AJG: Guidelines for the Management of Gastroesophageal Reflux Disease Gastroesophageal reflux disease (GERD) 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 the reflux of stomach contents into the esophagus, mouth, and/or lungs. (A) Diagnosis of GERD 1. The presumptive diagnosis of GERD can be based on the presence of typical symptoms such as heartburn and reflux. According to experience using proton pump inhibitors in the establishment of the diagnosis of the recommended application (the strength of the recommendation is strong, evidence-based evidence for intermediate). 2, suspected non-cardiac cause of chest pain due to gastroesophageal reflux disease needs to be diagnostic assessment before standardized treatment (strength of recommendation: conditional recommendation, evidence-based evidence is intermediate). Patients with chest pain need to be excluded from cardiac causes before gastrointestinal investigations are performed (strength of recommendation: strong, evidence-based evidence is 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 in patients who do not have Barrett’s esophagus and who do not have new onset of 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 has no role in the diagnosis of gastroesophageal reflux disease (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. The test is also an assessment of whether the patient is tolerant to proton pump inhibitors and is particularly indicated when there is doubt about the diagnosis of gastroesophageal reflux disease (strength of recommendation is strong, evidence-based evidence is low). Ambulatory esophageal reflux testing is the only method for assessing the correlation between reflux and symptoms (strength of recommendation is strong, evidence-based evidence is low). The ambulatory esophageal reflux test should not be relied upon for a definitive diagnosis of GERD, regardless of the length of the esophageal Barrett’s esophagus lesion (strong recommendation, moderate evidence). 9 Routine screening for H. pylori infection in patients with GERD is not recommended, and similarly eradication of H. pylori is not an integral part of the routine anti-reflux treatment regimen (strong recommendation, low evidence). is strong and evidence-based evidence is low). (ii) Treatment of GERD 1. Weight control is recommended for patients with GERD who are overweight and have recently experienced significant weight gain (strength of recommendation: conditional recommendation, moderate evidence). 2. For GERD patients with significant nocturnal reflux symptoms, it is recommended that they do not eat 2-3 hours before bedtime, and that they elevate their heads appropriately during sleep (strength of recommendation: conditional recommendation, low level of evidence). 3. Regular bulb-digested foods are generally prone to inducing reflux (e.g., chocolate, coffee, alcohol, acidic, or spicy foods), and it is recommended that they be avoided in the course of GERD treatment (strength of recommendation: conditional recommendation, low level of evidence). (Strength of Recommendation: Conditional recommendation with low evidence). 4. An 8-week course of proton pump inhibitor therapy is recommended for symptomatic relief and healing of putrefactive esophagitis, with no significant difference in efficacy between the different types of proton pump inhibitors (strength of recommendation: strong, high evidence). 5. The traditional delayed-release proton pump inhibitor class of drugs is recommended to be taken 30-60 minutes before meals 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: conditionally restricted recommendation, moderate evidence-based evidence). 6. A single one-day dose of a proton pump inhibitor before breakfast is recommended (strength of recommendation is strong, evidence-based evidence is moderate). For patients with poor therapeutic effects of a single one-day dose of proton pump inhibitors, the number of doses and dosage can be adjusted on an individual basis to individualize treatment. For patients with significant nocturnal reflux symptoms, irregular meal times, and sleep disorders, twice-daily dosing is recommended (strong recommendation, low evidence). 7.Patients who do not respond to proton pump inhibitor therapy can appropriately increase the dose (strength of recommendation: conditionally limited recommendation, evidence-based evidence is low). 8.Patients with partial response to proton pump inhibitor therapy, increase the number of doses to 2 or switch to other proton pump inhibitor drugs can increase the relief of symptoms (strength of recommendation: conditionally restricted 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. At the same time for the presence of erosive esophagitis and Barrett’s esophagus and other complications of patients are also recommended to continue to apply proton pump inhibitors (strength of recommendation is strong, evidence-based evidence is moderate). For patients who need long-term application of proton pump inhibitors need to be taken in accordance with the lowest effective dose, such as the use of on-demand regimens or intermittent dosing programs (strength of recommendation: conditionally restricted recommendations, evidence-based low). 10, H2 receptor antagonists can be used as an optional drug in the maintenance phase in patients who do not have celiac disease and whose heartburn resolves with treatment (Strength of Recommendation: Conditional Recommendation, Evidence-Based Evidence is Moderate). Some patients with objective nocturnal reflux can be treated with once-daily oral proton pump inhibitor therapy along with a nocturnal bedtime H2 receptor antagonist regimen if needed (strength of recommendation: qualified recommendation, low evidence-based evidence). 11. The application of acid suppression therapy combined with prokinetic therapy and/or baclofen orally is not recommended when patients with gastroesophageal reflux disease have not been diagnostically evaluated (Strength of Recommendation: Conditionally Restricted Recommendation, Evidence-Based Evidence is Moderate). 12. The use of aluminum thioglycollate in nonpregnant patients with gastroesophageal reflux disease does not have a significant effect (strength of recommendation: conditionally restricted recommendation, moderate evidence-based evidence). 13.If clinically necessary, the use of proton pump inhibitors in pregnant women is safe (Strength of Recommendation: Conditional Recommendation, Evidence-based Evidence is Moderate) (C) Surgical Treatment Selection Criteria for Patients with GERD 1.Surgery is a therapeutic option that can provide long-term relief of gastroesophageal reflux symptoms (Strength of Recommendation: Strong, Evidence-based Evidence is High). 2. Surgery 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 with a lack of evidence confirming the presence of erosive esophagitis. Therefore, preoperative esophageal manometry is required in all patients to exclude cardia delay and esophageal sclerosis (strength of recommendation is strong, evidence-based evidence is low). 4. Patients with chronic gastroesophageal reflux disease (GERD) who need surgical treatment based on experience need to take into account that the difference in efficacy between surgical and pharmacologic treatments is not obvious, and they need to be carefully selected (strength of recommendation is strong, evidence-based evidence is high). 5, for the consideration of surgical treatment of obese patients with gastroesophageal reflux disease, it is recommended to control obesity surgery. Gastric diversion surgery is a good choice for such patients (strength of recommendation: conditional recommendation, evidence-based evidence is moderate) 6, and does not recommend endoscopic treatment and traditional fundoplication as an alternative to drug therapy and traditional surgical treatment (strength of recommendation is strong, evidence-based evidence is moderate). (D) the potential risks of proton pump inhibitor application 1, arbitrarily changing the type of proton pump inhibitor 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 the combined presence of osteoporosis. In addition to the presence of other hip fracture other risk factors, the combined presence of osteoporosis in patients, and not as a reason to influence the proton pump inhibitor continued treatment program (strength of recommendation: conditional recommendation, evidence-based evidence is moderate) 3, proton pump inhibitor treatment is one of the risk factors for Clostridium difficile infection. Patients at high risk of developing C. difficile infection should be treated with caution (strength of recommendation: moderate, evidence-based evidence is moderate). 4. The likelihood of community-acquired pneumonia is increased in patients treated with short-term proton pump inhibitors, but this phenomenon has not been observed in patients treated with long-term medication (strength of recommendation: conditionally restricted recommendation, evidence-based evidence is moderate). 5, for patients who are also taking clopidogrel does not need to change the proton pump inhibitor treatment program, because the application of proton pump inhibitors does not increase the incidence of cardiovascular events (strength of recommendation: conditional recommendation, evidence-based evidence is high). (E) Extraesophageal manifestations of GERD: asthma, chronic cough, and laryngitis 1. GERD can be viewed as a potential influence in patients with asthma, chronic cough, and laryngitis. Patients with these conditions need to be carefully evaluated to rule out GERD (strong recommendation, moderate evidence). 2. The diagnosis of reflux laryngitis cannot be made solely on the basis of laryngoscopic findings (strong recommendation, moderate evidence). 3. Diagnostic proton pump inhibitor therapy is recommended for patients with extraesophageal symptoms and significant gastroesophageal reflux symptoms (strength of recommendation is strong, evidence-based evidence is low). 4. Upper gastrointestinal endoscopy is not recommended for the diagnosis of gastroesophageal reflux-associated asthma, chronic cough, and laryngitis (strength of recommendation is strong, evidence-based evidence is low). 5, for the presence of extraesophageal symptoms without typical gastroesophageal reflux symptoms of patients before the diagnostic treatment of proton pump inhibitors to carry out reflux monitoring tests (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 Drug-resistant gastroesophageal reflux disease (Strength of Recommendation: Conditional Recommendation, Evidence-Based Evidence is Low). 7. Surgical treatment is not recommended for patients presenting with extra-esophageal symptoms who do not respond to acid suppression therapy with proton pump inhibitors (Strength of Recommendation: Conditional Recommendation, Evidence-Based Evidence is moderate). (F) Using proton pump inhibitors to treat refractory gastroesophageal reflux disease (GERD) 1. The first step in resolving refractory GERD is to optimize the proton pump inhibitor treatment regimen (Strength of Recommendation: Strong, Evidence-Based Evidence: Low) 2. Upper gastrointestinal endoscopy is recommended to exclude non-GERD causes in patients with typical symptoms or dyspepsia (Strength of Recommendation: Conditional Recommendation: Low Evidence-Based) 3. For patients with extraesophageal symptoms who have no significant response to proton pump inhibitor therapy, persistence of reflux symptoms should be further evaluated for other etiologies and combined with otolaryngology, pulmonary examination, and allergies (strength of recommendation: strong, evidence-based evidence: low). 4.Patients with refractory gastroesophageal reflux disease with typical symptoms need to undergo dynamic reflux testing if upper gastrointestinal endoscopy is negative or if they are evaluated with otolaryngology, pulmonary examination, and allergens (strength of recommendation is strong, evidence-based evidence is low). 5. Reflux testing (pH or pH resistive value) can be performed using any drug form (strength of recommendation: conditionally limited recommendation, moderate evidence-based evidence). Resistive pH detection of drugs is required for the determination of non-acidic reflux (Strength of Recommendation: Conditionally limited recommendation with moderate evidence-based evidence). 6. Patients with refractory gastroesophageal reflux disease (GERD) who have objective evidence of reflux-induced symptoms may be considered for antireflux treatment options, including surgery or the use of lower esophageal sphincter muscle relaxant inhibitors (strength of recommendation: qualified recommendation, low evidence-based). Proton pump inhibitors may be discontinued if negative test results confirm that it is not gastroesophageal reflux that is causing the associated symptoms (strength of recommendation: strong, evidence-based evidence is low). (VII) Complications associated with GERD 1. The Los Angeles Classification System should be used to classify endoscopic manifestations of celiac esophagitis (strength of recommendation is strong, evidence-based evidence is moderate). For patients with a classification of A, further investigations are required to confirm the presence of GERD manifestations (strength of recommendation: conditionally limited recommendation, low evidence-based). 2, For patients with severe erosive esophagitis, a course of antisecretory therapy to rule out potential Barrett’s esophagus should be followed by endoscopic review (Strength of Recommendation: Conditionally Recommended, Evidence-Based Low). 3. Patients with dilated peptic strictures require ongoing treatment with proton pump inhibitors to improve dysphagia and reduce the number of repeat dilations required (strength of recommendation: conditionally restricted recommendation, moderate evidence-based). 4. For intractable, complex esophageal strictures caused by gastroesophageal reflux, intra-lesional corticosteroid injections may be indicated (strength of recommendation: conditionally restricted recommendation, low evidence-based evidence). 5, Treatment with a proton pump inhibitor is recommended after dilatation therapy in patients with the presence of a lower esophageal salzburgian ring (strength of recommendation: conditionally limited recommendation, evidence-based evidence is low). 6, Screening for Barrett’s esophagus needs to be considered in epidemiologic populations at high risk for gastroesophageal reflux disease (strength of recommendation: conditionally limited recommendation, evidence-based evidence is moderate). 7, Similar treatment regimens can be used for patients with Barrett’s esophagus who have the same symptoms and for patients with gastroesophageal reflux disease without Barrett’s esophagus (Strength of Recommendation: Strong, Evidence-Based Evidence is Moderate). 8. According to the guidelines, patients with endoscopically detected Barrett’s esophagus lesions need to undergo regular endoscopy testing (strength of recommendation is strong, evidence-based evidence is moderate).