Issue: January 2022
Disclosures: Katz reports consulting for Phathom Pharma and Medtronic and receiving research support from Diversatek. Please see the study for all other authors’ relevant financial disclosures.
November 22, 2021
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ACG updates guidelines for GERD diagnosis, management

Issue: January 2022
Disclosures: Katz reports consulting for Phathom Pharma and Medtronic and receiving research support from Diversatek. Please see the study for all other authors’ relevant financial disclosures.
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The ACG updated guidelines for GERD to include pharmacologic, lifestyle, surgical and endoscopic management. The changes were published in the American Journal of Gastroenterology.

“The ethos of the new GERD guidelines is to synthesize the highest quality, yet still practical, recommendations for the diagnosis and management of patients with GERD,” Philip O. Katz, MD, MACG, professor of medicine at Weill Cornell Medicine in New York City, told Healio Gastroenterology. “They have been developed for the clinician to enhance their opportunity to provide the best possible evidence-based patient care, using the full menu of diagnostic tests and therapeutic interventions for these often-complex patients. We hope you find them useful in your everyday practice.”

Katz, also of the division of gastroenterology and hepatology and director area of concentration program at Weill Cornell Medicine, used the Grading of Recommendations, Assessment, Development and Evaluation system to assess the evidence and strength of the recommendations.

Among the diagnosis and management recommendations are:

  • An 8-week trial of empiric proton pump inhibitors once daily before a meal is recommended in patients with heartburn and regurgitation who have no alarming symptoms. If patients respond to the 8-week trial, physicians should attempt discontinuing PPIs.
  • After PPIs are stopped for 2 to 4 weeks, diagnostic endoscopy should be performed in patients whose classic GERD symptoms do not respond well enough to the 8-week trial of empiric PPIs.
  • Objective testing for GERD (endoscopy and/or reflux monitoring) is recommended in patients who have chest pain without heartburn and were not assessed for heart disease.
  • The use of a barium swallow alone is not recommended as a diagnostic test for GERD.
  • Endoscopy is recommended as the first test to assess patients who present with dysphagia or other alarming symptoms and also for patients with risk factors for Barrett’s esophagus.
  • Reflux monitoring should be performed as off therapy for a diagnosis in patients for whom GERD is suspected but endoscopy did not show evidence of GERD. However, reflux monitoring off therapy should not be performed alone as a diagnostic test for GERD in those with endoscopic evidence of Los Angeles (LA) grade C or D reflux esophagitis or in patients with long-segment Barrett’s esophagus.
  • To improve GERD symptoms, weight loss is recommended in patients with overweight or obesity.
  • Eating meals within 2 to 3 hours of bedtime should be avoided.
  • Tobacco products and smoking should be avoided.
  • “Trigger foods” for GERD symptoms should be avoided.
  • Patients should elevate the head of their bed to alleviate nighttime GERD symptoms.
  • PPIs should be used as treatment rather than histamine-2-receptor antagonists for healing EE. Patients should attempt to discontinue PPIs or switch to on-demand therapy and take PPIs only when symptoms occur in those with GERD but not EE or Barrett’s esophagus.
  • PPIs should be administered 30 to 60 minutes before a meal vs. bedtime for GERD symptoms.
  • Routine addition of medical therapies in PPI nonresponders is recommended.
  • Maintenance PPI therapy is recommended indefinitely as well as anti-reflux surgery in patients with LA grade C or D esophagitis.
  • Baclofen is not recommended without evidence of GERD. A prokinetic agent should not be used without evidence of gastroparesis. Sucralfate for GERD is not recommended during pregnancy.