GERD guidelines establish diagnosis, management options

The American Gastroenterological Society issued guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD), “arguably the most common disease encountered by the gastroenterologist,” according to the authors. “It is equally likely that the primary care providers will find that complaints related to reflux disease constitute a large proportion of their practice.”

The full recommendations and evidence for them appeared in the March The American Journal of Gastroenterology and are also free online.

GERD should be defined as symptoms or complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or into the lung, according to the guidelines. This definition includes symptoms with or without erosions on endoscopic examination.

Following are all strong recommendations, with levels of evidence graded as “high” (implying that further research was unlikely to change the authors' confidence in the estimate of the effect) or “moderate” (further research would be likely to have an impact on the confidence in the estimate of effect):

Diagnosis

• GERD can be established in the setting of typical symptoms of heartburn and regurgitation. Empiric medical therapy with a PPI is recommended (moderate level of evidence).
• Barium radiographs should not be performed to diagnose GERD (high level of evidence).
• Upper endoscopy is not required in the presence of typical GERD symptoms. It is recommended in the presence of alarm symptoms and for screening patients at high risk for complications. Repeat endoscopy is not indicated in patients without Barrett's esophagus in the absence of new symptoms (moderate level of evidence).
• Routine biopsies from the distal esophagus are not recommended specifically to diagnose GERD (moderate level of evidence).
• Ambulatory reflux monitoring is not required in the presence of short- or long-segment Barrett's esophagus to establish a diagnosis of GERD (moderate level of evidence).

Management

• An 8-week course of proton-pump inhibitors (PPIs) is the therapy of choice for symptom relief and healing of erosive esophagitis, with no differences between the different PPIs (high level of evidence).
• Delayed-release PPIs should be administered 30 to 60 minutes before meals (moderate level of evidence).
• Maintenance PPI therapy should be given to patients who continue to have symptoms after stopping PPIs and in patients with complications including erosive esophagitis and Barrett's esophagus (moderate level of evidence).

Surgical options

• Surgery is a treatment option for long-term therapy in GERD (high level of evidence).
• Surgery is generally not recommended in patients who do not respond to PPIs (high level of evidence).
• Preoperative ambulatory pH monitoring is mandatory in patients without evidence of erosive esophagitis. All patients should undergo preoperative manometry to rule out achalasia or scleroderma-like esophagus (moderate level of evidence).
• Surgery is as effective as medical therapy for carefully selected patients with chronic GERD when performed by an experienced surgeon (high level of evidence).

Risks associated with PPIs

• Patients with osteoporosis can remain on PPIs, except in patients with other risk factors for hip fracture (moderate level of evidence).
• PPIs can be a risk factor for Clostridium difficile infections (moderate level of evidence).
• PPIs do not need to be altered in concomitant clopidogrel users because the evidence does not support an increased risk for cardiovascular events (high level of evidence).

Asthma, chronic cough, and laryngitis

• GERD can be considered as a potential co-factor in patients with asthma, chronic cough, or laryngitis. Careful evaluation for non-GERD causes should be undertaken in all of these patients (moderate level of evidence).
• A diagnosis of reflux laryngitis should not be made based solely upon laryngoscopy findings (moderate level of evidence).
• Surgery should generally not be performed to treat extraesophageal symptoms of GERD in patients who do not respond to acid suppression with a PPI (moderate level of evidence).

Also, the authors noted, the Los Angeles classification system should be used when describing the endoscopic appearance of erosive esophagitis. Symptoms in patients with Barrett's esophagus can be treated in a similar fashion to patients with GERD who do not have Barrett's esophagus. Patients with Barrett's esophagus found during endoscopy should undergo periodic surveillance according to guidelines.

The guidelines also review potential adverse events associated with PPI therapy, as well as lifestyle factors associated with GERD.