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    Diagnosis and Management of Gastroesophageal Reflux Disease (beta)

    Official guideline from the American College of Gastroenterology

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    Diagnosis

    Establishing diagnosis
    1. Empiric PPI is recommended if typical GERD symptoms.
    2. Diagnostic evaluation is required if non-cardiac chest pain suspicious for GERD. Exclude cardiac causes before evaluating GERD.
    3. Endoscopy for typical GERD is recommended if alarm symptoms, and for screening if high risk for Barrett’s esophagus.
    4. Ambulatory reflux monitoring is indicated before considering endoscopic or surgical therapy if refractory symptoms, or if GERD diagnosis is questionable.
    5. Esophageal manometry is indicated for preoperative evaluation.
    Extraesophageal presentation
    1. Extraesophageal GERD symptoms include asthma, chronic cough, or laryngitis.
    2. PPI trial indicated in patients if extraesophageal symptoms and typical GERD symptoms.
    3. Reflux monitoring should be pursued if extraesophageal symptoms without typical GERD symptoms.

    Management

    Medical
    1. Lifestyle modifications (weight loss, elevate head of bed, avoid food 2-3 hrs before bedtime) may be recommended in the appropriate clinical setting.
    2. Routine global elimination of trigger foods is not recommended.
    3. PPI (8-week course, once daily 30 mins before breakfast) is initial therapy for symptoms and erosive esophagitis.
    4. PPI can be increased to twice daily dosing or switched if initial therapy has partial response.
    5. Refractory symptoms require further evaluation.
    6. Maintenance PPI should be given if symptoms resume after initial therapy or for erosive esophagitis or Barrett’s esophagus.
    7. Maintenance H2RA can be given for heartburn relief if no erosive disease.
    8. PPIs are safe in pregnancy if clinically indicated.
    GERD Refractory to PPIs
    1. Attempt to optimize PPI therapy.
    2. Upper endoscopy is indicated to rule out non-GERD etiologies if typical symptoms.
    3. ENT, pulmonary, and allergy evaluation indicated in patients if extraesophageal GERD symptoms or if typical symptoms and negative upper endoscopy.
    4. pH monitoring is indicated in patients with unexplained GERD despite 1-3 above.
    5. PPIs should be discontinued if negative testing.
    6. Consider surgery or TLESR inhibitors if symptomatic reflux refractory to PPIs.
    Surgical
    1. Surgery is as effective as medical therapy for carefully selected patients with chronic GERD.
    2. Manometry and ambulatory pH monitoring are required before fundoplication.
    3. Surgery not recommended in PPI nonresponders.
    4. Obese patients considering surgery for GERD should be considered for gastric bypass.

    Risks and Complications

    PPI risks
    1. Patients with known osteoporosis can remain on PPI therapy.
    2. PPIs should be carefully used in patients at risk for Clostridium difficile infection.
    3. Short-term PPI may increase CAP risk. Long-term use has not been shown to increase risk.
    4. There is no increased risk for adverse cardiovascular events. No adjustments to PPI therapy indicated for patients on clopidogrel.
    Complications
    1. The LA classification system should be used to describe erosive esophagitis.
    2. LA Grade A patients should have further testing.
    3. Repeat endoscopy should be performed after PPI therapy to exclude Barrett’s esophagus if severe esophagitis.
    4. Patients with peptic stricture dilation or Schatzki ring dilation should be placed on continuous PPI.
    5. Intralesional corticosteroids can be used in refractory GERD stricture.
    6. High-risk GERD patients should be screened for Barrett’s esophagus.
    7. Patients with Barrett’s esophagus should undergo periodic surveillance based on guidelines.