What are the guideline sources, guidelines and references for Gastroesophageal reflux disease ?
Guideline sources The following summarized guidelines for the evaluation and management of gastroesophageal reflux disease are prepared by our editorial team based on guidelines from the American Gastroenterological Association (AGA 2023; 2012), the United European Gastroenterology (UEG/EAES 2022), the American College of Gastroenterology (ACG 2021; 2013), the European Society of Gastrointestinal Endoscopy (ESGE 2020), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN/NASPGHAN 2018), the American Academy of Pediatrics (AAP 2018), and the American College of Endocrinology (ACE/AACE 2016). 1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Definition GERD is a disorder characterized by symptoms or signs caused by regurgitation of gastric contents into the esophagus, larynx, oral cavity, or lungs. 12 Epidemiology https://web.pathway.md/diseases/recx1QuF4NuiAPSjI 1/11 6/24/23, 2:55 AM Gastroesophageal reflux disease Pathway Epidemiology GERD is due to transient lower esophageal sphincter relaxations, reduced lower esophageal sphincter pressure, hiatal hernias, impaired esophageal clearance, and delayed gastric emptying. 14 Pathophysiology The estimated prevalence of GERD symptoms in the United States ranges from 6% to 30%, with a weekly prevalence of symptoms approaching 20%. 13 Disease course Reflux of gastric contents leads to damage of the esophagus, heartburn, bronchoconstriction, esophagitis, strictures, Barrett's esophagus, and esophageal cancer. 15 Prognosis and risk of recurrence Barrett's esophagus occurs in about 10% of patients with chronic GERD. 16 Calculator Los Angeles classification of es Guidelines 1. Screening and diagnosis Diagnostic criteria: establish a presumptive diagnosis of GERD in the setting of typical symptoms of heartburn and regurgitation. B Differential diagnosis: Obtain diagnostic evaluation before institution of therapy in patients with non-cardiac chest pain suspected due to GERD. B Exclude a cardiac cause in patients with chest pain before the commencement of a gastrointestinal evaluation. B 2. Classification and risk stratification Endosopic classification: Categorize the endoscopic appearance of erosive esophagitis according to the Los Angeles classification system. B https://web.pathway.md/diseases/recx1QuF4NuiAPSjI 2/11 6/24/23, 2:55 AM Gastroesophageal reflux disease Pathway Obtain further testing in patients with Los Angeles Grade A esophagitis to confirm the presence of GERD. B 3. Diagnostic investigations Barium esophagram: do not obtain barium swallow solely as a diagnostic test for GERD. D Ambulatory esophageal reflux monitoring: obtain reflux monitoring off therapy to establish the diagnosis in patients with suspected but not clear GERD, if endoscopy shows no objective evidence of GERD. B Show 2 more Esophageal manometry: do not obtain high-resolution manometry solely as a diagnostic test for GERD. D Screening for Helicobacter pylori infection: do not screen patients with GERD for H. pylori infection. Do not administer eradication therapy routinely as part of antireflux therapy. D Evaluation for gastroparesis: consider evaluating for the presence of gastroparesis in patients with GERD refractory to acid-suppressive treatment. C 4. Diagnostic procedures Upper gastrointestinal endoscopy: perform upper gastrointestinal endoscopy as the first test for evaluation of patients presenting with dysphagia or other alarm symptoms (weight loss and gastrointestinal bleeding) and of patients with multiple risk factors for Barrett's esophagus. B Show 2 more 5. Medical management Initial therapy: administer an 8-week trial of empiric PPIs once daily before a meal in patients with classic GERD symptoms of heartburn and regurgitation without alarm symptoms. B Show 4 more Maintenance therapy: As per ACG 2021 guidelines: Administer PPIs at the lowest dose that effectively controls GERD symptoms and maintains healing of reflux esophagitis in patients with GERD requiring maintenance therapy with PPIs. B Initiate maintenance therapy indefinitely or perform antireflux surgery in patients with Los Angeles grade C or D esophagitis. B As per ACG 2012 guidelines, titrate long-term acid suppression therapy with PPIs or H2RAs to the lowest effective dose needed to achieve therapeutic goals for pharmacological treatment of patients with GERD. B https://web.pathway.md/diseases/recx1QuF4NuiAPSjI 3/11 6/24/23, 2:55 AM Gastroesophageal reflux disease Pathway Management of PPI side effects: consider switching PPIs in the setting of side effects. C Show 3 more Non-acid suppressive therapies: Do not use the following agents in patients with GERD: histamine-2-receptor antagonists for healing erosive esophagitis D baclofen in the absence of objective evidence of GERD D prokinetic agents of any kind unless there is objective evidence of gastroparesis D sucralfate, except during pregnancy. D Do not add medical therapies routinely in patients not responding to PPIs. D 6. Nonpharmacologic interventions Dietary modifications: Consider advising patients to avoid: meals within 2-3 hours of bedtime "trigger foods" for symptom control. C Weight loss: As per ACG 2021 guidelines, offer weight loss for improvement of GERD symptoms in patients with overweight or obesity. B As per AACE 2016 guidelines: Offer weight loss with the goal of losing 10% of body weight in patients with overweight or obesity and gastroesophageal reflux. A Prescribe PPIs during weight loss interventions in patients with overweight or obesity and persistent gastroesophageal reflux symptoms. A Smoking cessation: consider advising patients to avoid tobacco products/smoking. C Sleep-related interventions: consider advising elevating head of bed for nighttime symptom control. C 7. Therapeutic procedures Transoral incisionless fundoplication: As per ACG 2021 guidelines: Consider performing transoral incisionless fundoplication in patients with troublesome regurgitation or heartburn not wishing to undergo antireflux surgery and not having a severe esophagitis (Los Angeles grade C or D) or hiatal hernias > 2 cm. C Consider performing transoral incisionless fundoplication in patients with regurgitation as their primary PPI-refractory symptom and in patients with abnormal gastroesophageal reflux documented by objective testing. C https://web.pathway.md/diseases/recx1QuF4NuiAPSjI 4/11 6/24/23, 2:55 AM Gastroesophageal reflux disease Pathway As per ESGE 2020 guidelines, do not perform transoral incisionless fundoplication as an alternative to PPI therapy or antireflux surgery for the treatment of GERD. Consider offering transoral incisionless fundoplication in patients with mild GERD not willing to take PPIs or undergo antireflux surgery. D Medigus ultrasonic surgical endostapler: do not perform Medigus ultrasonic surgical endostapler for the treatment of patients with GERD. Perform Medigus ultrasonic surgical endostapler in clinical trials only. D Stretta radiofrequency ablation: consider offering Stretta radiofrequency ablation of the lower esophageal sphincter to relieve symptoms only in selective patients in the absence of erosive esophagitis and a hiatal hernia. C Magnetic sphincter augmentation: consider offering magnetic sphincter augmentation as an alternative to laparoscopic fundoplication in patients with regurgitation failed medical management. B 8. Perioperative care Preoperative evaluation: Obtain careful evaluation to ensure that GERD is present and causes the symptoms, to exclude achalasia (which can be associated with symptoms such as heartburn and regurgitation that can be confused with GERD) and conditions that might be contraindications to invasive treatment, such as absent contractility, before performing invasive therapy for GERD. B Obtain high-resolution manometry before antireflux surgery or endoscopic therapy to rule out achalasia and absent contractility. Obtain provocative testing to identify contractile reserve (such as multiple rapid swallows) in patients with ineffective esophageal motility. B 9. Surgical interventions Indications for antireflux surgery: As per ACG 2021 guidelines, offer antireflux surgery by an experienced surgeon as an option for long-term treatment in patients with objective evidence of GERD, especially in patients with: severe reflux esophagitis (Los Angeles grade C or D) large hiatal hernias persistent, troublesome GERD symptoms. B As per ESGE 2020 guidelines, do not perform antireflux mucosectomy for the treatment of patients with GERD. D Technical considerations for antireflux surgery: consider performing posterior partial fundoplication over total posterior or anterior 90 degrees fundoplication in adult patients with GERD. Consider performing anterior > 90 degrees fundoplication as an alternative. C Bariatric surgery: https://web.pathway.md/diseases/recx1QuF4NuiAPSjI 5/11 6/24/23, 2:55 AM Gastroesophageal reflux disease Pathway As per ACG 2021 guidelines, consider offering Roux-en-Y gastric bypass as an option for the treatment of GERD in patients with obesity eligible for bariatric surgery and willing to accept its risks and requirements for lifestyle alterations. C As per AACE 2016 guidelines: Consider offering Roux-en-Y gastric bypass as the bariatric surgery procedure of choice in patients with obesity and moderate-to-severe gastroesophageal reflux symptoms. C Do not use intragastric balloons for weight loss in patients with established gastroesophageal reflux. D 10. Specific circumstances Pregnant patients: recognize that PPIs are safe in pregnant patients, if clinically indicated. B Pediatric patients (diagnostic imaging): Consider obtaining a barium swallow or ultrasound to exclude anatomical abnormalities but not for the diagnosis of GERD in infant and pediatric patients. C Avoid obtaining scintigraphy for the diagnosis of GERD in infant and pediatric patients. D Pediatric patients (upper GI endoscopy): Avoid performing upper gastrointestinal endoscopy for the diagnosis of GERD in infant and pediatric patients. D Consider performing upper gastrointestinal endoscopy with biopsies to assess complications of GERD in patients with a suspected underlying mucosal disease or before escalating treatment. B Pediatric patients (manometry): Avoid obtaining manometry for the diagnosis of GERD in infant and pediatric patients. D Consider obtaining manometry in patients with a suspected motility disorder. B Pediatric patients (pH monitoring): Consider obtaining pH-multichannel intraluminal impedance testing only for the following purposes: correlate persistent troublesome symptoms with acid and non-acid gastroesophageal reflux events B clarify the role of acid and non-acid reflux in the etiology of esophagitis and other signs and symptoms suggestive of GERD C determine the efficacy of acid suppression therapy C differentiate non-erosive reflux disease, hypersensitive esophagus, and functional heartburn in patients with normal endoscopy. C Consider obtaining pH-metry only for the following purposes, if pH-multichannel intraluminal impedance testing is not available: correlate persistent troublesome symptoms with acid gastroesophageal reflux events https://web.pathway.md/diseases/recx1QuF4NuiAPSjI 6/11 6/24/23, 2:55 AM Gastroesophageal reflux disease Pathway clarify the role of acid reflux in the etiology of esophagitis and other signs and symptoms suggestive of GERD determine the efficacy of acid suppression therapy. B Pediatric patients (biomarkers): Do not use salivary pepsin for the diagnosis of GERD in infant and pediatric patients. D Avoid using currently available extraesophageal biomarkers for the diagnosis of GERD in infant and pediatric patients. D Pediatric patients (trial of transpyloric/jejunal feeding): avoid offering a trial of transpyloric/jejunal feeding for the diagnosis of GERD in infant and pediatric patients. D Pediatric patients (trial of PPIs): Consider offering a 4-8 week trial of PPIs for typical symptoms (heartburn, retrosternal or epigastric pain) as a diagnostic test for GERD in pediatric patients. C Avoid offering a trial of PPIs as a diagnostic test for GERD in infant patients and in patients presenting with extraesophageal symptoms. D Pediatric patients (dietary modifications): consider administering thickened feed for the treatment of visible regurgitation/vomiting in infant patients with GERD. C Show 2 more Pediatric patients (transpyloric/jejunal feeding): consider administering transpyloric/jejunal feeding as an alternative to fundoplication for the treatment of infant and pediatric patients with GERD refractory to optimal treatment. C Pediatric patients (positioning therapy): Consider advising head elevation or left lateral positioning for GERD symptoms in pediatric patients. C Do not offer positional therapy (head elevation, lateral and prone positioning) for the treatment of GERD symptoms in sleeping infants. D Pediatric patients (acid suppression therapy): initiate PPIs as first-line therapy for reflux-related erosive esophagitis in infant and pediatric patients with GERD. A Consider initiating H2RAs if PPIs are not available or contraindicated. B Show 4 more Pediatric patients (prokinetics): Consider administering baclofen before surgery in pediatric patients if other pharmacological treatments have failed. C Avoid using domperidone and metoclopramide in the treatment of GERD in infant and pediatric patients. Avoid using other prokinetics (erythromycin, bethanechol) as first-line therapy in infant and pediatric patients with GERD. D Pediatric patients (probiotics): avoid using prebiotics or probiotics for the treatment of GERD. D Pediatric patients (alternative and complementary medicine): Avoid offering massage therapy for the treatment of GERD in infant patients. D https://web.pathway.md/diseases/recx1QuF4NuiAPSjI 7/11 6/24/23, 2:55 AM Gastroesophageal reflux disease Pathway Avoid offering herbal medications for the treatment of GERD. D Pediatric patients (parental/patient counseling): Provide patient/parental education and support as part of the treatment of GERD. A Consider informing caregivers and patients that excessive body weight is associated with an increased prevalence of GERD. C Pediatric patients (assessment of treatment response): Assess treatment efficacy and exclude alternative causes of symptoms in infant and pediatric patients not responding to 4-8 weeks of optimal medical therapy for GERD. A Obtain a regular assessment of the ongoing need for long-term acid suppression therapy in infant and pediatric patients with GERD. A Pediatric patients (indications for referral): Refer infant and pediatric patients with GERD to a pediatric gastroenterologist in the following situations: presence of alarm signs or symptoms suggesting an underlying gastrointestinal disease patients are refractory to optimal treatment patients cannot be permanently weaned from pharmacological treatment within 6-12 months (consider obtaining additional evaluation after 4-8 weeks of optimal GERD therapy if clinically indicated). A Pediatric patients (indications for antireflux surgery): Consider performing antireflux surgery, including fundoplication, in infant and pediatric patients with GERD with any of the following: life-threatening complications (such as cardiorespiratory failure) of GERD after failure of optimal medical treatment symptoms refractory to optimal therapy, after appropriate evaluation excluding other underlying diseases chronic conditions (neurologically impaired, cystic fibrosis) with a significant risk of GERD- related complications the need for chronic pharmacotherapy to control signs and/or symptoms of GERD. C Pediatric patients (alternatives to fundoplication): do not perform total esophagogastric disconnection as first-line surgical treatment in infant and pediatric patients with GERD refractory to optimal treatment. D Consider performing total esophagogastric disconnection as a rescue procedure in neurologically impaired pediatric patients with a failed fundoplication. D Show 2 more Preterm infants: Recognize that: gastroesophageal reflux is almost universal in preterm infants gastroesophageal reflux is a physiologic process secondary to frequent transient lower esophageal sphincter relaxation, relatively large-volume liquid diet, and age-specific body positioning gastroesophageal reflux is a normal developmental phenomenon resolving with maturation pathologic gastroesophageal reflux occurs when reflux of acidic gastric contents causes injury to the lower esophageal mucosa https://web.pathway.md/diseases/recx1QuF4NuiAPSjI 8/11 6/24/23, 2:55 AM Gastroesophageal reflux disease Pathway most gastroesophageal reflux episodes in preterm infants are only weakly acidic because of their lower gastric acidity and frequent milk feedings, making esophageal injury unlikely to occur signs commonly ascribed to gastroesophageal reflux in preterm infants include feeding intolerance or aversion, poor weight gain, frequent regurgitation, apnea, desaturation, bradycardia, and behavioral signs, including irritability and perceived postprandial discomfort the temporal association of perceived signs of gastroesophageal reflux with either acidic or nonacidic reflux episodes as measured by multichannel intraesophageal impedance and pH is not supported, and the signs will usually improve with time without treatment data regarding the possible association between worsening lung disease attributable to gastroesophageal reflux and microaspiration in mechanically ventilated preterm infants are sparse there is marked variability in the diagnosis and treatment of gastroesophageal reflux in preterm infants among neonatal ICUs, perhaps because the diagnosis is usually made by clinical assessment of signs and symptoms and/or a trial of nonpharmacologic or pharmacologic treatment rather than definitive tests. (Expert Opinion). E Show 2 more Patients with peptic strictures: Administer continuous PPI therapy following peptic stricture dilation, in order to improve dysphagia and reduce the need for repeated dilations. B Consider performing intralesional injection of corticosteroids in refractory, complex strictures due to GERD. C Patients with extraesophageal symptoms, evaluation: As per AGA 2023 guidelines, assess for extraesophageal manifestations of GERD, including laryngitis, chronic cough, asthma, and dental erosions, in patients with GERD to determine whether GERD may be a contributing factor to these conditions. B Show 7 more As per ACG 2021 guidelines, obtain evaluation for non-GERD causes in patients with possible extraesophageal manifestations before ascribing symptoms to GERD. B Show 7 more Patients with extraesophageal symptoms, management: As per AGA 2023 guidelines, consider offering an initial single-dose PPI trial titrating up to BID in patients with typical GERD symptoms and potential extraesophageal manifestations. C Show 2 more As per ACG 2021 guidelines: Consider offering a trial of PPIs BID for 8-12 weeks before obtaining additional testing in patients with both extraesophageal and typical GERD symptoms. C Perform surgical or endoscopic antireflux procedures in patients treated for extraesophageal reflux disease only if objective evidence of reflux is present. B 11. Follow-up and surveillance https://web.pathway.md/diseases/recx1QuF4NuiAPSjI 9/11 6/24/23, 2:55 AM Gastroesophageal reflux disease Pathway Monitoring for Barrett's esophagus: Perform repeat endoscopy in patients with severe erosive reflux disease after a course of antisecretory therapy, in order to exclude underlying Barrett's esophagus. B Consider screening for Barrett's esophagus in patients with GERD being at high risk based on epidemiologic profile. C Management of refractory disease: optimize PPI therapy as the first step in the management of patients with refractory GERD. B Show 7 more References 1. Philip O Katz, Kerry B Dunbar, Felice H Schnoll-Sussman et al. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2021 Nov 22. Open 2. Stephan C Bischoff, Johann Ockenga, Ahad Eshraghian et al. Practical guideline on obesity care in patients with gastrointestinal and liver diseases Joint ESPEN/UEG guideline. Clin Nutr. 2023 Apr 10;42 6 987 1024. Open 3. Rachel Rosen, Yvan Vandenplas, Maartje Singendonk et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2018 Mar;66 3 516 554. Open 4. W Timothy Garvey, Jeffrey I Mechanick, Elise M Brett et al. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS WITH OBESITY. Endocr Pract. 2016 Jul;22 Suppl 3 1 203. Open 5. Bas L A M Weusten, Maximilien Barret, Albert J Bredenoord et al. Endoscopic management of gastrointestinal motility disorders - part 2 European Society of Gastrointestinal Endoscopy ESGE Guideline. Endoscopy. 2020 Jul;52 7 600 614. Open 6. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013 Mar;108 3 308 28. 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UEG and EAES rapid guideline: Update systematic review, network meta-analysis, CINeMA and GRADE assessment, and evidence-informed https://web.pathway.md/diseases/recx1QuF4NuiAPSjI 10/11 6/24/23, 2:55 AM Gastroesophageal reflux disease Pathway European recommendations on surgical management of GERD. United European Gastroenterol J. 2022 Oct;1 16. Open 12. Sandhu DS, Fass R. Current Trends in the Management of Gastroesophageal Reflux Disease. Gut Liver. 2018 Jan 15;12 1 7 16. Open 13. Richter JE, Rubenstein JH. Presentation and Epidemiology of Gastroesophageal Reflux Disease. Gastroenterology. 2018 Jan;154 2 267 276. Open 14. Clarrett DM, Hachem C. Gastroesophageal Reflux Disease GERD . Mo Med. 2018 May-Jun;115 3 214 218. Open 15. Tack J, Pandolfino JE. Pathophysiology of Gastroesophageal Reflux Disease. Gastroenterology. 2018 Jan;154 2 277 288. Open 16. Harnik IG. In the Clinic. Gastroesophageal Reflux Disease. Ann Intern Med. 2015 Jul 7;163 1 ITC1. Open 17. 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