AJG: Guidelines for the diagnosis and management of gastroesophageal reflux disease Gastroesophageal reflux disease is one of the most common types of diseases of the digestive system. This type of disease is defined as a combination of symptoms caused by reflux of gastric contents into the esophagus, mouth, and/or lungs.
(A) Diagnosis of GERD
1. The inferred diagnosis of GERD can be based on the presence of typical symptoms such as heartburn and reflux. Empirical use of proton pump inhibitors is recommended in establishing the diagnosis (strength of recommendation is strong, evidence-based evidence is intermediate).
2. Non-cardiac chest pain suspected to be caused by GERD requires diagnostic evaluation before standardized treatment (strength of recommendation: conditional recommendation, evidence-based evidence is intermediate). Patients with chest pain in the presence of gastrointestinal disease need to be excluded as being caused by cardiac disease prior to performing a gastrointestinal examination (strength of recommendation: strong, evidence-based evidence low).
3. Barium contrast is not recommended for the diagnosis of gastroesophageal reflux disease (strength of recommendation is strong, evidence-based evidence is high).
4. Upper gastrointestinal endoscopy is not recommended for patients with typical GERD symptoms. Endoscopic screening is recommended in patients at high risk for the presence of alarm symptoms or possible complications. Repeated repeat endoscopy is not recommended for patients without barrett’s esophagus and in the absence of new symptoms (strength of recommendation is strong, evidence-based evidence is moderate).
5. Distal esophageal mucosal biopsy is not recommended for patients with reflux esophagitis (strength of recommendation is strong, evidence-based evidence is moderate).
6. Esophageal manometry is recommended in the preoperative evaluation, but is not useful in diagnosing GERD (strength of recommendation is strong, evidence-based evidence is low).
7, Ambulatory esophageal reflux testing is recommended when considering whether a patient needs endoscopic or surgical treatment. This test is also an assessment method to evaluate whether the patient is tolerant to proton pump inhibitors and is particularly indicated in cases where there is a doubtful diagnosis of GERD (strength of recommendation is strong, evidence-based evidence is low). Ambulatory esophageal reflux testing is the only method to assess the correlation between reflux and symptoms (strength of recommendation is strong, evidence-based evidence is low).
8, Regardless of the length of the lesion in the esophagus in the presence of Barrett’s esophagus, there is no need to rely on ambulatory esophageal reflux testing to clarify the diagnosis of GERD (strength of recommendation is strong, evidence-based evidence is moderate)
9. It is not recommended that patients with GERD be routinely tested for H. pylori infection, and similarly H. pylori eradication therapy is not part of a routine anti-reflux treatment regimen (strength of recommendation is strong, evidence-based evidence is low).
(B) Treatment of GERD
1, Weight control management is recommended for overweight patients with GERD and significant recent weight gain (strength of recommendation: conditional recommendation, evidence-based evidence is moderate).
2. For GERD patients with significant nocturnal reflux symptoms, it is recommended not to eat 2-3 hours before bedtime and to elevate the head appropriately at bedtime (strength of recommendation: conditional recommendation, evidence-based evidence is low)
3, regular ball digestive foods are generally prone to induce reflux (e.g. chocolate, coffee, alcohol, acidic or spicy foods) and are recommended to be avoided during the course of treatment for GERD (strength of recommendation: conditional recommendation, evidence-based evidence is low).
4. To reduce symptoms and promote healing of decaying esophagitis, a course of 8 weeks of proton pump inhibitor therapy is recommended, with no significant differences in efficacy between proton pump inhibitor types (strength of recommendation: strong, evidence-based evidence: high).
5. Traditional delayed-release proton pump inhibitor drugs are recommended to be taken 30-60 minutes before a meal for optimal control of pH (strength of recommendation is strong, evidence-based evidence is moderate). Newer proton pump inhibitors may allow more flexibility in the timing of drug administration independent of meal times (strength of recommendation: conditional recommendation, moderate evidence-based).
6. A single one-day dose of a proton pump inhibitor before breakfast is recommended (strength of recommendation: strong, evidence-based evidence: moderate). The number of doses and doses can be adjusted to individualize treatment for patients who do not do well on a single dose of proton pump inhibitor therapy. For patients with significant nocturnal reflux symptoms, irregular meal times, and sleep disorders, a twice daily dosing regimen is recommended (strength of recommendation is strong, evidence-based evidence is low).
7, Patients who do not respond to proton pump inhibitor therapy may be treated with an appropriate dose increase (strength of recommendation: conditional recommendation, evidence-based evidence is low).
8, for patients who partially respond to proton pump inhibitor therapy, increasing the number of doses to 2 or switching to other proton pump inhibitor drugs can increase symptom relief (strength of recommendation: conditional recommendation, evidence-based evidence is low).
9. Continuous application of proton pump inhibitors is recommended for patients with recurrent symptoms after discontinuation of proton pump inhibitors. Continuous application of proton pump inhibitors is also recommended for patients with complications such as erosive esophagitis and Barrett’s esophagus (strength of recommendation is strong, evidence-based evidence is moderate). For patients who need long-term application of proton pump inhibitors need to take the lowest effective dose, such as using on-demand regimens or intermittent dosing regimens (strength of recommendation: conditional recommendation, evidence-based evidence is low).
10. H2 receptor antagonists can be used as an elective agent during the maintenance phase in patients without celiac disease and with relief of heartburn symptoms after treatment (strength of recommendation: conditional recommendation, evidence-based evidence is moderate). Some patients with objective nocturnal reflux may be treated with a regimen of H2 receptor antagonists at night at bedtime in addition to once-daily oral proton pump inhibitor therapy if needed (strength of recommendation: conditionally limited recommendation, evidence-based evidence is low).
11, The application of acid suppressive therapy combined with prokinetic therapy and/or baclofen orally is not recommended when patients with GERD have not been diagnostically evaluated (strength of recommendation: conditionally limited recommendation, evidence-based evidence is moderate).
12. There is no significant effect of thioglycollate in non-pregnant patients with GERD (strength of recommendation: conditional recommendation with moderate evidence-based).
13, If clinically indicated, the use of proton pump inhibitors is safe in pregnant women (strength of recommendation: conditional recommendation, moderate evidence-based)
(C) Surgical treatment selection criteria for patients with gastroesophageal reflux disease
1.Surgical treatment is the treatment option that can provide long-term relief of GERD symptoms (strength of recommendation is strong, evidence-based evidence is high).
2. Surgical treatment is not recommended for patients who do not respond to proton pump inhibitor therapy (strength of recommendation is strong, evidence-based evidence is high)
3. Preoperative dynamic esophageal pH testing is required for patients who lack evidence to confirm the presence of celiac esophagitis. Therefore, patients are required to undergo preoperative esophageal manometry to rule out cardia loss and esophageal sclerosis (strength of recommendation is strong, evidence-based evidence is low).
4. Patients with chronic GERD need to undergo surgery based on experience, taking into account that the difference in efficacy between surgical and pharmacological treatment is not significant and needs to be carefully selected (strong recommendation, high evidence-based).
5. For obese GERD patients who are considered for surgical treatment, obesity control surgery is recommended. Gastric diversion surgery is a good choice for such patients (strength of recommendation: conditional recommendation, evidence-based evidence is moderate)
6. Endoscopic treatment and conventional fundoplication are not recommended as an alternative treatment option to pharmacological treatment as well as conventional surgical treatment (strength of recommendation: strong, evidence-based evidence: moderate).
(D) potential risks of proton pump inhibitor application
1, randomly changing the type of proton pump inhibition taken can be considered to have side effects (strength of recommendation: conditional recommendation, evidence-based evidence is low).
2, Long-term maintenance proton pump inhibitor therapy is recommended for patients with coexisting osteoporosis. The combined presence of osteoporosis, except in patients with other risk factors for hip fracture, is not a reason to influence the continued treatment regimen with proton pump inhibitors (strength of recommendation: conditional recommendation with moderate evidence-based evidence)
3. Proton pump inhibitor therapy is a risk factor for C. difficile infection. Caution is required for patients at high risk of developing C. difficile infection (strength of recommendation moderate, evidence-based evidence moderate)
4. The likelihood of community-acquired pneumonia is increased in patients treated with short-term applications of proton pump inhibitors, but this phenomenon has not been observed in patients on long-term medication (strength of recommendation: conditional recommendation, moderate evidence-based).
5. There is no need to change the proton pump inhibitor regimen for patients taking concomitant clopidogrel because proton pump inhibitor application does not increase the incidence of cardiovascular events (strength of recommendation: conditional recommendation, evidence-based evidence is high).
(E) Extra-esophageal manifestations of GERD: asthma, chronic cough, and laryngitis
1. Gastroesophageal reflux can be seen as a potential influence in patients with asthma, chronic cough, and laryngitis. Patients with any of these conditions need to be carefully evaluated to rule out gastroesophageal reflux (strength of recommendation is strong, evidence-based is moderate).
The diagnosis of reflux laryngitis cannot be made solely on the basis of laryngoscopic findings (strong recommendation, moderate evidence-based).
3. Diagnostic proton pump inhibitor therapy is recommended for patients with extraesophageal symptoms and significant GERD symptoms (strong recommendation, low evidence-based).
4. Upper gastrointestinal endoscopy is not recommended for the diagnosis of GERD-associated asthma, chronic cough, and laryngitis (strength of recommendation is strong, evidence-based evidence is low).
5. Perform reflux monitoring in patients with extraesophageal symptoms without typical gastroesophageal reflux symptoms prior to diagnostic treatment with proton pump inhibitors (strength of recommendation: conditional recommendation, evidence-based evidence is low).
6. Patients who do not respond to proton pump inhibitor therapy require further diagnostic testing, which will be described in the section on drug-resistant GERD (strength of recommendation: condition-limited recommendation, evidence-based evidence is low)
7. Surgical treatment is not recommended for patients who present with extraesophageal symptoms and do not respond to acid suppression therapy with proton pump inhibitors (strength of recommendation: conditionally limited recommendation, evidence-based evidence is moderate).
(vi) Treatment of refractory GERD with proton pump inhibitors
1, the first step to address refractory GERD is to optimize the proton pump inhibitor treatment regimen (strength of recommendation is strong, evidence-based evidence is low)
2. Upper gastrointestinal endoscopy is recommended for patients with typical symptoms or dyspepsia to rule out non-gastroesophageal reflux disease causes (strength of recommendation: conditional recommendation, low evidence-based)
3. For patients with extra-esophageal symptoms who do not respond significantly to reflux symptoms persisting after treatment with proton pump inhibitors, further evaluation for other etiologies is required, in combination with ENT and pulmonary examinations and allergies (strength of recommendation is strong, evidence-based evidence is low).
4, Patients with refractory GERD with typical symptoms require dynamic reflux testing if upper gastrointestinal endoscopy is negative or after evaluation with ENT examination, pulmonary examination, and allergen screening (strength of recommendation is strong, evidence-based evidence is low).
5. Any drug form can be used for reflux testing (pH or pH resistance value) (strength of recommendation: conditional recommendation, evidence-based evidence is moderate). Need to use resistance value pH detection drug in order to determine non-acidic reflux (recommendation strength: conditional recommendation, evidence-based evidence is moderate).
6. Patients with refractory GERD with objective evidence of reflux-induced symptoms may be considered for anti-reflux treatment options, including surgery or the use of muscle relaxation inhibitors in the lower esophageal sphincter (strength of recommendation: conditional recommendation, evidence-based low). Proton pump inhibitors may be discontinued if the test results are negative confirming that it is not GERD causing the associated symptoms (strength of recommendation: strong, evidence-based evidence low).
(VII) Complications associated with GERD
1. The Los Angeles classification system should be used to classify the presentation of endoscopic erosive esophagitis (strength of recommendation is strong, evidence-based evidence is moderate). Further testing is required to confirm the presence of GERD manifestations in patients with a classification of A (strength of recommendation: conditional recommendation, evidence-based evidence is low).
2. Endoscopic review is required for patients with severe erosive esophagitis after a course of antisecretory therapy to exclude the possibility of underlying barrett’s esophagus (strength of recommendation: conditional recommendation, evidence-based evidence is low).
3. Patients with dilated peptic strictures require continuous treatment with proton pump inhibitors to improve dysphagia and reduce the number of repeated dilatations required (strength of recommendation: condition-limited recommendation, evidence-based evidence is moderate).
4. For intractable, complex esophageal strictures due to gastroesophageal reflux, intra-lesional corticosteroid injections may be indicated (strength of recommendation: condition-limited recommendation, evidence-based evidence is low).
5. Treatment with a proton pump inhibitor is recommended after dilation therapy in patients with the presence of a lower esophageal Schatzky ring (strength of recommendation: conditionally limited recommendation, evidence-based evidence is low).
6, Screening for Barrett’s esophagus needs to be considered in epidemiologically high risk groups for GERD (strength of recommendation: conditionally limited recommendation, evidence-based evidence is moderate).
7. Similar treatment regimens can be used for patients with Barrett’s esophagus with the same symptoms and patients with GERD but without Barrett’s esophagus (strength of recommendation is strong, evidence-based evidence is moderate).
8. According to the guidelines, regular endoscopy testing is required for patients with endoscopically detected Barrett’s esophagus lesions (strength of recommendation is strong, evidence-based evidence is moderate).