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©2013 UpToDate ® Print Email 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. What are indications for antireflux surgery, and what is the efficacy of this therapy?

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.