Evaluation and management of GERD: ACG issues updated guidelines

Following are the main recommendations of the updated ACG guidelines

• Adult patients with classic GERD symptoms of heartburn and regurgitation without alarm symptoms such as dysphagia, bleeding, weight loss, anaemia, vomiting, and chest pain can be treated with an 8-week empiric trial of a PPI taken once daily before meals. An upper age limit is not specified.
• Endoscopy is indicated in patients with alarm or refractory symptoms after optimization of PPI therapy.
• PPIs continue to be the mainstay of medical treatment. For patients with GERD whose symptoms have resolved and who do not have erosive esophagitis or Barrett's oesophagus, tapering the PPI to the lowest effective dose, replacement with intermittent PPI therapy or a histamine 2 receptor antagonist, and, when possible, discontinuation should be considered.
• Reflux testing with a wireless telemetry capsule attached to the oesophagal mucosa during endoscopy or transnasal catheter is considered in patients with suspected GERD and normal endoscopy, extraesophageal GERD symptoms, or refractory GERD.
• Surgical options are recommended for patients with objective evidence of GERD who have severe reflux esophagitis (Los Angeles grade C or D), large hiatal hernias, or persistent, troublesome GERD symptoms such as regurgitation.⁷ The treatment is fundoplication, in which the lower oesophagal sphincter is strengthened by wrapping the fundus of the stomach around the oesophagus in the abdomen. Roux-en-Y gastric bypass is an option to treat GERD in patients with obesity who are candidates for this procedure.
• Long-term PPI therapy or antireflux surgery is recommended for patients with Los Angeles classification grade C esophagitis (erosions extending over mucosal folds, but over less than three-quarters of the circumference) or grade D esophagitis (confluent erosions extending over more than three-quarters of the circumference).
• Transoral incisionless fundoplication (TIF), the endoscopic creation of a gastric fundal wrap with plication, and magnetic sphincter augmentation (MSA), the laparoscopic insertion of a flexible ring of interlinked magnetic beads to augment the weak lower oesophagal sphincter, can be alternatives in patients with troublesome regurgitation or heartburn who do not wish to undergo fundoplication and who do not have severe reflux esophagitis or large hiatal hernia.