How to Diagnose Gastroesophageal Reflux Disease (GERD)

1. A presumptive diagnosis of GERD can be established in the setting of typical symptoms of heartburn and regurgitation. Empiric medical therapy with a proton pump inhibitor (PPI) is recommended in this setting. (Strong recommendation, moderate level of evidence)

Establishing the Diagnosis of Gastroesophageal Reflux Disease (GERD)

2. Patients with non-cardiac chest pain suspected due to GERD should have a diagnostic evaluation before the institution of therapy. (Conditional recommendation, moderate level of evidence). A cardiac cause should be excluded in patients with chest pain before the commencement of a gastrointestinal evaluation (Strong recommendation, low level of evidence)

3. Barium radiographs should not be performed to diagnose GERD (Strong recommendation, high level of evidence).

4. Upper endoscopy is not required in the presence of typical GERD symptoms. Endoscopy is recommended in the presence of alarm symptoms and for screening of patients at high risk for complications. Repeat endoscopy is not indicated in patients without Barrett’s oesophagus in the absence of new symptoms. (Strong recommendation, moderate level of evidence)

5. Routine biopsies from the distal oesophagus are not recommended specifically to diagnose GERD. (Strong recommendation, moderate level of evidence)

6. Oesophagal manometry is recommended for preoperative evaluation but has no role in the diagnosis of GERD. (Strong recommendation, low level of evidence)

7. Ambulatory oesophagal reflux monitoring is indicated before considering endoscopic or surgical therapy in patients with the non-erosive disease, as part of the evaluation of patients refractory to PPl therapy, and in situations when the diagnosis of GERD is in question. (Strong recommendation, low level of evidence).

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Ambulatory reflux monitoring is the only test that can assess reflux symptom association (strong recommendation, low level of evidence).

8. Ambulatory reflux monitoring is not required in the presence of short or long-segment Barrett’s oesophagus to establish a diagnosis of GERD. (Strong recommendation, moderate level of evidence)

9. Screening for Helicobacter pylori infection is not recommended in GERD patients. Treatment of H. pylori infection is not routinely required as part of antireflux therapy. (Strong recommendation, low level of evidence)

Management of GERD

1. Weight loss is recommended for GERD patients who are overweight or have had recent weight gain. (Conditional recommendation, moderate level of evidence)

2. Head of bed elevation and avoidance of meals 2-3h before bedtime should be recommended for patients with nocturnal GERD. (Conditional recommendation, low level of evidence)

3. Routine global elimination of food that can trigger reflux (including chocolate, caffeine, alcohol, acidic and/or spicy foods) is not recommended in the treatment of GERD. (Conditional recommendation, low level of evidence)

4. An 8-week course of PPIs is the therapy of choice for symptom relief and healing of erosive esophagitis. There are no major differences in efficacy between the different PPls. (Strong recommendation, high level of evidence)

5. Traditional delayed release PPIs should be administered 30-60 min before meal for maximal pH control. (Strong recommendation, moderate level of evidence). Newer PPIs may offer dosing flexibility relative to meal timing. (Conditional recommendation, moderate level of evidence) 6. PPl therapy should be initiated once a day dosing, before the first meal of the day. (Strong recommendation, moderate level of evidence). For patients with partial response to once daily therapy, tailored therapy with adjustment of dose timing and/or twice daily dosing should be considered y dosing should be considered in patients with night-time symptoms, variable schedules, and/or sleep disturbance. (Strong recommendation, low level of evidence).

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7. Non-responders to PPI should be referred for evaluation. (Conditional recommendation, low level of evidence, see refractory GERD section).

8. In patients with partial response to PPI therapy, increasing the dose to twice daily therapy or switching to a different PPI may provide additional symptom relief. (Conditional
recommendation, low level evidence).

9. Maintenance PPI therapy should be administered for GERD patients who continue to have symptoms after PPl is discontinued, and in patients with complications
including erosive esophagitis and Barrett’s oesophagus. (Strong recommendation, moderate level of evidence). For patients who require long-term PPl therapy, it should be administered in the lowest effective dose, including on-demand or intermittent therapy. (Conditional recommendation, low level of evidence)

10. H -receptor antagonist (H. RA) therapy can be used as a maintenance option in patients without erosive disease if patients experience heartburn relief. (Conditional recommendation, moderate level of evidence). Bedtime H, RA therapy can be added to daytime PPl therapy in selected patients with objective evidence of night-time reflux if needed but may be associated with the development of tachyphylaxis after several weeks of use. (Conditional recommendation, low level of evidence)

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11. Therapy for GERD other than acid suppression, including prokinetic therapy and/or baclofen, should not be used in GERD patients without diagnostic evaluation.
(Conditional recommendation, moderate level of evidence)

12. There is no role for sucralfate in the non-pregnant GERD patient. (Conditional recommendation, moderate level of evidence) 13. PPIs are safe in pregnant patients if clinically indicated. (Conditional recommendation, moderate level of evidence)

Surgical options for GERD

1. Surgical therapy is a treatment option for long-term therapy in GERD patients. (Strong recommendation, high level of evidence)

2. Surgical therapy is generally not recommended in patients who do not respond to PPl therapy. (Strong recommendation, high level of evidence)

3. Preoperative ambulatory pH monitoring is mandatory in patients without evidence of erosive esophagitis. All patients should undergo preoperative
manometry to rule out achalasia or scleroderma-like oesophagus. (Strong recommendation, moderate level of evidence)

4. Surgical therapy is as effective as medical therapy for carefully selected patients with chronic GERD when performed by an experienced surgeon. (Strong recommendation, high level of evidence)

5. Obese patients contemplating surgical therapy for GERD should be considered for bariatric surgery. The gastric bypass would be the preferred operation in these patients.

(Conditional recommendation, moderate level of evidence)

6. The usage of current endoscopic therapy or transoral incisionless fundoplication cannot be recommended as an alternative to medical or traditional surgical therapy.
(Strong recommendation, moderate level of evidence)

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