USA: The American College of Gastroenterology (ACG) has issued updated guidelines on evaluating and managing gastroesophageal reflux disease (GERD).
The guideline, published in the Cleveland Clinic Journal of Medicine, offers a brief overview of changes in the outpatient management of GERD outlined in the latest guidelines. The guideline was released in response to advances in the diagnostic evaluation and management of GERD since the guideline was previously published in 2013. The updated guideline included the consequences of long-term proton pump inhibitor (PPI) therapy and emerging therapies.
Following are the main recommendations of the updated ACG guidelines
- Adult
patients with classic GERD symptoms of heartburn and regurgitation without
alarm symptoms such as dysphagia, bleeding, weight loss, anaemia, vomiting, and
chest pain can be treated with an 8-week empiric trial of a PPI taken once
daily before meals. An upper age limit is not specified. - Endoscopy is
indicated in patients with alarm or refractory symptoms after
optimization of PPI therapy. - PPIs
continue to be the mainstay of medical treatment. For patients with GERD whose
symptoms have resolved and who do not have erosive esophagitis or Barrett’s
oesophagus, tapering the PPI to the lowest effective dose, replacement with
intermittent PPI therapy or a histamine 2 receptor antagonist, and, when
possible, discontinuation should be considered. - Reflux testing
with a wireless telemetry capsule attached to the oesophagal mucosa during
endoscopy or transnasal catheter is considered in patients with suspected GERD
and normal endoscopy, extraesophageal GERD symptoms, or refractory GERD. - Surgical
options are recommended for patients with objective evidence of GERD who have
severe reflux esophagitis (Los Angeles grade C or D), large hiatal hernias, or
persistent, troublesome GERD symptoms such as regurgitation.7 The treatment is fundoplication, in which
the lower oesophagal sphincter is strengthened by wrapping the fundus of the
stomach around the oesophagus in the abdomen. Roux-en-Y gastric bypass is an
option to treat GERD in patients with obesity who are candidates for this
procedure. - Long-term
PPI therapy or antireflux surgery is recommended for patients with Los Angeles
classification grade C esophagitis (erosions extending over mucosal folds, but
over less than three-quarters of the circumference) or grade D esophagitis
(confluent erosions extending over more than three-quarters of the
circumference). - Transoral
incisionless fundoplication (TIF), the endoscopic creation of a gastric fundal
wrap with plication, and magnetic sphincter augmentation (MSA), the laparoscopic
insertion of a flexible ring of interlinked magnetic beads to augment the weak
lower oesophagal sphincter, can be alternatives in patients with troublesome
regurgitation or heartburn who do not wish to undergo fundoplication and who do
not have severe reflux esophagitis or large hiatal hernia.
Reference:
Sasankan P, Thota PN. Evaluation and management of gastroesophageal reflux disease: A brief look at the updated guidelines. Cleve Clin J Med. 2022 Dec 1;89(12):700-703. doi: 10.3949/ccjm.89a.22059. PMID: 36455971.