Diagnosis and Management of Gastroesophageal Reflux Disease
Diagnosis of GERD
Extraesophageal GERD Symptoms
Surgical and Endoscopic Options for GERD
Recommendations based on results of a review of studies involving lifestyle modifications
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
- We do not recommend HRM solely as a diagnostic test for GERD.
- 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.
- 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.
- 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.
Diagnosis and Management of Gastroesophageal Reflux Disease
November 22, 2021
External Publication Status
Country of Publication
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
Male, Female, Adolescent, Adult, Older adult
Health Care Settings
Assessment and screening, Treatment, Management
D005764 - Gastroesophageal Reflux, D054328 - Proton Pump Inhibitors
gastroesophageal reflux disease (GERD), proton pump inhibitor, gastroesophogeal reflux, PPI
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.