In this post, I link to and excerpt from ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease [PubMed Abstract] [Full-Text HTML] [Download Full-Text PDF]. Am J Gastroenterol. 2022 Jan 1;117(1):27-56.
All that follows is from the above resource.
Abstract
Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.
INTRODUCTION
A lot has changed, much remains the same. Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Since publication of the last American College of Gastroenterology guideline on reflux management (1), clinically important advances in surgical and endoscopic therapy of GERD have emerged. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The management of functional heartburn and other functional upper gastrointestinal (GI) symptoms is beyond the scope of this guideline. Additional detail regarding esophageal physiologic testing is covered in other guidelines.
Summary and strength of the recommendations can be found in Table 1 with key concepts summarized in Table 2.
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SUMMARY
We have made every effort to review and grade all available evidence to develop this guideline. Much is new and different compared with the 2013 guideline, particularly because it relates to approaching extraesophageal symptoms, refractory GERD, and surgical and endoscopic therapies. Each section provides a separate review of the evidence supporting our recommendations; therefore, some repetition was necessary to do this effectively. Our algorithms offer an overall approach to diagnosis and management of the major presentations of the disease and reflect our discussion in the body of the article. We have attempted to address all the key issues in PPI management and adverse events, so clinicians will have a comprehensive, go-to source in the guideline. We have performed our best to present a thorough review of the evidence for our recommendations and key concepts and to provide an evidence-based approach to GERD that can be used effectively in everyday practice.
We expect that new diagnostic tools and treatments will be developed and those that we have will be further refined. Mucosal integrity testing, e.g., is available commercially but is not developed sufficiently to warrant discussion in this guideline. Esophageal function testing is addressed in detail in another guideline, whereas other extensive reviews focus on valuable additions to our clinical armamentarium such as MSA and TIF. Potassium-competitive acid blockers are exciting potential new agents for pharmacologic treatment of GERD. One, currently available in Japan, presently is undergoing phase 3 trials in the United States as we complete this document and may well be approved for clinical use soon after this review is published. Future research with advanced endoscopic techniques, data on long-term efficacy of surgical intervention, and advances in artificial intelligence and basic science will almost certainly change the way we manage GERD going forward.
