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©2013 UpToDate ® Print Email AGAI management GERD What is the efficacy of lifestyle modifications for GERD? Which elements should be recommended and in which circumstances? Grade B: recommended with fair evidence that it improves important outcomes I. Weight loss should be advised for overweight or obese patients with esophageal GERD syndromes. II. Elevation of the head of the bed for selected patients who are troubled with heartburn or regurgitation when recumbent. Other lifestyle modifications including, but not limited to, avoiding late meals, avoiding specific foods, or avoiding specific activities should be tailored to the circumstances of the individual patient. Grade Insuff: no recommendation, insufficient evidence to recommend for or against I. Broadly advocating lifestyle changes for all (as opposed to selected) patients with GERD. How do antisecretory therapies compare in efficacy and under what circumstances might one be preferable to another? What is an acceptable upper limit of empirical therapy in patients with suspected typical esophageal GERD syndromes before performing esophagogastroduodenoscopy? Grade A: strongly recommended based on good evidence that it improves important health outcomes I. Antisecretory drugs for the treatment of patients with esophageal GERD syndromes (healing esophagitis, and symptomatic relief). In these uses, proton pump inhibitors (PPIs) are more effective than histamine2 receptor antagonists (H2RAs), which are more effective than placebo. Grade B: recommended with fair evidence that it improves important outcomes I. Twice-daily PPI therapy for patients with an esophageal syndrome with an inadequate symptom response to once-daily PPI therapy. II. A short course or as-needed use of antisecretory drugs in patients with a symptomatic esophageal syndrome without esophagitis when symptom control is the primary objective. For a short course of therapy, PPIs are more effective than H2RAs, which are more effective than placebo. Grade D: recommend against, fair evidence that it is ineffective or harms outweigh benefits I. Metoclopramide as monotherapy or adjunctive therapy in patients with esophageal or suspected extraesophageal GERD syndromes. Data from: Kahrilas PJ, Shaheen NJ, Vaezi M. American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroenterology 2008; 135:1383. AGAI management GERD (continued)

I. Metoclopramide as monotherapy or adjunctive therapy in patients with esophageal or suspected extraesophageal GERD syndromes. Data from: Kahrilas PJ, Shaheen NJ, Vaezi M. American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroenterology 2008; 135:1383. AGAI management GERD (continued) What is the role and priority of diagnostic tests (endoscopy with or without biopsy, esophageal manometry, ambulatory pH monitoring, impedance-pH monitoring) in the evaluation of patients with suspected esophageal GERD syndromes? Grade B: recommended with fair evidence that it improves important outcomes I. Endoscopy with biopsy for patients with an esophageal GERD syndrome with troublesome dysphagia. Biopsies should target any areas of suspected metaplasia, dysplasia, or in the absence of visual abnormalities, normal mucosa (at least 5 samples to evaluate for eosinophilic esophagitis). II. Endoscopy to evaluate patients with a suspected esophageal GERD syndrome who have not responded to an empirical trial of twice-daily PPI therapy. Biopsies should target any area of suspected metaplasia, dysplasia, or malignancy. III. Manometry to evaluate patients with a suspected esophageal GERD syndrome who have not responded to an empirical trial of twice-daily PPI therapy and have normal findings on endoscopy. Manometry will serve to localize the LES for potential subsequent pH monitoring, to evaluate peristaltic function preoperatively, and to diagnose subtle presentations of the major motor disorders. Evolving information suggests that high-resolution manometry has superior sensitivity to conventional manometry in recognizing atypical cases of achalasia and distal esophageal spasm. IV. Ambulatory impedance-pH, catheter pH, or wireless pH monitoring (PPI therapy withheld for 7 days) to evaluate patients with a suspected esophageal GERD syndrome who have not responded to an empirical trial of PPI therapy, have normal findings on endoscopy, and have no major abnormality on manometry. Wireless pH monitoring has superior sensitivity to catheter studies for detecting pathological esophageal acid exposure because of the extended period of recording (48 hours) and has also shown superior recording accuracy compared with some catheter designs. Grade Insuff: no recommendation, insufficient evidence to recommend for or against

IV. Ambulatory impedance-pH, catheter pH, or wireless pH monitoring (PPI therapy withheld for 7 days) to evaluate patients with a suspected esophageal GERD syndrome who have not responded to an empirical trial of PPI therapy, have normal findings on endoscopy, and have no major abnormality on manometry. Wireless pH monitoring has superior sensitivity to catheter studies for detecting pathological esophageal acid exposure because of the extended period of recording (48 hours) and has also shown superior recording accuracy compared with some catheter designs. Grade Insuff: no recommendation, insufficient evidence to recommend for or against I. Using alarm symptoms (other than troublesome dysphagia) as a screening tool to identify patients with GERD at risk for esophageal adenocarcinoma. II. Combined impedance-pH, catheter pH, or wireless pH monitoring studies to distinguish hypersensitivity syndromes from functional syndromes, the distinction being that in hypersensitivity syndromes symptoms are attributable to reflux events, whereas in functional syndromes they are not. III. Combined impedance-pH, catheter pH, or wireless pH esophageal monitoring studies performed while taking PPIs. What are the unique management considerations in patients with suspected reflux chest pain syndrome? Grade A: strongly recommended based on good evidence that it improves important health outcomes I. Twice-daily PPI therapy as an empirical trial for patients with suspected reflux chest pain syndrome after a cardiac etiology has been carefully considered. What is the best initial management for patients with suspected extraesophageal reflux syndromes (asthma, laryngitis, cough)? What are the unique management considerations with each? What is the appropriate dose and course of antisecretory therapy in each? Grade B: recommended with fair evidence that it improves important outcomes I. Acute or maintenance therapy with once- or twice-daily PPIs (or H2RAs) for patients with a suspected extraesophageal GERD syndrome (laryngitis, asthma) with a concomitant esophageal GERD syndrome. Grade D: recommend against, fair evidence that it is ineffective or harms outweigh benefits I. Once- or twice-daily PPIs (or H2RAs) for acute treatment of patients with potential extraesophageal GERD syndromes (laryngitis, asthma) in the absence of a concomitant esophageal GERD syndrome.

I. Acute or maintenance therapy with once- or twice-daily PPIs (or H2RAs) for patients with a suspected extraesophageal GERD syndrome (laryngitis, asthma) with a concomitant esophageal GERD syndrome. Grade D: recommend against, fair evidence that it is ineffective or harms outweigh benefits I. Once- or twice-daily PPIs (or H2RAs) for acute treatment of patients with potential extraesophageal GERD syndromes (laryngitis, asthma) in the absence of a concomitant esophageal GERD syndrome. Grade Insuff: no recommendation, insufficient evidence to recommend for or against I. Once- or twice-daily PPIs for patients with suspected reflux cough syndrome. Does GERD progress in severity, such that symptomatic patients without esophagitis develop esophagitis and Barrett's metaplasia, or are these distinct disease manifestations that do not exist along a continuum? If patients do progress, at what rate does this occur, and does it warrant endoscopic monitoring? Grade D: recommend against, fair evidence that it is ineffective or harms outweigh benefits I. Routine endoscopy in subjects with erosive or nonerosive reflux disease to assess for disease progression. What maintenance therapy is indicated for patients with the typical esophageal reflux syndrome (with or without esophagitis)? When and how should antisecretory therapy be decreased or discontinued? What, if any, risks are associated with this? Grade A: strongly recommended based on good evidence that it improves important health outcomes I. Long-term use of PPIs for the treatment of patients with esophagitis once they have proven clinically effective. Long-term therapy should be titrated down to the lowest effective dose based on symptom control. Grade D: recommend against, fair evidence that it is ineffective or harms outweigh benefits I. Less than daily dosing of PPI therapy as maintenance therapy in patients with an esophageal syndrome who previously had erosive esophagitis. Data from: Kahrilas PJ, Shaheen NJ, Vaezi M. American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroenterology 2008; 135:1383. AGAI management GERD (continued) What maintenance therapy is indicated for patients with suspected extraesophageal reflux syndromes (asthma, laryngitis, cough)? When and how should antisecretory therapy be decreased or discontinued?

Data from: Kahrilas PJ, Shaheen NJ, Vaezi M. American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroenterology 2008; 135:1383. AGAI management GERD (continued) What maintenance therapy is indicated for patients with suspected extraesophageal reflux syndromes (asthma, laryngitis, cough)? When and how should antisecretory therapy be decreased or discontinued? Grade B: recommended with fair evidence that it improves important outcomes I. Acute or maintenance therapy with once- or twice-daily PPIs (or H2RAs) for patients with a suspected extraesophageal GERD syndrome (laryngitis, asthma) with a concomitant esophageal GERD syndrome. Grade Insuff: no recommendation, insufficient evidence to recommend for or against I. Maintenance therapy with once- or twice-daily PPIs (or H2RAs) for patients with potential extraesophageal GERD syndromes (laryngitis, asthma) in the absence of a concomitant esophageal GERD syndrome. II. Once- or twice-daily PPIs for patients with suspected reflux cough syndrome. What are the clinical consequences of chronic potent acid inhibition? Do these potential side effects warrant specific testing (eg, bone density studies, calcium supplementation, Helicobacter pylori screening, and so on)? Grade Insuff: no recommendation, insufficient evidence to recommend for or against I. Advocating bone density studies, calcium supplementation, Helicobacter pylori screening, or any other routine precaution because of PPI use. What is the role of endoscopy in long-term management of patients with GERD, and under what circumstances should mucosal biopsy specimens be obtained when endoscopy is performed? Grade B: recommended with fair evidence that it improves important outcomes I. Endoscopy with biopsy for patients with an esophageal GERD syndrome with troublesome dysphagia. Biopsies should target any areas of suspected metaplasia, dysplasia, or in the absence of any visual abnormalities, normal mucosa (at least 5 samples to evaluate for eosinophilic esophagitis). Grade Insuff: no recommendation, insufficient evidence to recommend for or against I. Routine upper endoscopy in the setting of chronic GERD symptoms to diminish the risk of death from esophageal cancer. II. Endoscopic screening for Barrett's esophagus and dysplasia in adults 50 years or older with >5-10 years of heartburn to reduce mortality from esophageal adenocarcinoma.

Grade Insuff: no recommendation, insufficient evidence to recommend for or against I. Routine upper endoscopy in the setting of chronic GERD symptoms to diminish the risk of death from esophageal cancer. II. Endoscopic screening for Barrett's esophagus and dysplasia in adults 50 years or older with >5-10 years of heartburn to reduce mortality from esophageal adenocarcinoma. What are indications for antireflux surgery, and what is the efficacy of this therapy? Grade A: strongly recommended based on good evidence that it improves important health outcomes I. When antireflux surgery and PPI therapy are judged to offer similar efficacy in a patient with an esophageal GERD syndrome, PPI therapy should be recommended as initial therapy because of superior safety. II. When a patient with an esophageal GERD syndrome is responsive to, but intolerant of, acid suppressive therapy, antireflux surgery should be recommended as an alternative. Grade B: recommended with fair evidence that it improves important outcomes I. Antireflux surgery for patients with an esophageal GERD syndrome with persistent troublesome symptoms, especially troublesome regurgitation, despite PPI therapy. The potential benefits of antireflux surgery should be weighed against the deleterious effect of new symptoms consequent from surgery, particularly dysphagia, flatulence, an inability to belch, and postsurgery bowel symptoms. Grade C: balance of benefits and harms is too close to justify a general recommendation I. Patients with an extraesophageal GERD syndrome with persistent troublesome symptoms despite PPI therapy should be considered for antireflux surgery. The potential benefits of antireflux surgery should be weighed against the deleterious effect of new symptoms consequent from surgery, particularly dysphagia, flatulence, an inability to belch, and postsurgery bowel symptoms. Grade D: recommend against, fair evidence that it is ineffective or harms outweigh benefits I. Antireflux surgery for patients with an esophageal syndrome with or without tissue damage who are symptomatically well controlled on medical therapy. II. Antireflux surgery as an antineoplastic measure in patients with Barrett's metaplasia. Grade Insuff: no recommendation, insufficient evidence to recommend for or against I. The use of currently commercially available endoluminal antireflux procedures in the management of patients with an esophageal syndrome.

I. Antireflux surgery for patients with an esophageal syndrome with or without tissue damage who are symptomatically well controlled on medical therapy. II. Antireflux surgery as an antineoplastic measure in patients with Barrett's metaplasia. Grade Insuff: no recommendation, insufficient evidence to recommend for or against I. The use of currently commercially available endoluminal antireflux procedures in the management of patients with an esophageal syndrome. Data from: Kahrilas PJ, Shaheen NJ, Vaezi M. American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroenterology 2008; 135:1383.

©2013 UpToDate ® Print Email AGAI management GERD What is the efficacy of lifestyle modifications for GERD? Which elements should be recommended and in which circumstances? Grade B: recommended with fair evidence that it improves important outcomes I. Weight loss should be advised for overweight or obese patients with esophageal GERD syndromes. II. Elevation of the head of the bed for selected patients who are troubled with heartburn or regurgitation when recumbent. Other lifestyle modifications including, but not limited to, avoiding late meals, avoiding specific foods, or avoiding specific activities should be tailored to the circumstances of the individual patient. Grade Insuff: no recommendation, insufficient evidence to recommend for or against I. Broadly advocating lifestyle changes for all (as opposed to selected) patients with GERD. How do antisecretory therapies compare in efficacy and under what circumstances might one be preferable to another? What is an acceptable upper limit of empirical therapy in patients with suspected typical esophageal GERD syndromes before performing esophagogastroduodenoscopy? Grade A: strongly recommended based on good evidence that it improves important health outcomes I. Antisecretory drugs for the treatment of patients with esophageal GERD syndromes (healing esophagitis, and symptomatic relief). In these uses, proton pump inhibitors (PPIs) are more effective than histamine2 receptor antagonists (H2RAs), which are more effective than placebo. Grade B: recommended with fair evidence that it improves important outcomes I. Twice-daily PPI therapy for patients with an esophageal syndrome with an inadequate symptom response to once-daily PPI therapy. II. A short course or as-needed use of antisecretory drugs in patients with a symptomatic esophageal syndrome without esophagitis when symptom control is the primary objective. For a short course of therapy, PPIs are more effective than H2RAs, which are more effective than placebo. Grade D: recommend against, fair evidence that it is ineffective or harms outweigh benefits I. Metoclopramide as monotherapy or adjunctive therapy in patients with esophageal or suspected extraesophageal GERD syndromes. Data from: Kahrilas PJ, Shaheen NJ, Vaezi M. American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroenterology 2008; 135:1383.