New Guidelines for Diagnosis and Management of GERD

March 13, 2013

By Will Boggs, MD

NEW YORK (Reuters Health) Mar 13 - The American College of Gastroenterology has published new guidelines for diagnosing and managing gastroesophageal reflux disease (GERD).

Many of the recommendations appeared in somewhat different form in the 2005 guidelines from ACG. So what's new here?

Dr. Lauren B. Gerson from Stanford University School of Medicine, Redwood City, California, a member of the guidelines panel, highlighted six new topic areas in email to Reuters Health:

1) Weight loss, in addition to head of bed elevation (for patients with nocturnal GERD symptoms), is an effective lifestyle measure for GERD. Avoidance of foods thought to provoke reflux is not routinely advised for most GERD patients.

2) Routine screening and treatment for H. pylori infection are not recommended because there isn't enough evidence that testing and treatment will affect GERD symptoms. In addition, testing for H. pylori is not recommended based on potential concerns that infected patients on long-term proton pump inhibitor (PPI) therapy might develop atrophic gastritis.

3) While the guidelines continue to advise against routine biopsies of the distal esophagus to diagnose GERD, eosinophilic esophagitis (EoE) has become more recognized since the 2005 guidelines, particularly in patients with GERD and dysphagia or patients with refractory GERD. Therefore, biopsies of the distal and mid-esophagus should be obtained when EoE is suspected.

4) Since the last guidelines, there have been multiple concerns regarding the long-term safety of PPIs. There does not appear to be an increased risk of osteoporosis, except in patients with other risk factors for hip fracture. There also does not appear to be an increased risk of cardiovascular events in patients using concomitant clopidogrel. PPI therapy does appear to be a risk factor for the development of Clostridium difficile infection.

5) GERD can be considered to be a co-factor for patients with extra-esophageal symptoms including cough, laryngitis, and asthma. While a PPI trial can be recommended in patients who also have typical GERD symptoms, reflux monitoring should be considered before a PPI trial in patients without GERD symptoms. Evaluation for non-GERD causes should occur in all patients.

6) Endoscopic therapy is not recommended as therapy for GERD. Obese patients with GERD should consider gastric bypass surgery as treatment for heartburn symptoms.

Overall, the guidelines include nine recommendations for establishing the diagnosis of GERD, a baker's dozen for managing GERD, six points outlining the surgical options for GERD, five potential risks associated with PPIs, seven points regarding extraesophageal presentations of GERD, six recommendations for managing GERD refractory to treatment with PPIs, and eight notes regarding complications associated with GERD.

Dr. Gerson and colleagues published their exhaustive list of recommendations, as well as justification for these recommendations, online February 19th in The American Journal of Gastroenterology.

"As the obesity rates continue to rise in the US, the incidence of GERD and associated complications (including erosive esophagitis and Barrett's esophagus) will continue to increase," Dr. Gerson told Reuters Health.

"While PPIs are highly effective for treatment of GERD, they should be administered in the lowest effective dose for patients requiring long-term therapy, including as on demand or intermittent usage," Dr. Gerson said. "The efficacy of the currently available PPIs appears to be equivalent. Maintenance PPI therapy should be continued for patients with GERD-associated complications."

"In patients who are refractory to PPI therapy despite optimization of timing and dose escalation, evaluation should occur with upper endoscopy and ambulatory pH monitoring," Dr. Gerson added. "For patients with refractory extra-esophageal symptoms, evaluation should occur by pulmonary, ENT, and allergy specialists."

As for surgery, Dr. Gerson said, "Response to PPI therapy, in addition to the presence of typical heartburn symptoms, remains the best predictor of a good outcome to surgical therapy. In patients refractory to PPI therapy and those with extra-esophageal symptoms, response rates after fundoplication continue to be less encouraging."

SOURCE: http://bit.ly/Zy53Ex

Am J Gastroenterol 2013.

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