Last updated March 15, 2022

Diagnosis and Management of Celiac Disease

Recommendations

ESTABLISHING THE DIAGNOSIS OF GERD

A presumptive diagnosis of GERD can be established in the setting of typical symptoms of heartburn and regurgitation. Empiric medical therapy with a PPI is recommended in this setting. (Strong  “We recommend”, Moderate)
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Patients with non-cardiac chest pain suspected due to GERD should have diagnostic evaluation before institution of therapy. (Conditional (weak)  “We suggest”, Moderate)
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A cardiac cause should be excluded in patients with chest pain efore the commencement of a gastrointestinal evaluation. (Strong  “We recommend”, Low)
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Barium radiographs should not be performed to diagnose GERD. (Strong  “We recommend”, High)
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Upper endoscopy is not required in the presence of typical GERD symptoms. Endoscopy is recommended in the presence of alarm symptoms and for screening of patients at high risk for complications. Repeat endoscopy is not indicated in patients without Barrett’s esophagus in the absence of new symptoms. (Strong  “We recommend”, Moderate)
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Routine biopsies from the distal esophagus are not recommended specifically to diagnose GERD. (Strong  “We recommend”, Moderate)
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Esophageal manometry is recommended for preoperative evaluation, but has no role in the diagnosis of GERD. (Strong  “We recommend”, Low)
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Ambulatory esophageal reflux monitoring is indicated before consideration of endoscopic or surgical therapy in patients with NERD, as part of the evaluation of patients refractory to PPI therapy, and in situations when the diagnosis of GERD is in question. (Strong  “We recommend”, Low)
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Ambulatory reflux monitoring is the only test that can assess reflux symptom association. (Strong  “We recommend”, Low)
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Ambulatory reflux monitoring is not required in the presence of short or long-segment Barrett’s esophagus to establish a diagnosis of GERD. (Strong  “We recommend”, Moderate)
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Screening for Helicobacter pylori infection is not recommended in GERD. Eradication of H. pylori infection is not routinely required as part of antireflux therapy. (Strong  “We recommend”, Low)
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MANAGEMENT OF GERD

Weight loss is recommended for GERD patients who are overweight or have had recent weight gain. (Conditional (weak)  “We suggest”, Moderate)
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Head of bed elevation and avoidance of meals 2–3 h before bedtime should be recommended for patients with nocturnal GERD. (Conditional (weak)  “We suggest”, Low)
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Routine global elimination of food that can trigger reflux (including chocolate, caffeine, alcohol, acidic and/or spicy foods) is not recommended in the treatment of GERD. (Conditional (weak)  “We suggest”, Low)
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An 8-week course of PPIs is the therapy of choice for symptom relief and healing of erosive esophagitis. There are no major diff erences in efficacy between the different PPIs. (Strong  “We recommend”, High)
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Traditional delayed release PPIs should be administered 30–60 min before meal for maximal pH control. (Strong  “We recommend”, Moderate)
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Newer PPIs may offer dosing flexibility relative to meal timing. (Conditional (weak)  “We suggest”, Moderate)
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PPI therapy should be initiated at once a day dosing, before the first meal of the day. (Strong  “We recommend”, Moderate)
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For patients with partial response to once daily thera y, tailored therapy with adjustment of dose timing and/or twice daily dosing should be considered in patients with night-time symptoms, variable schedules, and/or sleep disturbance.

(Strong  “We recommend”, Low)
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Non-responders to PPI should be referred for evaluation. (Conditional (weak)  “We suggest”, Low)

(See refractory GERD section)

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In patients with partial response to PPI therapy, increasing the dose to twice daily therapy or switching to a different PPI may provide additional symptom relief. (Conditional (weak)  “We suggest”, Low)
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Maintenance PPI therapy should be administered for GERD patients who continue to have symptoms after PPI is discontinued and in patients with complications including erosive esophagitis and Barrett’s esophagus. (Strong  “We recommend”, Moderate)
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For patients who require long-term PPI therapy, it should be administered in the lowest effective dose, including on demand or intermittent therapy. (Conditional (weak)  “We suggest”, Low)
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H2-receptor antagonist therapy can be used as a maintenance option in patients without erosive disease if patients experience heartburn relief. (Conditional (weak)  “We suggest”, Moderate)
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Bedtime H2RA therapy can be added to daytime PPI therapy in selected patients with objective evidence of night-time reflux if needed but may be associated with the development of tachyphlaxis after several weeks of usage. (Conditional (weak)  “We suggest”, Low)
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Therapy for GERD other than acid suppression, including prokinetic therapy and/or baclofen, should not be used in GERD patients without diagnostic evaluation. (Conditional (weak)  “We suggest”, Moderate)
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There is no role for sucralfate in the non-pregnant GERD patient. (Conditional (weak)  “We suggest”, Moderate)
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PPIs are safe in pregnant patients if clinically indicated. (Conditional (weak)  “We suggest”, Moderate)
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SURGICAL OPTIONS FOR GERD

Surgical therapy is a treatment option for long-term therapy in GERD patients. (Strong  “We recommend”, High)
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Surgical therapy is generally not recommended in patients who do not respond to PPI therapy. (Strong  “We recommend”, High)
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Preoperative ambulatory pH monitoring is mandatory in patients without evidence of erosive esophagitis. All patients should undergo preoperative manometry to rule out achalasia or scleroderma-like esophagus. (Strong  “We recommend”, Moderate)
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Surgical therapy is as effective as medical therapy for carefully selected patients with chronic GERD when performed by an experienced surgeon. (Strong  “We recommend”, High)
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Obese patients contemplating surgical therapy for GERD should be considered for bariatric surgery. Gastric bypass would be the preferred operation in these patients. (Conditional (weak)  “We suggest”, Moderate)
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The usage of current endoscopic therapy or transoral incisionless fundoplication cannot be recommended as an alternative to medical or traditional surgical therapy. (Conditional (weak)  “We suggest”, Moderate)
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POTENTIAL RISKS ASSOCIATED WITH PPIs

Switching PPIs can be considered in the setting of side effects.

(Conditional (weak)  “We suggest”, Low)
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Patients with known osteoporosis can remain on PPI therapy. Concern for hip fractures and osteoporosis should not affect the decision to use PPI long-term except in patients with other risk factors for hip fracture. (Strong  “We recommend”, Moderate)
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PPI therapy can be a risk factor for Clostridium difficile infection and should be used with care in patients at risk. (Strong  “We recommend”, Moderate)
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Short-term PPI usage may increase the risk of community-acquired pneumonia. The risk does not appear elevated in long-term users. (Conditional (weak)  “We suggest”, Moderate)
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PPI therapy does not need to be altered in concomitant clopidogrel users as clinical data does not support an increased risk for adverse cardiovascular events. (Strong  “We recommend”, High)
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EXTRAESOPHAGEAL PRESENTATIONS OF GERD: ASTHMA, CHRONIC COUGH, AND LARYNGITIS

GERD can be considered as a potential co-factor in patients with asthma, chronic cough, or laryngitis. Careful evaluation for non-GERD causes should be undertaken in all of these patients. (Strong  “We recommend”, Moderate)
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A diagnosis of reflux laryngitis should not be made based solely upon laryngoscopy findings. (Strong  “We recommend”, Moderate)
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A PPI trial is recommended to treat extraesophageal symptoms in patients who also have typical symptoms of GERD. (Strong  “We recommend”, Low)
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Upper endoscopy is not recommended as a means to establish a diagnosis of GERD-related asthma, chronic cough, or laryngitis. (Strong  “We recommend”, Low)
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Reflux monitoring should be considered before a PPI trial in patients with extraesophageal symptoms who do not have typical symptoms of GERD. (Conditional (weak)  “We suggest”, Low)
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Non-responders to a PPI trial should be considered for further diagnostic testing, and are addressed in the refractory GERD section below. (Conditional (weak)  “We suggest”, Low)
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Surgery should generally not be performed to treat extraesophageal symptoms of GERD in patients who do not respond to acid suppression with a PPI. (Strong  “We recommend”, Moderate)
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GERD REFRACTORY TO TREATMENT WITH PPIs

The first step in management of refractory GERD is optimization of PPI therapy. (Strong  “We recommend”, Low)
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Upper endoscopy should be performed in refractory patients with typical or dyspeptic symptoms principally to exclude non-GERD etiologies. (Conditional (weak)  “We suggest”, Low)
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In patients in whom extraesophageal symptoms of GERD persist despite PPI optimization, assessment for other etiologies should be pursued through concomitant evaluation by ENT, pulmonary, and allergy specialists. (Strong  “We recommend”, Low)
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Patients with refractory GERD and negative evaluation by endoscopy (typical symptoms) or evaluation by ENT, pulmonary, and allergy specialists (extraesophageal symptoms), should undergo ambulatory reflux monitoring. (Strong  “We recommend”, Low)
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Reflux monitoring off medication can be performed by any available modality (pH or impedance-pH). (Conditional (weak)  “We suggest”, Moderate)
Testing on medication should be performed with impedance-pH monitoring in order to enable measurement of nonacid reflux.
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Refractory patients with objective evidence of ongoing reflux as the cause of symptoms should be considered for additional antireflux therapies that may include surgery or TLESR inhibitors. (Conditional (weak)  “We suggest”, Low)
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Patients with negative testing are unlikely to have GERD and PPI therapy should be discontinued. (Strong  “We recommend”, Low)
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COMPLICATIONS ASSOCIATED WITH GERD

The Los Angeles (LA) classification system should be used when describing the endoscopic appearance of erosive esophagitis. (Strong  “We recommend”, Moderate)
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Patients with LA Grade A esophagitis should undergo further testing to confirm the presence of GERD. (Conditional (weak)  “We suggest”, Low)
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Repeat endoscopy should be performed in patients with severe ERD after a course of antisecretory therapy to exclude underlying Barrett’s esophagus. (Conditional (weak)  “We suggest”, Low)
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Continuous PPI therapy is recommended following peptic stricture dilation to improve dysphagia and reduce the need for repeated dilations. (Strong  “We recommend”, Moderate)
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Injection of intralesional corticosteroids can be used in refractory, complex strictures due to GERD. (Conditional (weak)  “We suggest”, Low)
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Treatment with a PPI is suggested following dilation in patients with lower esophageal ring (Schatzki) rings. (Conditional (weak)  “We suggest”, Low)
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Screening for Barrett’s esophagus should be considered in patients with GERD who are at high risk based on epidemiologic profile. (Conditional (weak)  “We suggest”, Moderate)
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Symptoms in patients with Barrett’s esophagus can be treated in a similar fash on to patients with GERD who do not have Barrett’s esophagus. (Strong  “We recommend”, Moderate)
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Patients with Barrett’s esophagus found at endoscopy should undergo periodic surveillance according to guidelines. (Strong  “We recommend”, Moderate)
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Recommendation Grading

Overview

Title

Diagnosis and Management of Celiac Disease

Authoring Organization

Publication Month/Year

May 1, 2013

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This guideline presents recommendations for the diagnosis and management of patients with celiac disease. 

Target Patient Population

Patients with celiac disease

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D002446 - Celiac Disease, D055050 - Diet, Gluten-Free, D005983 - Glutens

Keywords

gastrointestinal, celiac disease, gluten

Source Citation

American Journal of Gastroenterology: May 2013 - Volume 108 - Issue 5 - p 656-676
doi: 10.1038/ajg.2013.79