ACG updates guideline on diagnosis and management of GERD
Diagnosing patients with classic GERD symptoms such as heartburn and regurgitation calls for an 8-week trial of empiric proton pump inhibitors once daily prior to a meal.
USA: The American Journal of Gastroenterology has released clinical guidance for the diagnosis and management of gastroesophageal reflux disease (GERD). The guideline was published in The American Journal of Gastroenterology on November 22, 2021.
GERD continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPI remains the choice of treatment for GERD, multiple publications have raised questions about adverse events. This has raised doubts about the safety of long-term use and increasing concern about overprescribing of PPIs.
New data regarding the potential for surgical and endoscopic interventions have emerged. The guideline by Philip O. Katz, Weill Cornell Medicine, New York, New York, USA, and colleagues contains updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. Given below are the key recommendations:
Diagnosis of GERD
- For patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms, we recommend an 8-wk trial of empiric PPIs once daily before a meal.
- The authors recommend attempting to discontinue the PPIs in patients whose classic GERD symptoms respond to an 8-wk empiric trial of PPIs.
- In patients with chest pain who have had adequate evaluation to exclude heart disease, objective testing for GERD (endoscopy and/or reflux monitoring) is recommended.
- The authors do not recommend the use of a barium swallow solely as a diagnostic test for GERD.
- The authors recommend endoscopy as the first test for 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.
- In patients for whom the diagnosis of GERD is suspected but not clear, and endoscopy shows no objective evidence of GERD, the authors recommend reflux monitoring be performed off therapy to establish the diagnosis.
- The authors suggest against performing reflux monitoring off therapy solely as a diagnostic test for GERD in patients known to have endoscopic evidence of LA grade C or D reflux esophagitis or in patients known to have long-segment Barrett's esophagus.
- The authors recommend weight loss in overweight and obese patients for improvement of GERD symptoms.
- The authors suggest avoiding meals within 2–3 hr of bedtime.
- The authors suggest the avoidance of tobacco products/smoking in patients with GERD symptoms.
- The authors suggest the avoidance of "trigger foods" for GERD symptom control.
- suggest elevating head of bed for nighttime GERD symptoms.
- The authors recommend treatment with PPIs over treatment with H2RA for healing EE.
- The authors recommend treatment with PPIs over H2RA for maintenance of healing for EE.
- The authors recommend PPI administration 30–60 min before a meal rather than at bedtime for GERD symptom control.
- For patients with GERD who do not have EE or Barrett's esophagus, and whose symptoms have resolved with PPI therapy, an attempt should be made to discontinue PPIs.
- For patients with GERD who require maintenance therapy with PPIs, the PPIs should be administered in the lowest dose that effectively controls GERD symptoms and maintains healing of reflux esophagitis.
- The authors recommend against routine addition of medical therapies in PPI non-responders.
- The authors recommend maintenance PPI therapy indefinitely or antireflux surgery for patients with LA grade C or D esophagitis.
- The authors do not recommend baclofen in the absence of objective evidence of GERD.
- recommend against treatment with a prokinetic agent of any kind for GERD therapy unless there is objective evidence of gastroparesis.
- The authors do not recommend sucralfate for GERD therapy except during pregnancy.
- suggest on-demand/or intermittent PPI therapy for heartburn symptom control in patients with NERD.
Extraesophageal GERD symptoms
- The authors recommend evaluation for non-GERD causes in patients with possible extraesophageal manifestations before ascribing symptoms to GERD.
- The authors recommend that patients who have extraesophageal manifestations of GERD without typical GERD symptoms (e.g., heartburn and regurgitation) undergo reflux testing for evaluation before PPI therapy.
- For patients who have both extraesophageal and typical GERD symptoms, we suggest considering a trial of twice-daily PPI therapy for 8–12 wk before additional testing.
- The authors suggest that upper endoscopy should not be used as the method to establish a diagnosis of GERD-related asthma, chronic cough, or LPR.
- The authors suggest against a diagnosis of LPR based on laryngoscopy findings alone and recommend additional testing should be considered.
- In patients treated for extraesophageal reflux disease, surgical or endoscopic antireflux procedures are only recommended in patients with objective evidence of reflux.
- The authors recommend optimization of PPI therapy as the first step in management of refractory GERD.
- The authors recommend esophageal pH monitoring (Bravo, catheter-based, or combined impedance-pH monitoring) performed OFF PPIs if the diagnosis of GERD has not been established by a previous pH monitoring study or an endoscopy showing long-segment Barrett's esophagus or severe reflux esophagitis.
- The authors recommend esophageal impedance-pH monitoring performed ON PPIs for patients with an established diagnosis of GERD whose symptoms have not responded adequately to twice-daily PPI therapy.
- For patients who have regurgitation as their primary PPI-refractory symptom and who have had abnormal gastroesophageal reflux documented by objective testing, we recommend consideration of antireflux surgery or TIF.
Surgical and endoscopic options for GERD
- The authors recommend antireflux surgery performed by an experienced surgeon as an option for long-term treatment of patients with objective evidence of GERD. Those who have severe reflux esophagitis (LA grade C or D), large hiatal hernias, and/or persistent, troublesome GERD symptoms who are likely to benefit most from surgery.
- The authors recommend consideration of MSA as an alternative to laparoscopic fundoplication for patients with regurgitation who fail medical management.
- The authors recommend consideration of 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.
- Because data on the efficacy of radiofrequency energy (Stretta) as an antireflux procedure is inconsistent and highly variable, we cannot recommend its use as an alternative to medical or surgical antireflux therapies.
- The authors suggest consideration of TIF for patients with troublesome 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.
"Future research with advanced endoscopic techniques, data on long-term efficacy of surgical intervention, and advances in artificial intelligence and basic science will almost certainly change the way we manage GERD going forward," concluded the authors.
Katz, Philip O. MD, MACG1; Dunbar, Kerry B. MD, PhD2,3; Schnoll-Sussman, Felice H. MD, FACG1; Greer, Katarina B. MD, MS, FACG4; Yadlapati, Rena MD, MSHS5; Spechler, Stuart Jon MD, FACG6,7 ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease, The American Journal of Gastroenterology: November 22, 2021 - Volume - Issue - 10.14309/ajg.0000000000001538 doi: 10.14309/ajg.0000000000001538