ACG Updates Guideline for GERD

The American College of Gastroenterology (ACG) has released an updated clinical guideline on diagnosing and managing gastroesophageal reflux disease (GERD), noting that “clinically important advances in surgical and endoscopic therapy of GERD have emerged” since its last guideline was published.

The authors developed PICO (patient/population, intervention, comparison, and outcomes) questions and conducted a literature search for each question. They used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process to rate the quality of evidence for each statement.

The key concept guiding diagnosis in the guideline is the recommendation not to use high-resolution manometry (HRM) solely as a diagnostic test for GERD.

The strong recommendations for diagnosis included:

• An 8-week trial of empiric proton pump inhibitors (PPIs) patients with classic GERD symptoms of heartburn and regurgitation but without alarm symptoms.
• Diagnostic endoscopy for patients whose classic GERD symptoms do not respond to empiric PPIs or return when PPIs are discontinued;
• Endoscopy as the first test for patients presenting with alarm symptoms (dysphagia, weight loss, GI bleeding) and for patients with multiple risk factors for Barrett’s esophagus
• Reflux monitoring while off therapy for patients with suspected GERD but no objective evidence to establish the diagnosis

The guideline strongly recommends against performing reflux monitoring off therapy

solely as a diagnostic test for GERD in patients known to have endoscopic evidence of Los Angeles (LA) grade C or D reflux esophagitis or in patients with long-segment Barrett’s esophagus. It conditionally recommends against the use of barium swallow solely as a diagnostic test for GERD.

For the management of GERD, the guideline strongly recommends, with moderate to high quality of evidence

• Weight loss in overweight and obese patients to mitigate GERD symptoms.
• Treatment with PPIs over treatment with h2 receptor antagonists (H2Ras) for healing erosive esophagitis (EE) and for maintenance of healing.
• PPI administration 30 to 60 minutes before a meal rather than at bedtime for GERD symptom control.
• Maintenance PPI therapy indefinitely or antireflux surgery for patients with LA grade C or D esophagitis.
• Evaluation for non-GERD causes among patients with possible extraesophageal manifestations before ascribing symptoms to GERD.
• Reflux testing for evaluation of extraesophageal manifestations of GERD without typical GERD symptoms (e.g., heartburn and regurgitation) prior to PPI therapy.
• Optimization of PPI therapy as the first step in management of refractory GERD.
• Antireflux surgery as an option for long-term treatment of patients with objective evidence of GERD, especially patients with severe reflux esophagitis (LA grade C or D), large hiatal hernias, and/or persistent symptoms.
• Consideration of magnetic sphincter augmentation (MSA) as an alternative to laparoscopic fundoplication for patients with regurgitation who fail medical management.

The authors did not recommend baclofen in the absence of objective evidence of GERD.

“We expect that new diagnostic tools and treatments will be developed and those that we have will be further refined,” the authors concluded. “Future research with advanced endoscopic techniques, data on longterm efficacy of surgical intervention, and advances in artificial

intelligence and basic science will almost certainly change the way we manage GERD going forward.”

Read the full guideline here.

—Rebecca Mashaw

Reference:
Katz PO, Dunbar KB, Schnoll-Sussman, FH, et al. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2022;117:27–56. https://doi.org/10.14309/ajg.0000000000001538