This consensus opinion is divided into six major sections of symptoms, diagnosis, treatment, refractory GERD, comorbidities of GERD, and extraesophageal symptoms with a total of 30 items. The consensus opinions of each section are described below.
1.Symptoms
Heartburn and reflux are the most common typical symptoms of GERD. Chest pain, epigastric pain, burning sensation in epigastrium and belching are atypical symptoms of GERD.
Some patients with GERD do not have symptoms of heartburn and reflux, but may show atypical symptoms such as chest pain, epigastric pain, burning sensation in the epigastrium and belching.
GERD can be accompanied by extra-esophageal symptoms, including cough, throat symptoms, asthma and dental erosion.
2.Diagnosis
The PPI test is simple, effective and can be used as a preliminary diagnosis of GERD.
PPI test is highly operable and still has high significance in clinical practice.
Esophageal reflux monitoring is an effective screening method for GERD. Those who are not using PPI can choose pH monitoring alone, and if PPI is being used, impedance monitoring should be added to detect non-acid reflux.
Endoscopy is recommended for first-time patients with reflux symptoms, and routine esophageal biopsy is not recommended for those with normal endoscopy.
Barium esophagography is not recommended as a diagnostic method for GERD.
Esophageal manometry can be used to understand esophageal dynamic status for preoperative evaluation and cannot be used as a diagnostic tool for GERD.
3.Treatment
Lifestyle changes, such as weight loss, elevation of the head of the bed, and smoking cessation, may be effective for GERD.
Lifestyle changes are part of GERD treatment. Currently, common clinical recommendations to improve lifestyle include reducing body mass, elevating the head of the bed, quitting smoking/alcohol, avoiding eating before bedtime, and avoiding foods that may trigger reflux symptoms, such as coffee, chocolate, spicy or acidic foods, and high-fat diets.
PPI is the drug of choice for GERD treatment. If single dose PPI treatment is not effective, switch to double dose, and if one PPI is not effective, try to switch to another PPI.
The course of PPI should be at least 8 weeks.
For patients with GERD combined with esophageal hiatal hernia and severe esophagitis.
Esophageal hiatal hernia is one of the main risk factors for failure of single-dose PPI therapy in GERD patients. The use of double-dose PPI may be effective, but this result still needs to be verified in a large randomized controlled study.
Anti-reflux surgery is another treatment option for patients who are effectively treated with PPI but require long-term medication.
For patients who are effective on PPI therapy but require long-term medication, surgical treatment may be considered. The most common anti-reflux surgical procedure used today is laparoscopic fundoplication.
The long-term effectiveness of endoscopic treatment of GERD needs further confirmation. Endoscopic treatments currently used for GERD are divided into 3 main categories: radiofrequency therapy, injection or implantation techniques and endoscopic endoluminal gastroesophagoplasty.
Some studies have shown that long-term application of PPI may promote the proliferation of intestinal flora by raising the pH in the stomach, thus increasing the probability of Clostridium difficile infection.
The effect of PPI in combination with antiplatelet agents on the incidence of cardiovascular events is controversial.
Maintenance therapies include on-demand and long-term therapy. on-demand therapy is available for patients with NERD and mild esophagitis (LA-A and LA-B grades). PPI is the drug of choice, and antacids are also optional.
Patients with recurrence of symptoms after PPI discontinuation and severe esophagitis (LA-A and LA-B grades) usually require long term maintenance therapy with PPI.
Refractory GERD
Refractory GERD has not been uniformly defined, and it can be considered that there is no significant improvement in symptoms such as heartburn and/or reflux after 8-12 weeks of treatment with double doses of PPI.
There are many reasons for the ineffectiveness of PPI therapy, and the first step is to check the patient’s compliance and optimize the use of PPI.
In fact, there are many etiologies that cause refractory GERD, mainly including.
① persistent acid reflux (incorrect timing of medication, poor patient compliance, pathological acid reflux, fast metabolism of PPI, hypersecretory state, anatomical abnormalities such as giant esophageal hiatal hernia, etc.)
② persistent gastric or duodenal non-acid reflux.
(iii) persistent disruption of esophageal mucosal integrity.
④ hypersensitivity of the esophagus to acid, weak acid and/or gas reflux.
Endoscopy in refractory GERD can exclude other esophageal and gastric diseases.
Management of concomitant comorbidities
Patients with reflux esophagitis, especially severe esophagitis (LA-C and LA-D grades), are recommended to undergo regular follow-up after treatment. For patients with Barrett’s esophagus, regular endoscopic review is recommended.
Patients with combined esophageal strictures require PPI maintenance therapy after dilatation to improve the symptoms of dysphagia and reduce the need for re-dilatation, but no relevant studies have been reported in China.
Chronic ulcerative inflammatory changes in the esophagus can lead to scar formation and esophageal stricture, which is particularly common in the lower esophagus.
Extra-esophageal symptoms
GERD is a possible cause of asthma, chronic cough and laryngitis, and non-reflux factors need to be excluded before a diagnosis of reflux-related is confirmed. Unexplained asthma, chronic cough and laryngitis with typical reflux symptoms can be tested with a PPI test.
Chronic laryngitis is a persistent inflammatory response in the larynx. The common cause can be exogenous irritation, such as smoking and alcohol consumption, or endogenous irritation, such as asthma and GERD.
Surgical treatment is not recommended for patients with extraesophageal symptoms who have failed PPI treatment.