AGA Expert Clinical Practice Update for Adults with GERD

R Yadiatpati et al. Clin Gastroenterol Hepatol 2022; 20: 984-994. AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review

The general approach, outlined in Figure 1, is to empirically treat patients with typical GERD symptoms for 4-8 weeks with single-dose PPI. In those with response, the goal is to use the lowest effective dose and consider reflux testing (“offer endoscopy with prolonged wireless reflux monitoring”) if needing prolonged treatment (>1 yr). In those without a response, adjusting treatment (possibly change medication or change to twice a day) should be considered and reflux testing (off treatment) is recommended as well in those lacking response to treatment.

Some of the recommendations/best practice advice:

  • Clinicians should provide standardized educational material on GERD mechanisms, weight management, lifestyle and dietary behaviors, relaxation strategies, and awareness about the brain-gut axis relationship to patients with reflux symptoms.
  • Clinicians should emphasize safety of proton pump inhibitors (PPIs) for the treatment of GERD.
  • Clinicians should provide patients presenting with troublesome heartburn, regurgitation, and/or non-cardiac chest pain without alarm symptoms a 4- to 8-week trial of single-dose PPI therapy. With inadequate response, dosing can be increased to twice a day or switched to a more effective acid suppressive agent once a day. When there is adequate response, PPI should be tapered to the lowest effective dose.
  • If troublesome heartburn, regurgitation, and/or non-cardiac chest pain do not respond adequately to a PPI trial or when alarm symptoms exist, clinicians should investigate with endoscopy and, in the absence of erosive reflux disease (Los Angeles B or greater) or long-segment (≥3 cm) Barrett’s esophagus, perform prolonged wireless pH monitoring off medication (96-hour preferred if available) to confirm and phenotype GERD or to rule out GERD.
  • Clinicians should perform upfront objective reflux testing off medication (rather than an empiric PPI trial) in patients with isolated extra-esophageal symptoms and suspicion for reflux etiology.
  • Clinicians should provide pharmacologic neuromodulation, and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies in patients with functional heartburn or reflux disease associated with esophageal hypervigilance reflux hypersensitivity and/or behavioral disorders.
  • In patients with proven GERD, laparoscopic fundoplication and magnetic sphincter augmentation are effective surgical options, and transoral incisionless fundoplication is an effective endoscopic option in carefully selected patients.

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