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©2013 UpToDate ® Print Email 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 I. Using alarm symptoms (other than troublesome dysphagia) as a screening tool to identify patients with GERD at risk for esophageal adenocarcinoma.

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.