Italian guidelines for the diagnosis and management of gastro-esophageal reflux disease: Joint consensus from the Italian Societies of: Gastroenterology and Endoscopy (SIGE), Neurogastroenterology and Motility (SINGEM), Hospital Gastroenterologists and Endoscopists (AIGO), Digestive Endoscopy (SIED), and General Medicine (SIMG)

Abstract

Gastroesophageal reflux disease (GERD) is one of the most common conditions encountered in outpatient general medicine and gastroenterology clinics. However, uncertainties remain, particularly concerning the optimal diagnostic work-up and the most effective management. To address this issue, experts from 5 Italian Societies conducted a Delphi consensus process, which included a review of the current literature and voting process on 27 key statements. Recommendations and quality of evidence were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. Consensus for each statement was defined as ≥ 80 % agreement. Diagnostic Approach: The consensus supports a symptom-based diagnostic strategy for GERD, focusing on the exclusion of alarm symptoms and/or multiple risk factors for Barrett's esophagus or eosinophilic esophagitis (EoE) as well as non-GERD causes in cases of extra-esophageal symptoms. Esophago-gastro-duodenoscopy (EGD) is recommended in patients with alarm features or in patients unresponsive to proton pump inhibitors (PPIs). In addition, the consensus recommends esophageal pH-metry or impedance-pH recording in patients with reflux-like symptoms not responding to medical treatments, in those with extra-oesophageal symptoms, prior to anti-reflux endoscopic or surgical procedures, in patients with belching disorders and to diagnose functional heartburn (FH) and reflux hypersensitivity (RH) in PPI-refractory patients. Treatment Approach: The consensus strongly supports a standard 4-8 weeks course of PPIs for patients with heartburn and regurgitation but without alarm symptoms and an 8 weeks treatment for those with erosive oesophagitis. Twice daily dose PPIs is recommended only if a concomitant Barrett oesophagus is present, in patients with laryngopharyngeal reflux disease (LPRD) or when there is no response or an incomplete response to once daily dose. Bedtime histamine-2 receptor antagonists (H₂RAs) as add-on therapy is suggested in patients with persistent nocturnal symptoms and in those with objective evidence of nocturnal acid reflux on pH monitoring despite PPI treatment, while prokinetic agents are advocated as add-on therapy in patients with concomitant symptoms suggestive of delayed gastric emptying. Moreover, the consensus voted for the use of potassium competitive acid blockers (P-CABs), antacids, alginate-containing formulations, neuromodulators in treating visceral hypersensitivity, complementary and alternative medicine and anti-reflux surgery in patients with refractory GERD. Finally, the consensus voted against surgical anti-reflux therapy in patients with extra-esophageal symptoms of GERD, who do not respond to PPI therapy and against the use of ensoscopic procedures [i.e., Medigus ultrasonic surgical endostapler (MUSE), radiofrequency energy application (Stretta), anti-reflux mucosectomy (ARMS)] outside clinical trials.

Keywords: Alginate; GERD; Guidelines; PPI; Reflux disease; Vonoprazan.