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Gastroesophageal reflux disease

What's new

Updated 2023 AGA guidelines for the diagnosis and management of extraesophageal manifestations of gastroesophageal reflux disease.

Background

Overview

Definition
GERD is a disorder characterized by symptoms or signs caused by regurgitation of gastric contents into the esophagus, larynx, oral cavity, or lungs.
1
Pathophysiology
GERD is due to transient lower esophageal sphincter relaxations, reduced lower esophageal sphincter pressure, hiatal hernias, impaired esophageal clearance, and delayed gastric emptying.
2
Epidemiology
The estimated prevalence of GERD symptoms in the US ranges from 6% to 30%, with a weekly prevalence of symptoms approaching 20%.
3
Disease course
Reflux of gastric contents leads to damage of the esophagus, heartburn, bronchoconstriction, esophagitis, strictures, Barrett's esophagus, and esophageal cancer.
4
Prognosis and risk of recurrence
Barrett's esophagus occurs in about 10% of patients with chronic GERD.
5

Guidelines

Key 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 American College of Gastroenterology (ACG 2022,2013), the United European Gastroenterology (UEG/EAES 2022), the European Society of Gastrointestinal Endoscopy (ESGE 2020), the American Academy of Pediatrics (AAP 2018), the European Society ...
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Screening and diagnosis

Diagnostic criteria: as per ACG 2013 guidelines, establish a presumptive diagnosis of GERD in the setting of typical symptoms of heartburn and regurgitation.
B
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  • Differential diagnosis

Classification and risk stratification

Endoscopic classification
As per ACG 2013 guidelines:
Categorize the endoscopic appearance of erosive esophagitis according to the Los Angeles classification system.
B
Obtain further testing in patients with Los Angeles Grade A esophagitis to confirm the presence of GERD.
B
Los Angeles classification of esophagitis
Endoscopic findings
One or more mucosal break(s) ≤ 5 mm, not extending between the tops of two mucosal folds
One or more mucosal break(s) > 5 mm, not extending between the tops of two mucosal folds
One or mucosal break(s) continuous between the tops of ≥ 2 mucosal folds involving < 75% of the esophageal circumference
One or more mucosal break(s) involving ≥ 75% of the esophageal circumference
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Diagnostic investigations

Barium esophagram: as per ACG 2022 guidelines, do not obtain barium swallow solely as a diagnostic test for GERD.
D

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  • Ambulatory esophageal reflux monitoring

  • Esophageal manometry

  • Screening for H. pylori infection

  • Evaluation for gastroparesis

Diagnostic procedures

Upper gastrointestinal endoscopy: as per ACG 2022 guidelines, perform upper gastrointestinal endoscopy as the first test for the 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
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Medical management

Initial therapy: as per ACG 2022 guidelines, 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
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  • Maintenance therapy

  • Management of PPI side effects

  • Non-acid suppressive therapies

Nonpharmacologic interventions

Dietary modifications: as per ACG 2022 guidelines, consider advising patients to avoid:
meals within 2-3 hours of bedtime
"trigger foods" for symptom control.
C

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  • Weight loss

  • Smoking cessation

  • Sleep-related interventions

Therapeutic procedures

Transoral incisionless fundoplication
As per ACG 2022 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

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  • Medigus ultrasonic surgical endostapler

  • Stretta radiofrequency ablation

  • Magnetic sphincter augmentation

Perioperative care

Preoperative evaluation
As per ACG 2022 guidelines:
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

Surgical interventions

Indications for antireflux surgery: as per ACG 2022 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

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  • Technical considerations for antireflux surgery

  • Bariatric surgery

Specific circumstances

Pregnant patients: as per ACG 2013 guidelines, recognize that PPIs are safe in pregnant patients, if clinically indicated.
B

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  • Pediatric patients (diagnostic imaging)

  • Pediatric patients (upper gastrointestinal endoscopy)

  • Pediatric patients (manometry)

  • Pediatric patients (pH monitoring)

  • Pediatric patients (biomarkers)

  • Pediatric patients (trial of transpyloric/jejunal feeding)

  • Pediatric patients (trial of PPIs)

  • Pediatric patients (dietary modifications)

  • Pediatric patients (transpyloric/jejunal feeding)

  • Pediatric patients (positioning therapy)

  • Pediatric patients (acid suppression therapy)

  • Pediatric patients (prokinetics)

  • Pediatric patients (probiotics)

  • Pediatric patients (alternative and complementary medicine)

  • Pediatric patients (parental/patient counseling)

  • Pediatric patients (assessment of treatment response)

  • Pediatric patients (indications for referral)

  • Pediatric patients (indications for antireflux surgery)

  • Pediatric patients (alternatives to fundoplication)

  • Preterm infants

  • Patients with peptic strictures

  • Patients with extraesophageal symptoms (evaluation)

  • Patients with extraesophageal symptoms (management)

Follow-up and surveillance

Monitoring for Barrett's esophagus
As per ACG 2013 guidelines:
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

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  • Management of refractory disease