Table 1.
Summary and strength of recommendations
| GRADE quality of evidence |
GRADE strength of recommendation |
|
|---|---|---|
| Diagnosis of GERD | ||
| For patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms, we recommend an 8-wk trial of empiric PPIs once daily before a meal. | Moderate | Strong |
| We recommend attempting to discontinue the PPIs in patients whose classic GERD symptoms respond to an 8-wk empiric trial of PPIs. | Low | Conditional |
| In patients with chest pain who have had adequate evaluation to exclude heart disease, objective testing for GERD (endoscopy and/or reflux monitoring) is recommended. | Low | Conditional |
| We do not recommend the use of a barium swallow solely as a diagnostic test for GERD. | Low | Conditional |
| We recommend endoscopy as the first test for evaluation of patients presenting with dysphagia or other alarm symptoms (weight loss and GI bleeding) and for patients with multiple risk factors for Barrett’s esophagus. | Low | Strong |
| In patients for whom the diagnosis of GERD is suspected but not clear, and endoscopy shows no objective evidence of GERD, we recommend reflux monitoring be performed off therapy to establish the diagnosis. | Low | Strong |
| We suggest against performing reflux monitoring off therapy solely as a diagnostic test for GERD in patients known to have endoscopic evidence of LA grade C or D reflux esophagitis or in patients known to have long-segment Barrett’s esophagus. | Low | Strong |
| GERD management | ||
| We recommend weight loss in overweight and obese patients for improvement of GERD symptoms. | Moderate | Strong |
| We suggest avoiding meals within 2–3 hr of bedtime. | Low | Conditional |
| We suggest avoidance of tobacco products/smoking in patients with GERD symptoms. | Low | Conditional |
| We suggest avoidance of “trigger foods” for GERD symptom control. | Low | Conditional |
| We suggest elevating head of bed for nighttime GERD symptoms. | Low | Conditional |
| We recommend treatment with PPIs over treatment with H2RA for healing EE. | High | Strong |
| We recommend treatment with PPIs over H2RA for maintenance of healing for EE. | Moderate | Strong |
| We recommend PPI administration 30–60 min before a meal rather than at bedtime for GERD symptom control. | Moderate | Strong |
| For patients with GERD who do not have EE or Barrett’s esophagus, and whose symptoms have resolved with PPI therapy, an attempt should be made to discontinue PPIs | Low | Conditional |
| For patients with GERD who require maintenance therapy with PPIs, the PPIs should be administered in the lowest dose that effectively controls GERD symptoms and maintains healing of reflux esophagitis. | Low | Conditional |
| We recommend against routine addition of medical therapies in PPI nonresponders. | Moderate | Conditional |
| We recommend maintenance PPI therapy indefinitely or antireflux surgery for patients with LA grade C or D esophagitis. | Moderate | Strong |
| We do not recommend baclofen in the absence of objective evidence of GERD. | Moderate | Strong |
| We recommend against treatment with a prokinetic agent of any kind for GERD therapy unless there is objective evidence of gastroparesis. | Low | Strong |
| We do not recommend sucralfate for GERD therapy except during pregnancy. | Low | Strong |
| We suggest on-demand/or intermittent PPI therapy for heartburn symptom control in patients with NERD. | Low | Conditional |
| Extraesophageal GERD symptoms | ||
| We recommend evaluation for non-GERD causes in patients with possible extraesophageal manifestations before ascribing symptoms to GERD. | Moderate | Strong |
| We recommend that patients who have extraesophageal manifestations of GERD without typical GERD symptoms (e.g., heartburn and regurgitation) undergo reflux testing for evaluation before PPI therapy. | Moderate | Strong |
| For patients who have both extraesophageal and typical GERD symptoms, we suggest considering a trial of twice-daily PPI therapy for 8–12 wk before additional testing. | Low | Conditional |
| We suggest that upper endoscopy should not be used as the method to establish a diagnosis of GERD-related asthma, chronic cough, or LPR. | Low | Conditional |
| We suggest against a diagnosis of LPR based on laryngoscopy findings alone and recommend additional testing should be considered. | Low | Conditional |
| In patients treated for extraesophageal reflux disease, surgical or endoscopic antireflux procedures are only recommended in patients with objective evidence of reflux. | Low | Conditional |
| Refractory GERD | ||
| We recommend optimization of PPI therapy as the first step in management of refractory GERD. | Moderate | Strong |
| We recommend esophageal pH monitoring (Bravo, catheter-based, or combined impedance-pH monitoring) performed OFF PPIs if the diagnosis of GERD has not been established by a previous pH monitoring study or an endoscopy showing long-segment Barrett’s esophagus or severe reflux esophagitis (LA grade C or D). | Low | Conditional |
| We recommend esophageal impedance-pH monitoring performed ON PPIs for patients with an established diagnosis of GERD whose symptoms have not responded adequately to twice-daily PPI therapy. | Low | Conditional |
| For patients who have regurgitation as their primary PPI-refractory symptom and who have had abnormal gastroesophageal reflux documented by objective testing, we recommend consideration of antireflux surgery or TIF. | Low | Conditional |
| Surgical and endoscopic options for GERD | ||
| We recommend antireflux surgery performed by an experienced surgeon as an option for long-term treatment of patients with objective evidence of GERD. Those who have severe reflux esophagitis (LA grade C or D), large hiatal hernias, and/or persistent, troublesome GERD symptoms who are likely to benefit most from surgery. | Moderate | Strong |
| We recommend consideration of MSA as an alternative to laparoscopic fundoplication for patients with regurgitation who fail medical management. | Moderate | Strong |
| We recommend consideration of RYGB as an option to treat GERD in obese patients who are candidates for this procedure and who are willing to accept its risks and requirements for lifestyle alterations. | Low | Conditional |
| Because data on the efficacy of radiofrequency energy (Stretta) as an antireflux procedure is inconsistent and highly variable, we cannot recommend its use as an alternative to medical or surgical antireflux therapies. | Low | Conditional |
| We suggest consideration of TIF for patients with troublesome regurgitation or heartburn who do not wish to undergo antireflux surgery and who do not have severe reflux esophagitis (LA grade C or D) or hiatal hernias >2 cm. | Low | Conditional |
EE, erosive esophagitis; GERD, gastroesophageal reflux disease; GI, gastrointestinal; GRADE, Grading of Recommendations, Assessment, Development, and Evaluation; H2RA, histamine-2-receptor antagonists; LA, Los Angeles; LPR, laryngopharyngeal reflux; MSA, magnetic sphincter augmentation; NERD, nonerosive reflux disease; PPI, proton pump inhibitor; TIF, transoral incisionless fundoplication; RYGB, Roux-en-Y gastric bypass.