the Management of Gastroesophageal Reflux Disease

- Recommendations

Section 1: Diagnosis of GERD:

·  For patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms, we recommend an 8-week trial of empiric proton pump inhibitor (PPI) once daily before a meal, (Strong recommendation, moderate level of evidence, ⁽¹⁾).

· We recommend attempting to discontinue the PPIs in patients whose classic GERD symptoms respond to an 8-week empiric trial of PPIs, (Strong recommendation, low level of evidence, ⁽¹⁾).

·  We recommend diagnostic endoscopy, ideally after PPIs are stopped for 2 to 4 weeks, in patients whose classic GERD symptoms do not respond adequately to an 8-week empiric trial of PPIs, or whose symptoms return when PPIs are discontinued, (Strong recommendation, low level of evidence, ⁽¹⁾).

·  In patients who have chest pain without heartburn and who have had adequate evaluation to exclude heart disease, endoscopy and/or reflux monitoring is suggested, (Conditional recommendation, low level of evidence, ⁽¹⁾).

·  We recommend against the use of a barium swallow solely as a diagnostic test for GERD, (Strong recommendation, low level of evidence, ^{( 1)}).

·  We recommend endoscopy as the first test for evaluation of patients presenting with dysphagia or other alarm symptoms (weight loss, GI bleeding), and for patients with multiple risk factors for Barrett’s esophagus, (Strong recommendation, low level of evidence, ^{( 1)}).

· In patients for whom the diagnosis of GERD is suspected but not clear, and endoscopy shows no objective evidence of GERD, we recommend reflux monitoring be performed off therapy to establish the diagnosis, (Strong recommendation, low level of evidence, ⁽¹⁾).

·  We recommend against performing reflux monitoring off therapy solely as a diagnostic test for GERD in patients known to have endoscopic evidence of Los Angeles grade C or D reflux esophagitis, or in patients with long-segment Barrett’s esophagus, (Strong recommendation, low level of evidence, ⁽¹⁾).

·  We recommend against high resolution manometry (HRM) solely as a diagnostic test for GERD, (Strong recommendation, low level of evidence, ⁽¹⁾).

·  We prefer esophageal manometry for excluding rare motility disorders especially prior to surgery. (Conditional recommendation, low level of evidence, ⁽¹⁾).

Section 2: Medical Management of GERD:

·  We recommend weight loss in overweight and obese patients for improvement of GERD symptoms, (Strong recommendation, moderate level of evidence, ⁽¹⁾).

·  We suggest avoiding meals within 2-3 hours of bedtime, (Conditional recommendation, low level of evidence, ⁽¹⁾).

·  We suggest avoidance of tobacco products/smoking in patients with GERD symptoms, (Conditional recommendation, low level of evidence, ⁽¹⁾).

· We suggest avoidance of "trigger foods" for GERD symptom control, Conditional recommendation, low level of evidence, ⁽¹⁾).

·  We suggest elevating head of bed for night-time GERD symptoms, (Conditional recommendation, low level of evidence, ⁽¹⁾).

·  We recommend treatment with PPI over treatment with H2RA for healing erosive esophagitis, (Strong recommendation, high level of evidence, ⁽¹⁾).

·  We recommend PPI administration 30 to 60 minutes prior to a meal rather than at bedtime for GERD symptom control, (Strong recommendation, moderate level of evidence, ⁽¹⁾).

· For GERD patients who do not have erosive esophagitis or Barrett’s esophagus, and whose symptoms have resolved with PPI therapy, an attempt should be made to discontinue PPIs or to switch to on-demand therapy in which PPIs are taken only when symptoms occur and discontinued when they are relieved, (Strong recommendation, low level of evidence, ⁽¹⁾).

·  For GERD patients who require maintenance therapy with PPIs, we suggest that PPIs should be administered in the lowest dose that effectively controls GERD symptoms and maintains healing of reflux esophagitis, (Conditional recommendation, low level of evidence ⁽¹⁾).

· We recommend against routine addition of medical therapies in PPI non-responders, (Strong recommendation, moderate level of evidence, ⁽¹⁾).

·  We recommend maintenance PPI therapy indefinitely or anti-reflux surgery for patients with Los Angeles grade C or D esophagitis, (Strong recommendation, moderate level of evidence, ⁽¹⁾).

·  We recommend against treatment with a prokinetic agent of any kind for GERD therapy unless there is objective evidence of gastroparesis, (Strong recommendation, low level of evidence, ⁽¹⁾).

·  We recommend against sucralfate for GERD therapy except during pregnancy, (Strong recommendation, low level of evidence, ⁽¹⁾).

·  We suggest on-demand or intermittent PPI therapy for heartburn symptom control in patients with non-erosive reflux disease, (Conditional recommendation, low level of evidence, ⁽¹⁾).

Section 3: Extra-esophageal GERD Symptoms:

·  We recommend evaluation for non-GERD causes in patients with possible extra-esophageal manifestations before ascribing symptoms to GERD, (Strong recommendation, moderate level of evidence, ⁽¹⁾).

·  We recommend that patients who have extra-esophageal manifestations of GERD without typical GERD symptoms (e.g. heartburn, regurgitation) undergo reflux testing for evaluation prior to PPI therapy, (Strong recommendation, moderate level of evidence, ⁽¹⁾).

·  For patients who have both extra-esophageal and typical GERD symptoms we suggest considering a trial of twice-daily PPI therapy for 8 to 12 weeks prior to additional testing, (Conditional recommendation, low level of evidence, ⁽¹⁾).

·  We suggest that upper endoscopy should not be used as the method to establish a diagnosis of GERD-related asthma, chronic cough, or laryngopharyngeal reflux, (Conditional recommendation, low level of evidence, ⁽¹⁾).

Section 4: Refractory GERD:

·  We recommend optimization of PPI therapy as the first step in management of refractory GERD, (Strong recommendation, moderate level of evidence, ⁽¹⁾).

·  We suggest esophageal pH monitoring performed off PPIs if the diagnosis of GERD has not been established by a prior pH monitoring study, (Conditional recommendation, low level of evidence, ⁽¹⁾).

·   For patients who have regurgitation as their primary PPI-refractory symptom and who have had abnormal gastroesophageal reflux documented by objective testing, we suggest consideration of anti-reflux surgery, (Conditional recommendation, low level of evidence, ⁽¹⁾).

·   Esophageal high resolution manometry (HRM) is advised as part of the evaluation for refractory GERD in patients with a normal endoscopy and pH monitoring study, and for patients being considered for surgical or endoscopic treatment, (Conditional recommendation, low level of evidence, ⁽²⁾).

Section 5: Surgical and Endoscopic Options for GERD:

· We recommend anti-reflux surgery performed by an experienced surgeon as an option for long-term treatment of patients with objective evidence of GERD, especially those who have severe reflux esophagitis (LA grades C or D), large hiatal hernias, and/or persistent, troublesome GERD symptoms, (Strong recommendation, moderate level of evidence, ⁽¹⁾).

·  We suggest consideration of Roux-en-Y gastric bypass (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, (Conditional recommendation, low level of evidence, ⁽¹⁾).

·   Since data on the efficacy of radiofrequency energy (Stretta) as an anti-reflux procedure is inconsistent and highly variable, we recommend against its use as an alternative to medical or surgical anti-reflux therapies, (Strong recommendation, low level of evidence, ⁽¹⁾).

·  We suggest the use of an esophageal dilator, (French Bougie 56) to decrease the long-term incidence of dysphagia, (Conditional recommendation, high level of evidence, ⁽¹⁾).

 Section 6: Management of Barrett^’s oesophagus:

·  We recommend endoscopic mucosal resection in conjunction with antireflux surgery for patients with Barret’s disease especially with low grade dysplasia, (Good practice statement).

·  We recommend considering endoscopic deep mucosectomy in conjunction with anti-reflux surgery for patients with high grade dysplasia of Barret’s disease if endosonography excludes malignant invasion as alternative to esophagectomy, (Good practice statement).