Diagnosis and Management of Gastroesophageal Reflux Disease
Official guideline from the American College of Gastroenterology.
summary by Rachel Niec, MD Rachel Engelberg, MD
Diagnosis
Establishing diagnosis
Empiric PPI is recommended if typical GERD symptoms.
Strong recommendation
Moderate quality evidence
Diagnostic evaluation is required if non-cardiac chest pain suspicious for GERD. Exclude cardiac causes before evaluating GERD.
Strong recommendation
Low quality evidence
Endoscopy for typical GERD is recommended if alarm symptoms, and for screening if high risk for Barrett’s esophagus.
Strong recommendation
Moderate quality evidence
Ambulatory reflux monitoring is indicated before considering endoscopic or surgical therapy if refractory symptoms, or if GERD diagnosis is questionable.
Strong recommendation
Low quality evidence
Esophageal manometry is indicated for preoperative evaluation.
Strong recommendation
Low quality evidence
Extraesophageal presentation
Extraesophageal GERD symptoms include asthma, chronic cough, or laryngitis.
Strong recommendation
Moderate quality evidence
PPI trial indicated in patients if extraesophageal symptoms and typical GERD symptoms.
Strong recommendation
Low quality evidence
Reflux monitoring should be pursued if extraesophageal symptoms without typical GERD symptoms.
Conditional recommendation
Low quality evidence
Management
Medical
Lifestyle modifications (weight loss, elevate head of bed, avoid food 2-3 hrs before bedtime) may be recommended in the appropriate clinical setting.
Conditional recommendation
Moderate quality evidence
Routine global elimination of trigger foods is not recommended.
Conditional recommendation
Low quality evidence
PPI (8-week course, once daily 30 mins before breakfast) is initial therapy for symptoms and erosive esophagitis.
Strong recommendation
High quality evidence
PPI can be increased to twice daily dosing or switched if initial therapy has partial response.
Strong recommendation
Low quality evidence
Refractory symptoms require further evaluation.
Conditional recommendation
Low quality evidence
Maintenance PPI should be given if symptoms resume after initial therapy or for erosive esophagitis or Barrett’s esophagus.
Strong recommendation
Moderate quality evidence
Maintenance H2RA can be given for heartburn relief if no erosive disease.
Conditional recommendation
Moderate quality evidence
PPIs are safe in pregnancy if clinically indicated.
Conditional recommendation
Moderate quality evidence
GERD Refractory to PPIs
Attempt to optimize PPI therapy.
Strong recommendation
Low quality evidence
Upper endoscopy is indicated to rule out non-GERD etiologies if typical symptoms.
Conditional recommendation
Low quality evidence
ENT, pulmonary, and allergy evaluation indicated in patients if extraesophageal GERD symptoms or if typical symptoms and negative upper endoscopy.
Strong recommendation
Low quality evidence
pH monitoring is indicated in patients with unexplained GERD despite 1-3 above.
Strong recommendation
Low quality evidence
PPIs should be discontinued if negative testing.
Strong recommendation
Low quality evidence
Consider surgery or TLESR inhibitors if symptomatic reflux refractory to PPIs.
Conditional recommendation
Low quality evidence
Surgical
Surgery is as effective as medical therapy for carefully selected patients with chronic GERD.
Strong recommendation
High quality evidence
Manometry and ambulatory pH monitoring are required before fundoplication.
Conditional recommendation
Moderate quality evidence
Surgery not recommended in PPI nonresponders.
Strong recommendation
High quality evidence
Obese patients considering surgery for GERD should be considered for gastric bypass.
Conditional recommendation
Moderate quality evidence
Risks and Complications
PPI risks
Patients with known osteoporosis can remain on PPI therapy.
Conditional recommendation
Moderate quality evidence
PPIs should be carefully used in patients at risk for Clostridium difficile infection.
Conditional recommendation
Moderate quality evidence
Short-term PPI may increase CAP risk. Long-term use has not been shown to increase risk.
Conditional recommendation
Moderate quality evidence
There is no increased risk for adverse cardiovascular events. No adjustments to PPI therapy indicated for patients on clopidogrel.
Strong recommendation
High quality evidence
Complications
The LA classification system should be used to describe erosive esophagitis.
Strong recommendation
Moderate quality evidence
LA Grade A patients should have further testing.
Conditional recommendation
Low quality evidence
Repeat endoscopy should be performed after PPI therapy to exclude Barrett’s esophagus if severe esophagitis.
Conditional recommendation
Low quality evidence
Patients with peptic stricture dilation or Schatzki ring dilation should be placed on continuous PPI.
Strong recommendation
Moderate quality evidence
Intralesional corticosteroids can be used in refractory GERD stricture.
Conditional recommendation
Low quality evidence
High-risk GERD patients should be screened for Barrett’s esophagus.
Conditional recommendation
Moderate quality evidence
Patients with Barrett’s esophagus should undergo periodic surveillance based on guidelines.
Strong recommendation
Moderate quality evidence
What do the icons mean?
How strong is the ACG's recommendation?
Strong recommendation
Intervention's desirable effects clearly outweigh undesirable effects.Moderate recommendation
Further research likely to impact confidence in estimate of effect.
Conditional recommendation
Uncertainty in tradeoffs between desirable & undesirable effects of intervention.Weak recommendation
Uncertainty in tradeoffs between desirable & undesirable effects of intervention.
High quality evidence
Further research unlikely to change guideline authors' confidence in estimate of effect.Moderate-high quality evidence
Between high and moderate levels of evidence.
Moderate quality evidence
Further research likely to impact confidence in estimate of effect.Low quality evidence
Further research expected to have important impact in confidence in estimate of effect.Very low quality evidence
Effect is very uncertain.
Literature
