Updates to the modern diagnosis of GERD: Lyon consensus 2.0

Abstract

The Lyon Consensus provides conclusive criteria for and against the diagnosis of gastro-oesophageal reflux disease (GERD), and adjunctive metrics that consolidate or refute GERD diagnosis when primary criteria are borderline or inconclusive. An international core and working group was assembled to evaluate research since publication of the original Lyon Consensus, and to vote on statements collaboratively developed to update criteria. The Lyon Consensus 2.0 provides a modern definition of actionable GERD, where evidence from oesophageal testing supports revising, escalating or personalising GERD management for the symptomatic patient. Symptoms that have a high versus low likelihood of relationship to reflux episodes are described. Unproven versus proven GERD define diagnostic strategies and testing options. Patients with no prior GERD evidence (unproven GERD) are studied using prolonged wireless pH monitoring or catheter-based pH or pH-monitoring off antisecretory medication, while patients with conclusive GERD evidence (proven GERD) and persisting symptoms are evaluated using pH-impedance monitoring while on optimised antisecretory therapy. The major changes from the original Lyon Consensus criteria include establishment of Los Angeles grade B oesophagitis as conclusive GERD evidence, description of metrics and thresholds to be used with prolonged wireless pH monitoring, and inclusion of parameters useful in diagnosis of refractory GERD when testing is performed on antisecretory therapy in proven GERD. Criteria that have not performed well in the diagnosis of actionable GERD have been retired. Personalisation of investigation and management to each patient's unique presentation will optimise GERD diagnosis and management.

Keywords: AMBULATORY pH MONITORING; ENDOSCOPY; GASTROESOPHAGEAL REFLUX DISEASE.

Figure 1

Troublesome typical and atypical symptoms suspicious for gastro-oesophageal reflux disease (GERD), and usual approach to evaluation of these symptoms. An empiric trial of antisecretory therapy is appropriate for typical symptoms in the absence of alarm symptoms. Prolonged wireless pH monitoring is most appropriate for quantification of reflux burden with typical symptoms, although pH-impedance or even pH only monitoring may be options depending on availability and expertise. Belching, cough and asthma may have a potential association with reflux episodes. Supragastric belching and rumination need to be identified, preferably using high-resolution impedance manometry (HRIM) and managed with behavioural therapy. Up-front testing is performed primarily to rule out a reflux basis for symptoms for all other atypical symptoms. Pulmonary evaluation and laryngoscopy serve to rule out primary non-GERD disorders, and may precede oesophageal physiological testing.

Figure 2

The presence or absence of prior conclusive evidence for gastro-oesophageal reflux disease determines test strategy and methodology. When conclusive GERD evidence is absent (unproven GERD), testing is performed to establish or refute the presence of GERD, hence ambulatory reflux monitoring is performed off antisecretory therapy. Wireless pH monitoring and catheter based pH or pH monitoring are alternatives, based on local feasibility, availability and cost of each technique. Conclusive GERD evidence, and borderline evidence with supportive adjunctive metrics according to the Lyon Consensus (figure 3) serve to provide evidence of GERD. In contrast, when symptoms persist despite adequate therapy of previously proven GERD, pH-impedance monitoring is performed on therapy to look for evidence for treatment refractory GERD necessitating management escalation. AET, acid exposure time; GERD, gastro-oesophageal reflux disease; LA, Los Angeles; MNBI, mean nocturnal baseline impedance.

Figure 3

Findings that establish conclusive evidence for gastro-oesophageal reflux disease (GERD) can be acquired from endoscopy and/or ambulatory reflux monitoring off therapy in unproven GERD. When evidence is borderline, adjunctive evidence on endoscopy, pH-impedance monitoring and manometry can sway confidence towards or away from conclusive GERD. Findings on pH-impedance monitoring or wireless pH monitoring can establish absence of GERD, especially when endoscopy is also normal. Similar levels of conclusive, borderline and adjunctive metrics are described for endoscopy and pH-impedance monitoring performed on optimised antisecretory therapy. AET, acid exposure time; HRM, high-resolution manometry; IEM: ineffective esophageal motilityl LA, Los Angeles; MNBI, mean nocturnal baseline impedance.