Diagnosis and Management of Gastroesophageal Reflux Disease(beta)
Official guideline from the American College of Gastroenterology.
summary by Rachel Niec, MD Rachel Engelberg, MD
Diagnostic evaluation is required if non-cardiac chest pain suspicious for GERD. Exclude cardiac causes before evaluating GERD.
Endoscopy for typical GERD is recommended if alarm symptoms, and for screening if high risk for Barrett’s esophagus.
Ambulatory reflux monitoring is indicated before considering endoscopic or surgical therapy if refractory symptoms, or if GERD diagnosis is questionable.
Extraesophageal GERD symptoms include asthma, chronic cough, or laryngitis.
PPI trial indicated in patients if extraesophageal symptoms and typical GERD symptoms.
Lifestyle modifications (weight loss, elevate head of bed, avoid food 2-3 hrs before bedtime) may be recommended in the appropriate clinical setting.
Routine global elimination of trigger foods is not recommended.
PPI (8-week course, once daily 30 mins before breakfast) is initial therapy for symptoms and erosive esophagitis.
PPI can be increased to twice daily dosing or switched if initial therapy has partial response.
Maintenance PPI should be given if symptoms resume after initial therapy or for erosive esophagitis or Barrett’s esophagus.
Maintenance H2RA can be given for heartburn relief if no erosive disease.
Upper endoscopy is indicated to rule out non-GERD etiologies if typical symptoms.
ENT, pulmonary, and allergy evaluation indicated in patients if extraesophageal GERD symptoms or if typical symptoms and negative upper endoscopy.
pH monitoring is indicated in patients with unexplained GERD despite 1-3 above.
Surgery is as effective as medical therapy for carefully selected patients with chronic GERD.
Manometry and ambulatory pH monitoring are required before fundoplication.
Risks and Complications
Patients with known osteoporosis can remain on PPI therapy.
PPIs should be carefully used in patients at risk for Clostridium difficile infection.
Short-term PPI may increase CAP risk. Long-term use has not been shown to increase risk.
Repeat endoscopy should be performed after PPI therapy to exclude Barrett’s esophagus if severe esophagitis.
Patients with peptic stricture dilation or Schatzki ring dilation should be placed on continuous PPI.
Intralesional corticosteroids can be used in refractory GERD stricture.
High-risk GERD patients should be screened for Barrett’s esophagus.
How strong is the ACG's recommendation?