnosis of GERD has not been established by a prior pH monitoring study or endoscopy showing Barrett’s esophagus of long or serious segment. reflux esophagitis (LA grade C or D) (conditional recommendation, low level of evidence).
3. We suggest esophageal pH-impedance monitoring performed with PPI for patients with an established diagnosis of GERD whose symptoms have not responded adequately to twice-daily PPI therapy (conditional recommendation, low level of evidence).
4. For patients who have regurgitation as their main symptom refractory to PPIs and who have had abnormal gastroesophageal reflux documented by objective testing, we suggest considering antireflux surgery or TIF (conditional recommendation, low level of evidence).
> Key concepts
1. It is important to discontinue PPI treatment in patients whose off-treatment reflux tests are negative, unless there is another indication to continue PPIs.
2. Esophageal manometry should be considered as part of the evaluation for refractory GERD in patients with a normal endoscopy and pH monitoring study and for patients being considered for surgical or endoscopic treatment.
3. If not already performed without PPI, we recommend diagnostic upper endoscopy after stopping PPI treatment, ideally for 2 to 4 weeks. Esophageal biopsies should be performed even if endoscopy reveals normal mucosa.
4. We recommend performing high-resolution esophageal manometry in patients with refractory GERD if reflux monitoring and endoscopy are unrevealing.
| ? Surgery and endoscopy for GERD |
> Recommendations
1. We recommend antireflux surgery performed by an experienced surgeon as an option for the long-term treatment of patients with objective evidence of GERD, especially those who have severe reflux esophagitis (LA grade C or D), large hiatal hernias and/or , bothersome GERD symptoms (strong recommendation, moderate level of evidence).
2. We recommend considering SMA as an alternative to laparoscopic fundoplication for patients with regurgitation who fail medical treatment (strong recommendation, moderate level of evidence).
3. We suggest considering Roux-en-Y gastric bypass (RYGB) as an option to treat GERD in obese patients who are candidates for this procedure and who are willing to accept its risks and requirements for lifestyle alterations (conditional recommendation , low level). of evidence).
4. Because data on the effectiveness of radiofrequency energy (Stretta) as an antireflux procedure are inconsistent and highly variable, we cannot recommend its use as an alternative to medical or surgical antireflux therapies (conditional recommendation, low level of evidence ).
5. We suggest considering TIF for patients with problematic regurgitation or heartburn who do not wish to undergo antireflux surgery and who do not have severe reflux esophagitis (LA grade C or D) or hiatal hernias >2 cm (conditional recommendation, low level of evidence ).
> Key concepts
1. We recommend HRM before antireflux surgery or endoscopic therapy to rule out achalasia and absence of contractility. For patients with ineffective esophageal motility, HRM should include provocative testing to identify contractile reserve (eg, multiple rapid swallows).
2. Before performing invasive therapy for GERD, careful evaluation is required to ensure that GERD is present and, to the best of our ability, determine the cause of the symptoms to be addressed by therapy, to exclude achalasia ( which may be associated with these symptoms). such as heartburn and regurgitation that may be confused with GERD), and to exclude conditions that could be contraindications to invasive treatment, such as lack of contractility.
