Diagnosis and Management of Gastroesophageal Reflux Disease

Patient Guideline Summary

Publication Date: November 22, 2021
Last Updated: March 3, 2023

Objective

Objective

This patient summary means to summarize key recommendations from the American College of Gastroenterology (ACG) for the diagnosis and management of gastroesophageal reflux. This patient summary is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

Overview

  • We will use the abbreviation (GERD) throughout this summary to refer to gastroesophageal reflux disease.
  • GERD is among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians.
  • GERD is a medical condition where reflux (return) of gastric contents into the esophagus (the swallowing tube) results in symptoms and/or complications.
  • Symptoms include:
    • Heartburn is the most common GERD symptom. It is a burning sensation below the sternum (the bone in the front-middle of your chest) rising from the epigastrium (the upper middle part of the abdomen) up toward the neck.
    • Regurgitation is the effortless return of gastric contents upward toward the mouth. It is often accompanied by acid or bitter taste.
    • Chest pain, which is hard to differentiate from cardiac pain, may present with heartburn and regurgitation or as the only GERD symptom.
    • The symptoms of GERD are nonspecific. Also, they may be confused with those of other disorders related to other diseases of the digestive system or even heart and lung diseases.
    • Other symptoms not related to the digestive system include: hoarseness of voice (when your voice sounds strained or rough), throat clearing, and chronic cough.
  • This patient summary focuses primarily on the evaluation and management of GERD, including the medications, lifestyle, surgical, and endoscopic (procedure when the healthcare provider inserts an instrument with a camera at the end to look inside your body) management.
  • The best care plan will depend on whether Erosive Esophagitis (EE) is present or not.

Diagnosis of GERD

Diagnosis of GERD

  • If you have classic GERD symptoms of heartburn and regurgitation and no alarm symptoms, your doctor will probably
    • recommend an 8-week trial of medications called proton pump inhibitors (PPIs) once per day before a meal. That is because a PPI response establishes the diagnosis of GERD.
    • stop the PPIs after the 8-wk empiric trial of PPIs if your classic GERD symptoms improve.
    • order a diagnostic endoscopy after PPIs are stopped for 2–4 weeks if your classic GERD symptoms do not respond well to the 8-week trial of PPIs or if your symptoms return when PPIs are discontinued.
  • If you have chest pain and you were tested to exclude heart disease, your doctor may order objective testing for GERD (endoscopy and/or reflux monitoring).
  • The ACG does not recommend the use of a barium swallow (X-rays with barium that lights up gut) alone as a diagnostic test for GERD.
  • Your doctor will probably order endoscopy as the first test for evaluation if you have:
    • difficulty in swallowing
    • other alarm symptoms (weight loss or gastrointestinal bleeding)
    • many risk factors for Barrett’s esophagus (a condition in which the lining of the swallowing tube [esophagus] is damaged by acid reflux).
  • If you have a suspected GERD diagnosis, and endoscopy shows no objective evidence (observations made during medical evaluations that are not under the patient's control) of GERD, your doctor will probably order reflux monitoring after stopping your GERD medicines.

Erosive Esophagitis (EE)

Erosive Esophagitis (EE)

  • If, on the other hand, endoscopy reveals erosive esophagitis, your doctor may recommend a modified treatment plan.
  • The LA (Los Anglos) classification of erosive esophagitis is the most widely used scoring system to describe its endoscopic appearance. Erosive esophagitis is severe reflux esophagitis characterized by mucosal breaks, as erosions or ulcers on endoscopy. LA classification includes grades A, B, C, and D.
    • LA grade A is not enough for a definitive diagnosis of GERD because it is not different from normal.
    • LA grade B can be diagnostic of GERD in the presence of classic GERD symptoms and PPI response.
    • LA grade C is virtually always diagnostic of GERD.
    • In outpatients, LA grade D is a manifestation of severe GERD, but LA grade D might not be a reliable index of GERD severity in hospitalized patients.
    • ACG does not suggest performing reflux monitoring off therapy solely as a diagnostic test for GERD if you have endoscopic evidence of LA grade C or D reflux esophagitis or in patients known to have long-segment Barrett’s esophagus.

Management

Management

Medical management of GERD includes lifestyle modifications, pharmacologic therapy, surgical and endoscopic options.

Diet and lifestyle changes:
  • If you are an overweight patient, weight loss can help for the improvement of GERD symptoms.
  • Elevate the head of the bed to alleviate nighttime GERD symptoms.
  • Other things you should avoid doing to help reduce GERD symptoms:
    • meals within 2–3 hours before bedtime
    • tobacco products/smoking
    • foods that worsen reflux symptoms such as coffee, chocolate, carbonated beverages, spicy foods, acidic foods, and foods with high-fat content
Medications:
  • ACG recommends PPIs over treatment with histamine-2-receptor antagonists (H2RA) for:
    • healing EE
    • maintenance of healing from EE
  • ACG recommends PPI administration 30–60 minutes before a meal rather than at bedtime for GERD symptom control.
  • If you have GERD and don’t have EE or Barrett’s esophagus, and your symptoms have resolved with PPI, your doctor may stop PPIs or tell you to take PPIs only when symptoms occur.
  • If you need maintenance therapy with PPIs, your doctor may prescribe PPIs in the lowest dose that controls GERD symptoms and maintains the healing of reflux esophagitis.
  • If you are LA grade C or D esophagitis, your doctor will probably prescribe continuing the PPI therapy antireflux surgery.
  • If you have non-erosive reflux disease (NERD), your doctor may prescribe as-needed or intermittent PPI therapy for heartburn symptom control.

Treatment of GERD during pregnancy:
  • About 2/3 of pregnant women get heartburn.
  • Treatment of GERD during pregnancy should start with lifestyle. When lifestyle modifications fail, some antacids, alginates, and sucralfate are the first-line drug agents.
  • If you are pregnant, consult with your doctor about the safety of the drugs used during pregnancy.

For symptoms not related to the esophagus (extra-esophageal)

For symptoms not related to the esophagus (extra-esophageal)

Diagnosis:
  • Your doctor will probably want to look for other causes of your symptoms.
  • If you have extra-esophageal manifestations of GERD without typical GERD symptoms (e.g., heartburn and regurgitation), your doctor will likely order reflux testing for evaluation before PPI therapy.
  • If you have both extra-esophageal and typical GERD symptoms, the ACG suggests a trial of twice-daily PPI therapy for 8–12 weeks before more testing.
  • ACG suggests that upper endoscopy should not be used as the method to establish a diagnosis of GERD-related asthma, chronic cough, or laryngopharyngeal reflux (LPR).
  • ACG does not suggest a diagnosis of LPR based on laryngoscopy findings alone. It recommends more testing.
  • If you are a patient treated for extra-esophageal reflux disease, surgical or endoscopic antireflux procedures are recommended only if you have objective evidence of reflux.

Refractory GERD (stubborn or persistent)

Refractory GERD (stubborn or persistent)

Management of refractory GERD
  • ACG recommends optimization of PPI as the first step in the management of refractory GERD.
    • “Optimization” of PPI therapy means verifying compliance, confirming that you take PPI 30–60 minutes before your first meal of the day for the daily dose and before the first and dinner meal for the twice-daily dose.
  • ACG suggests esophageal pH (a measure of acidity) monitoring off PPIs if:
    • the diagnosis of GERD has not been confirmed by a previous pH monitoring study or
    • an endoscopy showing long-segment Barrett’s esophagus or severe reflux esophagitis (LA grade C or D).
  • ACG suggests esophageal impedance-pH monitoring performed on PPIs for patients with a confirmed diagnosis of GERD when symptoms have not responded well to twice-daily PPI therapy.
  • ACG suggests consideration of antireflux surgery or transoral incisionless fundoplication (TIF) (an advanced endoscopic procedure) if you have regurgitation as a primary PPI-refractory symptom and who have had abnormal gastroesophageal reflux documented by objective testing.

Surgical and endoscopic options for GERD

Surgical and endoscopic options for GERD

  • ACG recommends antireflux surgery by an experienced surgeon for long-term treatment if you have objective evidence of GERD, especially if you have:
    • severe reflux esophagitis (LA grade C or D)
    • large hiatal hernias (hernia is when your stomach bulges up into your chest through an enlarged opening [hiatus] in your diaphragm). Diaphragm is the muscle which separates the two areas.
    • and/or persistent, troublesome GERD symptoms
  • ACG recommends consideration of magnetic sphincter augmentation (MSA) (an operation done through a laparoscope [a thin telescope inserted into the abdomen]) as an alternative to laparoscopic fundoplication if you have regurgitation and fail medical management.
  • MSA uses magnetic titanium beads around the esophagus to create pressure on the esophagus, helping keep it closed.
  • ACG suggests Roux-en-Y gastric bypass (RYGB) (a type of weight-loss surgery) as an option to treat GERD if you are obese and are a candidate for this procedure. You need first to accept the procedure as it has risks and requirements for a lifestyle change.
  • ACG suggests consideration of TIF if you have troublesome regurgitation or heartburn, do not want antireflux surgery, and do not have severe reflux esophagitis (LA grade C or D) or a hiatal hernia >2 cm.

Abbreviations

  • ACG: American College Of Gastroenterology 
  • EE: Erosive Esophagitis
  • GERD: Gastro-esophageal Reflux Disease
  • HRM: High-resolution Manometry 
  • LPR: Laryngopharyngeal Reflux
  • MSA: Magnetic Sphincter Augmentation 
  • NERD: Nonerosive Reflux Disease
  • PPI: Proton Pump Inhibitor
  • TIF: Transoral Incisionless Fundoplication 

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.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.