Last updated March 14, 2022

Diagnosis and Management of Gastroesophageal Reflux Disease

Diagnosis of GERD

Recommendation
GRADE Quality of Evidence GRADE Strength of Recommendation
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

Recommendation
GRADE Quality of Evidence GRADE Strength of Recommendation
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

Recommendation
GRADE Quality of Evidence GRADE Strength of Recommendation
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

Recommendation
GRADE Quality of Evidence GRADE Strength of Recommendation
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

Recommendation
GRADE Quality of Evidence GRADE Strength of Recommendation
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

Recommendations based on results of a review of studies involving lifestyle modifications

Lifestyle modification Strength of scientific evidence Pathophysiologically conclusive? Recommendable?
Avoid fatty meals Equivocal Equivocal Yes
Avoid carbonated beverages Moderate Yes Yes
Select decaffeinated beverages Equivocal Equivocal Not generally
Avoid citrus Weak Yes Yes, if citrus triggers symptoms
Eat smaller meals Weak Yes Yes
Lose weight Equivocal Equivocal Yesa
Avoid alcoholic beverages Weak Mechanisms not understood; different alcoholic beverages have different effects Not generally
Stop smoking Weak Yes Yesa
Avoid excessive exercise Weak Yes Yes
Sleep with head elevated Equivocal Equivocal Yes
Sleep on the left side Unequivocal Yes Yes

Potential mechanisms underlying symptoms suspected due to GERD but refractory to PPI therapy

  • Despite PPI therapy, abnormal acid reflux persists and is causing symptoms
  • There is reflux hypersensitivity, a condition in which PPIs have normalized esophageal acid exposure, but “physiologic” reflux episodes (acidic or nonacidic) nevertheless are strongly associated with and evoke symptoms
  • The symptoms are not due to GERD, but are caused by esophageal disorders other than GERD (e.g., EoE and achalasia)
  • The symptoms are not due to GERD, but are caused by nonesophageal disorders (e.g., gastroparesis, rumination, and heart disease)
  • The symptoms are functional (i.e., not because of GERD or any other identifiable histopathologic, motility, or structural abnormality).

Key Concept Statements

Diagnosis of GERD
  • We do not recommend HRM solely as a diagnostic test for GERD.


GERD management
  • There is conceptual rationale for a trial of switching PPIs for patients who have not responded to one PPI. For patients who have not responded to one PPI, more than one switch to another PPI cannot be supported.
  • Use of the lowest effective dose is recommended and logical but must be individualized. One area of controversy relates to abrupt PPI discontinuation and potential rebound acid hypersecretion, resulting in increased reflux symptoms. Although this has been demonstrated to occur in healthy controls, strong evidence for an increase in symptoms after abrupt PPI withdrawal is lacking.


Extraesophageal GERD
  • Although GERD may be a contributor to extraesophageal symptoms in some patients, careful evaluation for other causes should be considered for patients with laryngeal symptoms, chronic cough, and asthma.
  • Diagnosis, evaluation, and management of potential extraesophageal symptoms of GERD is limited by lack of a gold-standard test, variable symptoms, and other disorders which may cause similar symptoms
  • Endoscopy is not sufficient to confirm or refute the presence of extraesophageal GERD.
  • Because of difficulty in distinguishing between patient with laryngeal symptoms and normal controls, salivary pepsin testing is not recommended for evaluation of patients with extraesophageal reflux symptoms
  • For patients whose extraesophageal symptoms have not responded to a trial of twice-daily PPIs, we recommend upper endoscopy, ideally off PPIs for 2–4 wk. If endoscopy is normal, consider reflux monitoring. If EGD shows EE, that does not confirm that the extraesophageal symptoms are from GERD. Patients still may need pH-impedance testing
  • For patients with extraesophageal symptoms, we do not routinely recommend oropharyngeal or pharyngeal pH monitoring.


Refractory GERD
  • It is important to stop PPI therapy in patients whose off-therapy reflux testing is negative, unless another indication for continuing PPIs is present. In 1 study, 42% of patients reported continuing PPI treatment after a negative evaluation for refractory GERD, which included negative endoscopy and pH-impedance monitoring.
  • Esophageal manometry should be considered as part of the evaluation for patients with refractory GERD in patients with a normal endoscopy and pH monitoring study and for patients being considered for surgical or endoscopic treatment.
  • If not already performed off PPIs, we recommend diagnostic upper endoscopy with esophageal biopsies after discontinuing PPI therapy, ideally for 2 to 4 wk
  • For patients with PPI-refractory symptoms who have a normal pH monitoring test OFF PPIs or a normal impedance-pH monitoring test ON PPIs (including a negative SI and SAP), we recommend discontinuation of PPIs unless there is an indication for PPI therapy other than the refractory symptoms.


Surgical and endoscopic therapy
  • We recommend HRM before antireflux surgery or endoscopic therapy to rule out achalasia and absent contractility. For patients with ineffective esophageal motility, HRM should include provocative testing to identify contractile reserve (e.g., multiple rapid swallows).
  • We recommend a careful evaluation and caution before proceeding with invasive therapy for patients with PPI-refractory GERD symptoms other than regurgitation.
  • Before performing invasive therapy for GERD, a careful evaluation is required to ensure that GERD is present and as best as possible determine is the cause of the symptoms to be addressed by the therapy, to exclude achalasia (which can be associated with symptoms such as heartburn and regurgitation that can be confused with GERD), and to exclude conditions that might be contraindications to invasive treatment such as absent contractility.


Long-term PPI issues
  • Regarding the safety of long-term PPI usage for GERD, we suggest that patients should be advised as follows: “PPIs are the most effective medical treatment for GERD. Some medical studies have identified an association between the long-term use of PPIs and the development of numerous adverse conditions including intestinal infections, pneumonia, stomach cancer, osteoporosis-related bone fractures, chronic kidney disease, deficiencies of certain vitamins and minerals, heart attacks, strokes, dementia, and early death. Those studies have flaws, are not considered definitive, and do not establish a cause-and-effect relationship between PPIs and the adverse conditions. High-quality studies have found that PPIs do not significantly increase the risk of any of these conditions except intestinal infections. Nevertheless, we cannot exclude the possibility that PPIs might confer a small increase in the risk of developing these adverse conditions. For the treatment of GERD, gastroenterologists generally agree that the well-established benefits of PPIs far outweigh their theoretical risks.”
  • Switching PPIs can be considered for patients who experience minor PPI side effects including headache, abdominal pain, nausea, vomiting, diarrhea, constipation, and flatulence.
  • For patients with GERD on PPIs who have no other risk factors for bone disease, we do not recommend that they raise their intake of calcium or vitamin D or that they have routine monitoring of bone mineral density.
  • For patients with GERD on PPIs who have no other risk factors for vitamin B12 deficiency, we do not recommend that they raise their intake of vitamin B12 or that they have routine monitoring of serum B12 levels.
  • For patients with GERD on PPIs who have no other risk factors for kidney disease, we do not recommend that they have routine monitoring of serum creatinine levels.
  • For patients with GERD on clopidogrel who have LA grade C or D esophagitis or whose GERD symptoms are not adequately controlled with alternative medical therapies, the highest quality data available suggest that the established benefits of PPI treatment outweigh their proposed but highly questionable cardiovascular risks.
  • PPIs can be used to treat GERD in patients with renal insufficiency with close monitoring of renal function or consultation with a nephrologist.

Recommendation Grading

Overview

Title

Diagnosis and Management of Gastroesophageal Reflux Disease

Authoring Organization

Publication Month/Year

November 22, 2021

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The document will review the presentations of any risk factors for GERD, the diagnostic modalities and their recommendation for use and recommendations for medical, surgical and endoscopic management including comparative effectiveness of different treatments.

Target Patient Population

Patients with GERD

Inclusion Criteria

Male, Female, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Scope

Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D005764 - Gastroesophageal Reflux, D054328 - Proton Pump Inhibitors

Keywords

gastroesophageal reflux disease (GERD), proton pump inhibitor, gastroesophogeal reflux, PPI

Source Citation

Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2021 Nov 22. doi: 10.14309/ajg.0000000000001538. Epub ahead of print. PMID: 34807007.