New 2013 guidelines for diagnosis and management of GERD!

The American Gastroenterological Society has recently published a new set of guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD). Nearly 25 million people suffer from GERD in the United States, therefore correct diagnosis and management is essential to prevention of complications, and improvement of quality of life. 

GERD is a common condition which involves the regurgitation of stomach contents into the esophagus or furthermore into the mouth and even into the lung. It is commonly described as “heart burn” due to mid-epigastric and sub-sternal burning sensations when stomach acid refluxes into the esophagus. If the lower esophageal sphincter (LES) is regurgitant, then patients may suffer from chronic GERD which may lead to significant complications such as Barrett’s esophagus, and esophageal cancer. According to the A.D.A.M. Medical Encyclopedia, risk factors for GERD include: alcohol use, haital hernia, obesity, pregnancy, scleroderma, smoking, and several medication side-effects.

The new guidelines published in February 2013 state the following, (direct reference from publication):

Establishing the diagnosis of Gastroesophageal Reflux Disease (GERD) [2]

1.  A presumptive diagnosis of GERD can be established in the setting of typical symptoms of heartburn and regurgitation. Empiric medical therapy with a proton pump inhibitor (PPI) is recommended in this setting.

2.  Patients with non-cardiac chest pain suspected due to GERD should have diagnostic evaluation before institution of therapy. (Conditional recommendation, moderate level of evidence). A cardiac cause should be excluded in patients with chest pain before the commencement of a gastrointestinal evaluation.

3. Barium radiographs should not be performed to diagnose GERD.

4.  Upper endoscopy is not required in the presence of typical GERD symptoms. Endoscopy is recommended in the presence of alarm symptoms and for screening of patients at high risk for complications. Repeat endoscopy is not indicated in patients without Barrett’s esophagus in the absence of new symptoms.

5. Routine biopsies from the distal esophagus are not recommended specifi cally to diagnose GERD.

6. Esophageal manometry is recommended for preoperative evaluation, but has no role in the diagnosis of GERD.

7.  Ambulatory esophageal reflux monitoring is indicated before consideration of endoscopic or surgical therapy in patients with non-erosive disease, as part of the evaluation of patients refractory to PPI therapy, and in situations when the diagnosis of GERD is in question. Ambulatory reflux monitoring is the only test that can assess reflux symptom association.

8.  Ambulatory reflux monitoring is not required in the presence of short or long-segment Barrett’s esophagus to establish a diagnosis of GERD.

9.  Screening for Helicobacter pylori infection is not recommended in GERD patients. Treatment of  H. pylori infection is not routinely required as part of antireflux therapy.

Management of GERD [2]

1. Weight loss is recommended for GERD patients who are overweight or have had recent weight gain.

2.  Head of bed elevation and avoidance of meals 2 – 3 h before bedtime should be recommended for patients with nocturnal GERD.

3.  Routine global elimination of food that can trigger reflux (including chocolate, caffeine, alcohol, acidic and / or spicy foods) is not recommended in the treatment of GERD.

4.  An 8-week course of PPIs is the therapy of choice for symptom relief and healing of erosive esophagitis. There are no major differences in effi cacy between the different PPIs.

5.  Traditional delayed release PPIs should be administered 30 – 60   min before meal for maximal pH control. Newer PPIs may offer dosing flexibility relative to meal timing.

6.  PPI therapy should be initiated at once a day dosing, before the first meal of the day. (Strong recommendation, moderate level of evidence). For patients with partial response to once daily therapy, tailored therapy with adjustment of dose timing and / or twice daily dosing should be considered in patients with night-time symptoms, variable schedules, and / or sleep disturbance.

7. Non-responders to PPI should be referred for evaluation.

8.  In patients with partial response to PPI therapy, increasing the dose to twice daily therapy or switching to a different PPI may provide additional symptom relief.

9.  Maintenance PPI therapy should be administered for GERD patients who continue to have symptoms after PPI is discontinued, and in patients with complications including erosive esophagitis and Barrett’s esophagus. For patients who require long-term PPI therapy, it should be administered in the lowest effective dose, including on demand or intermittent therapy.

10.  H2-receptor antagonist (H2RA) therapy can be used as a maintenance option in patients without erosive disease if patients experience heartburn relief. Bedtime H2RA therapy can be added to daytime PPI therapy in selected patients with objective evidence of night-time reflux if needed, but may be associated with the development of tachyphlaxis after several weeks of use.

11.  Therapy for GERD other than acid suppression, including prokinetic therapy and / or baclofen, should not be used in GERD patients without diagnostic evaluation.

12. There is no role for sucralfate in the non-pregnant GERD patient.

13. PPIs are safe in pregnant patients if clinically indicated.

Surgical Options for GERD [2]

1. Surgical therapy is a treatment option for long-term therapy in GERD patients.

2. Surgical therapy is generally not recommended in patients who do not respond to PPI therapy.

3.  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.

4.  Surgical therapy is as effective as medical therapy for carefully selected patients with chronic GERD when performed by an experienced surgeon.

5.  Obese patients contemplating surgical therapy for GERD should be considered for bariatric surgery. Gastric bypass would be the preferred operation in these patients.

6.  The usage of current endoscopic therapy or transoral incisionless fundoplication cannot be recommended as an alternative to medical or traditional surgical therapy.

GERD refractory to treatment with PPIs [2]

1. The first step in management of refractory GERD is optimization of PPI therapy.

2.  Upper endoscopy should be performed in refractory patients with typical or dyspeptic symptoms principally to exclude non-GERD etiologies.

3.  In patients in whom extraesophageal symptoms of GERD persist despite PPI optimization, assessment for other etiologies should be pursued through concomitant evaluation by ENT, pulmonary, and allergy specialists.

4.  Patients with refractory GERD and negative evaluation by endoscopy (typical symptoms) or evaluation by ENT, pulmonary, and allergy specialists (extraesophageal symptoms), should undergo ambulatory reflux monitoring.

5.  Reflux monitoring off  medication can be performed by any available modality (pH or impedance-pH). Testing  on medication should be performed with impedance-pH monitoring in order to enable measurement of nonacid reflux.

6.  Refractory patients with objective evidence of ongoing reflux as the cause of symptoms should be considered for additional antireflux therapies, which may include surgery or TLESR inhibitors. Patients with negative testing are unlikely to have GERD and PPI therapy should be discontinued.

Disclaimer: Please note that the information above has been obtained from multiple sources for the sole purpose of student education and should not be used in the direct care of patients and/or clinical decision making.

References:

1) http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001311/

2) http://gi.org/wp-content/uploads/2013/03/ACG_Guideline_GERD_March_2013.pdf

3) http://www.acpinternist.org/weekly/archives/2013/3/12/index.html#1

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