Gastroesophageal Reflux Disease

Begin with EGD with biopsies when symptoms persist after a PPI trial or when alarm features prompt structural and mucosal evaluation. Biopsy during endoscopy is used to exclude alternative mucosal disorders, including eosinophilic and infectious esophagitis. A normal EGD does not exclude GERD, whereas high-grade erosive esophagitis, long-segment Barrett mucosa, or peptic stricture establishes objective evidence of GERD. BMJ+1BMJModern diagnosis of GERD: the Lyon ConsensusNatureAdvances in the physiological assessment and diagnosis of GERD | Nature Reviews Gastroenterology & Hepatology

Classify the patient as having unproven versus proven GERD before ordering ambulatory reflux testing. Unproven GERD includes persistent symptoms with normal or nondiagnostic endoscopy and no prior abnormal reflux study. Proven GERD includes prior conclusive endoscopic complications or abnormal acid exposure; persistent symptoms in this group may reflect residual reflux, reflux hypersensitivity, motility disease, supragastric belching, rumination, or a nonreflux disorder. BMJ+1BMJUpdates to the modern diagnosis of GERD: Lyon ...BMJModern diagnosis of GERD: the Lyon Consensus

Treat extraesophageal complaints—chronic cough, asthma, laryngitis, or dental erosion—as possible rather than presumptive reflux syndromes. The lower background prevalence of GERD in extraesophageal presentations reduces the diagnostic yield of reflux testing compared with typical symptoms, making objective confirmation particularly important before prolonged escalation of reflux-directed treatment or invasive therapy. Wolters Kluwer+1Wolters KluwerACG Practice Guidelines : American Journal of GastroenterologyWolters KluwerThe Montreal Definition and Classification of... : American Journal of Gastroenterology

Use ambulatory reflux monitoring off PPI when the question is whether GERD exists. Withhold antisecretory therapy for at least 7 days before off-therapy monitoring. Catheter pH, wireless pH, and pH-impedance can provide acid-exposure data; the selection depends on availability and cost. Wireless pH monitoring may record for up to 96 hours and is generally better tolerated than a transnasal catheter. BMJ+1BMJModern diagnosis of GERD: the Lyon ConsensusNatureAdvances in the physiological assessment and diagnosis of GERD | Nature Reviews Gastroenterology & Hepatology

Use pH-impedance monitoring on therapy when GERD is already proven and the question is whether reflux persists despite antisecretory treatment. Impedance detects reflux episodes regardless of acidity, while pH characterizes acidity; therefore, pH-impedance is the preferred modality when monitoring is indicated during PPI therapy. BMJBMJModern diagnosis of GERD: the Lyon Consensus

Interpret distal esophageal acid exposure time (AET) as a continuum. Off therapy, AET greater than 6% is diagnostic of GERD. AET below 4%, particularly with fewer than 40 reflux episodes and normal endoscopy, supports a non-GERD explanation. AET from 4% to 6% is inconclusive and should be adjudicated with symptom-reflux association and adjunctive endoscopic, motor, and anatomic evidence rather than treated as unequivocal pathologic reflux. BMJ+1BMJUpdates to the modern diagnosis of GERD: Lyon ...BMJModern diagnosis of GERD: the Lyon Consensus

For proven GERD, continue long-term PPI therapy at the lowest dose that provides symptom control and/or healing of reflux-related mucosal injury. When symptoms persist, do not assume pharmacologic failure until objective testing distinguishes ongoing reflux from reflux hypersensitivity, behavioral disorders, or another diagnosis. Gastroenterology+2GastroenterologyManagement of Gastroesophageal Reflux DiseaseBMJUpdates to the modern diagnosis of GERD: Lyon ...BMJModern diagnosis of GERD: the Lyon Consensus

For patients taking chronic high-intensity PPI therapy without an ongoing indication, use a planned, supervised dose reduction or discontinuation strategy rather than indefinite continuation by default. In GERD patients receiving multiple daily doses, reported success with step-down to once-daily therapy ranged from 42% to 79%; however, recurrent symptoms after discontinuation are expected in chronic GERD because the defective antireflux barrier remains. BMJBMJPrimary carE PPi dEprescRibing (PEPPER) trial: a protocol for determining the optimal strategy for stopping chronic proton pump inhibitor therapy in primary care patients | BMJ Open

Avoid interpreting a PPI trial as a definitive diagnostic test. In predicting erosive esophagitis or an abnormal pH study, the empiric PPI trial has reported sensitivity of approximately 80% but specificity of only 50% to 60%; persistent or atypical symptoms therefore warrant objective evaluation when the result will alter long-term treatment or procedural decisions. NatureNatureAdvances in the physiological assessment and diagnosis of GERD | Nature Reviews Gastroenterology & Hepatology

Consider antireflux surgery or endoscopic antireflux therapy only after objective reflux documentation, particularly in patients whose symptoms persist despite PPI therapy. In a randomized trial of patients with heartburn incompletely responsive to PPI therapy, abnormal reflux burden on pH-impedance was present in 78 of 366 patients evaluated; among those treated, antireflux surgery produced symptom relief in 67% compared with 28% receiving continued medical management. BMJBMJUpdates to the modern diagnosis of GERD: Lyon ...

For patients with previously proven GERD studied on twice-daily PPI therapy, AET greater than 4.0% and/or more than 80 reflux episodes identified a group in which 85% reported symptom benefit after antireflux surgery in a separate study. These thresholds apply to an on-therapy, previously proven-GERD population and should not be substituted for off-PPI diagnostic thresholds. BMJBMJUpdates to the modern diagnosis of GERD: Lyon ...

Before procedural referral, use the physiologic assessment to exclude phenotypes less likely to benefit from further acid-directed intervention: normal off-PPI reflux burden, borderline AET without corroborating evidence, reflux hypersensitivity, motility disorders, supragastric belching, and rumination. The key tradeoff is avoiding an irreversible or invasive intervention for symptoms not driven by pathologic reflux. BMJ+1BMJUpdates to the modern diagnosis of GERD: Lyon ...BMJModern diagnosis of GERD: the Lyon Consensus

Consider Barrett esophagus screening in patients with chronic GERD symptoms plus at least three additional risk factors: male sex, age older than 50 years, White race, current or prior tobacco smoking, central obesity, or a first-degree family history of Barrett esophagus or esophageal adenocarcinoma. PubMedPubMedBarrett Esophagus - StatPearls - NCBI Bookshelf

When Barrett-associated dysplasia is diagnosed, obtain confirmation by a second expert gastrointestinal pathologist because the diagnosis materially changes surveillance and treatment decisions. Endoscopic eradication therapy is used for low-grade dysplasia, high-grade dysplasia, and early esophageal adenocarcinoma and is preferred to surveillance and acid suppression alone for these neoplastic stages. PubMedPubMedBarrett Esophagus - StatPearls - NCBI Bookshelf

Do not use antireflux procedures as a substitute for Barrett surveillance or dysplasia-directed care. Current Barrett surveillance guidance specifically addresses the role of antireflux procedures in prevention of progression, alongside surveillance methods, sampling strategies, biomarkers, and chemoprevention. GastroenterologyGastroenterologyAGA Clinical Practice Guideline on Surveillance of Barrett's ...