AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review

Abstract

Background & aims: As many as one-half of all patients with suspected gastroesophageal reflux disease (GERD) do not derive benefit from acid suppression. This review outlines a personalized diagnostic and therapeutic approach to GERD symptoms.

Methods: The Best Practice Advice statements presented here were developed from expert review of existing literature combined with extensive discussion and expert opinion to provide practical advice. Formal rating of the quality of evidence or strength of recommendations was not the intent of this clinical practice update. BEST PRACTICE ADVICE 1: Clinicians should develop a care plan for investigation of symptoms suggestive of GERD, selection of therapy (with explanation of potential risks and benefits), and long-term management, including possible de-escalation, in a shared-decision making model with the patient. BEST PRACTICE ADVICE 2: Clinicians should provide standardized educational material on GERD mechanisms, weight management, lifestyle and dietary behaviors, relaxation strategies, and awareness about the brain-gut axis relationship to patients with reflux symptoms. BEST PRACTICE ADVICE 3: Clinicians should emphasize safety of proton pump inhibitors (PPIs) for the treatment of GERD. BEST PRACTICE ADVICE 4: Clinicians should provide patients presenting with troublesome heartburn, regurgitation, and/or non-cardiac chest pain without alarm symptoms a 4- to 8-week trial of single-dose PPI therapy. With inadequate response, dosing can be increased to twice a day or switched to a more effective acid suppressive agent once a day. When there is adequate response, PPI should be tapered to the lowest effective dose. BEST PRACTICE ADVICE 5: If PPI therapy is continued in a patient with unproven GERD, clinicians should evaluate the appropriateness and dosing within 12 months after initiation, and offer endoscopy with prolonged wireless reflux monitoring off PPI therapy to establish appropriateness of long-term PPI therapy. BEST PRACTICE ADVICE 6: If troublesome heartburn, regurgitation, and/or non-cardiac chest pain do not respond adequately to a PPI trial or when alarm symptoms exist, clinicians should investigate with endoscopy and, in the absence of erosive reflux disease (Los Angeles B or greater) or long-segment (≥3 cm) Barrett's esophagus, perform prolonged wireless pH monitoring off medication (96-hour preferred if available) to confirm and phenotype GERD or to rule out GERD. BEST PRACTICE ADVICE 7: Complete endoscopic evaluation of GERD symptoms includes inspection for erosive esophagitis (graded according to the Los Angeles classification when present), diaphragmatic hiatus (Hill grade of flap valve), axial hiatus hernia length, and inspection for Barrett's esophagus (graded according to the Prague classification and biopsied when present). BEST PRACTICE ADVICE 8: Clinicians should perform upfront objective reflux testing off medication (rather than an empiric PPI trial) in patients with isolated extra-esophageal symptoms and suspicion for reflux etiology. BEST PRACTICE ADVICE 9: In symptomatic patients with proven GERD, clinicians should consider ambulatory 24-hour pH-impedance monitoring on PPI as an option to determine the mechanism of persisting esophageal symptoms despite therapy (if adequate expertise exists for interpretation). BEST PRACTICE ADVICE 10: Clinicians should personalize adjunctive pharmacotherapy to the GERD phenotype, in contrast to empiric use of these agents. Adjunctive agents include alginate antacids for breakthrough symptoms, nighttime H2 receptor antagonists for nocturnal symptoms, baclofen for regurgitation or belch predominant symptoms, and prokinetics for coexistent gastroparesis. BEST PRACTICE ADVICE 11: Clinicians should provide pharmacologic neuromodulation, and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies in patients with functional heartburn or reflux disease associated with esophageal hypervigilance reflux hypersensitivity and/or behavioral disorders. BEST PRACTICE ADVICE 12: In patients with proven GERD, laparoscopic fundoplication and magnetic sphincter augmentation are effective surgical options, and transoral incisionless fundoplication is an effective endoscopic option in carefully selected patients. BEST PRACTICE ADVICE 13: In patients with proven GERD, Roux-en-Y gastric bypass is an effective primary anti-reflux intervention in obese patients, and a salvage option in non-obese patients, whereas sleeve gastrectomy has potential to worsen GERD. BEST PRACTICE ADVICE 14: Candidacy for invasive anti-reflux procedures includes confirmatory evidence of pathologic GERD, exclusion of achalasia, and assessment of esophageal peristaltic function.

Keywords: Ambulatory Reflux Monitoring; Gastroesophageal Reflux Disease; Proton Pump Inhibitors.

Figure 1.

Utilization of empiric PPI therapy in suspected gastroesophageal reflux disease. Patients with typical reflux symptoms (heartburn, acid regurgitation) without alarm symptoms can be offered a trial of single dose PPI therapy, and response assessed in 4 to 8 weeks. Responders can be weaned down to the lowest effective dose, and if symptoms remain controlled, titrated further to on demand therapy if possible. Patients who need to remain on chronic PPI therapy can be offered reflux testing at the 1-year time point to determine appropriateness of long term therapy. Dose increase to twice a day or a switch to a more efficacious PPI can be offered to non- or partial responders to single-dose PPI trial. If response remains suboptimal, esophageal testing is suggested (see Figure 3). Patients with isolated extra-esophageal GERD symptoms benefit most from upfront esophageal testing rather than an empiric PPI trial.

Figure 2.

Utilization of prolonged reflux monitoring off PPI therapy to characterize severity of GERD. Reflux monitoring is offered in patients without higher grades of reflux esophagitis on endoscopy. Absence of pathologic acid exposure on ambulatory reflux monitoring (AET <4.0% on all 4 days of the prolonged wireless pH study) with a normal endoscopy rules out GERD. Erosive esophagitis of Los Angeles Grade B or higher, and/or AET ≥6.0% on 2 or more days constitutes conclusive GERD evidence. Patients with LA grade A esophagitis, and/or AET ≥4.0% but otherwise not meeting criteria for conclusive GERD are considered to have borderline GERD.

Figure 3.

Personalized approach to diagnosis and GERD based on findings on endoscopy and prolonged ambulatory wireless pH monitoring. Patients with no GERD likely have an alternate explanation for symptoms, which can be a functional disorder; hence, PPIs can be discontinued, and other management options explored. Patients with borderline GERD may need PPIs but these are titrated to the lowest dose or frequency that controls symptoms, or replaced with H2RAs. Adjunctive approaches include lifestyle and behavior modification. Patients with GERD have Los Angeles grade B esophagitis or higher, and/or AET ≥6.0% on 2 or more days on prolonged wireless pH monitoring performed off PPI therapy. Within patients with GERD, a severe GERD phenotype exists characterized by advanced grade esophagitis (Los Angeles grade C or D), and/or AET >12.0%, bipositional reflux or Demeester score >50, which requires either continuous long-term PPI therapy or invasive anti-reflux procedures, in addition to optimization of lifestyle measures. Medical management may be adequate for patients with GERD who respond to therapy, whereas escalation to anti-reflux procedures can be considered after appropriate esophageal physiologic testing for non-responders despite optimization of therapy.