The American Journal of Gastroenterology

Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians.

GERD is the condition in which the reflux of gastric contents into the esophagus results in symptoms and/or complications. GERD is defined by the presence of characteristic mucosal injury seen at endoscopy and/or abnormal esophageal acid exposure demonstrated on a reflux monitoring study.

TAKE-HOME MESSAGE

The American College of Gastroenterology clinical guideline utilizes the GRADE methodology to provide practical, evidence-based recommendations for gastroesophageal reflux disease (GERD), including lifestyle, pharmacologic, and interventional management options.

Patients with typical GERD symptoms (heartburn and regurgitation) without alarm symptoms (dysphagia, weight loss, and bleeding) may be administered an 8-week trial of antisecretory therapy, whereas further diagnostic evaluation (including endoscopy) is appropriate for patients whose symptoms do not respond appropriately.

Among patients without a confirmed diagnosis of GERD, ambulatory reflux monitoring should be performed off antisecretory therapy, whereas pH-impedance monitoring on antisecretory therapy is appropriate for patients with persistent symptoms in the setting of an established diagnosis of GERD (ie, advanced reflux esophagitis, long-segment Barrett’s esophagus, peptic strictures, and prior abnormal reflux monitoring).

DIAGNOSIS OF GERD

Symptoms

Typical symptoms of GERD include heartburn and regurgitation. Heartburn is the most common GERD symptom and is described as substernal burning sensation rising from the epigastrium up toward the neck. Regurgitation is the effortless return of gastric contents upward toward the mouth, often accompanied by an acid or bitter taste.

There is no gold standard for the diagnosis of GERD. Thus, the diagnosis is based on a combination of symptom presentation, endoscopic evaluation of esophageal mucosa, reflux monitoring, and response to therapeutic intervention. Heartburn and regurgitation remain the most sensitive and specific symptoms for GERD.

Recommendations

1. For patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms, guidelines recommend an 8-week trial of empiric PPIs once daily before a meal (strong recommendation, moderate level of evidence).

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

3. Guidelines recommend diagnostic endoscopy, ideally after PPIs are stopped for 2–4 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).

4. In patients who have chest pain without heartburn and who have had adequate evaluation to exclude heart disease, objective testing for GERD (endoscopy and/or reflux monitoring) is recommended (conditional recommendation, low level of evidence).

5. Guidelines do not recommend the use of barium swallow solely as a diagnostic test for GERD (conditional recommendation, low level of evidence).

6. Guidelines recommend endoscopy as the first test for evaluation of patients presenting with dysphagia or other alarm symptoms (weight loss and GI bleeding) and for patients with multiple risk factors for Barrett's esophagus (strong recommendation, low level of evidence).

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

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

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