David A. Johnson, MD


April 30, 2013

In This Article

Johnson's Top 10 Recommendations

10. Endoscopy is not required to establish the diagnosis of GERD. This makes sense. In the absence of alarm features, that makes intuitive sense. Too many patients are still referred for endoscopy for the diagnosis of GERD. It is a clinical diagnosis.

9. Helicobacter pylori testing should not be done in patients with GERD. In fact, if you treat H pylori in GERD patients, they may actually be less responsive to proton pump inhibitors (PPIs). When treating H pylori patients who had no prior GERD, one of the primary relapse symptoms is GERD. Do not test. We see this a lot in primary care and it is not recommended, certainly not by this consensus guideline.

8. Weight reduction matters. Size matters, and this is a very strong recommendation. However, it wasn't supported by much evidence until we saw the current issue. In the same issue in which these guidelines are published, a very nice cohort study from Norway called the HUNT study[2] looked at more than 100,000 patients in a patient cohort analysis. A body mass index (BMI) reduction of 3.5 units resulted in less likelihood of reporting GERD symptoms or using GERD-related medications.

BMI and patterns of body mass make a difference. I tell my patients this every time: Weight reduction matters. Don't lose 40 pounds by Friday, but weight loss, over time, may be a significant factor in reducing GERD-related symptoms and improving the response to medication. Now we have evidence, and we certainly have the support of the guidelines.

7. The use of transoral fundoplication is not warranted by current clinical data supporting it in clinical practice as an alternative to surgery. Because this review looked at data from 1990 to 2011, it did not include the most recent development of the magnetic sphincter device that was reported in the New England Journal of Medicine in February.[3] The transoral device is out there. The committee reviewed it and decided that the evidence was not there to support it.

6. The diagnosis of laryngopharyngeal reflux cannot be made solely using laryngoscopic findings. How many of you see patients with laryngopharyngeal reflux (LPR) who are sent by your ear-nose-throat (ENT) colleagues saying that it's GERD and that they should see a gastroenterologist? The findings of erythema, retinoid changes, cobblestoning, and loss of vascular patterns are all nonspecific. In my practice, I see them a lot for habituation, repetitive throat clearing, cough, and many other things that have nothing to do with reflux. Even if patients have reflux, the symptoms should get better after it is controlled and you address the habituation.

A diagnosis of LPR that is based only on laryngoscopic findings is not an accurate diagnosis. The majority of these patients will not even respond to empiric therapy in the absence of GERD-related symptoms.