Deep Dive: Gastroesophageal Reflux Disease (GERD) Diagnosis and Treatment

This Guideline Deep Dive was originally published in our TLDR Primary Care newsletter, but we wanted to share it here so it was easily accessible. If you want more content like this straight to you inbox, be sure to subscribe to our weekly emails here! And for more guideline summaries and simplified study breakdowns, head over to Pathway.

The American College of Gastroenterology (ACG) recently released new guidelines on Gastroesophageal reflux disease (GERD) in late 2021 – here are the salient points from these important practice guidelines. But first, let’s review key findings of this very common pathology.

GERD is typically defined as the occurrence of heartburn or acid regurgitation symptoms at least once a week, or typical reflux syndrome. GERD is also a frequent cause of atypical chest pain, the so-called reflux chest pain syndrome. In addition, GERD is associated with extra-esophageal symptoms and signs such as cough, wheezing, and dental erosions. Finally, longstanding GERD can cause esophageal injury such as esophagitis and strictures, which can lead to symptoms of dysphagia and weight loss.

Endoscopic view of normal versus two important GERD complications: erosive esophagitis and Barrett’s esophagus. The latter is associated with an increased risk of esophageal cancer.
Endoscopic view of normal versus two important GERD complications: erosive esophagitis and Barrett’s esophagus. The latter is associated with an increased risk of esophageal cancer.

For a full review of the 2021 American College of Gastroenterology guidelines on GERD, head over to Pathway. We’ll cover some key takeaways below (with the recommendation strength in parentheses).

  1. Diagnosis and Screening: 
  • Make a presumptive diagnosis of GERD in patients with typical symptoms of heartburn and regurgitation, but exclude cardiac causes first if chest pain is present (B)
  • Do not obtain a barium swallow study or esophageal manometry solely to diagnose GERD, and do not screen patients with GERD for H. pylori (D)
  • Perform upper GI endoscopy in patients with alarm symptoms of dysphagia, weight loss or GI bleeding - as well as in patients with multiple risk factors for Barrett’s esophagus (B)
  1. Medical Treatment:
  • Administer an 8-week trial of a once-daily PPI 30-60 minutes before a meal in patients with GERD without alarm symptoms, and discontinue PPIs after 8 weeks if symptoms have resolved (B)
  • Perform upper GI endoscopy if classic GERD symptoms do not respond to an 8-week PPI trial, or if symptoms return after discontinuation (B)
  • Administer PPIs at lowest dose possible to control GERD symptoms and heal reflux esophagitis if maintenance therapy is needed (B)
  • Continue maintenance therapy indefinitely, or perform antireflux surgery, in patients with Los Angeles grade C or D esophagitis (B)
  1. Medication Considerations:
  • Recognize that PPIs are safe in pregnant patients (B)
  • Avoid withholding PPIs on the sole basis of osteoporosis except in patients at risk of hip fracture (D)
  • Avoid withholding PPIs in patients on clopidogrel, as data does not support increased cardiovascular risk (D)
  • Do not use H-2 blockers to heal erosive esophagitis, and do not use prokinetic agents unless there is objective evidence of gastroparesis (D)
  1. Other interventions:
  • Consider advising patients to avoid meals within 2-3 hours of bedtime, and decreasing consumption of trigger foods for symptom control (C)
  • Advise weight loss in overweight or obese patients to improve symptoms (B)
  1. Indications for Surgery:
  • Perform antireflux surgery (laparoscopic fundoplication) in patients with severe reflux esophagitis (LA grade 3 or 4), large hiatal hernias, or persistent and troublesome symptoms (B)

Guideline Bonus - Courtesy of the new ACG 2022 Barrett’s Esophagus Guidelines:

Patients with chronic GERD and 3 or more risk factors (shown below) should receive an endoscopy to screen for Barrett’s. Repeat screening is not recommended if initial screening is negative.

  • Male sex
  • Age > 50 years
  • White race
  • Tobacco smoking
  • Obesity
  • Family history of Barrett’s or Esophageal adenocarcinoma
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