- Weight loss should be advised for overweight and obese patients with GERD symptoms. (II)
- The only other lifestyle modification that has sufficient evidence to support its efficacy is elevating the head of the bed.
- Antisecretory drugs recommended for patients with esophageal symptoms. (I)
- Proton pump inhibitors (PPIs*) are more effective than histamine2-receptor antagonists (H2RAs) for both symptoms and esophageal mucosal injury. (II)
- In case of chest pain, a cardiac cause must first be ruled out.
- Chronic cough, laryngitis, and asthma due to GERD may present atypically without accompanying esophageal symptoms.
- Long-term treatment of esophageal symptoms, but not extra-esophageal symptoms, with lowest effective dose PPI* is recommended.
- Antireflux surgery is successful when patients demonstrate good PPI* response.
- Progression from nonerosive disease to erosive esophagitis to Barrett’s esophagus is distinctly unusual. Endoscopic monitoring of patients with chronic GERD is limited to excluding Barrett’s esophagus once in a lifetime.
- No direct evidence supports routine biopsy (when a suspicious lesion is absent).
- The use of endoscopy as a screening test for Barrett’s esophagus or esophageal adenocarcinoma in the setting of chronic GERD remains an area of intense controversy, but one endoscopy during a patient’s lifetime to rule-out Barrett’s esophagus is recommended.
*Proton pump inhibitors may increase the risk of fractures of the hip, wrist, and spine with high-dose or chronic use.
- Endoscopy with biopsy is recommended in patients with GERD symptoms and troublesome dysphagia who have not responded to an empirical trial of twice-daily PPI* therapy (at least 5 samples to evaluate for eosinophilic esophagitis) and have either a normal endoscopy or multiple esophageal rings, furrows or narrow esophagus on endoscopy. (II)
- Routine endoscopy in subjects with erosive or nonerosive reflux disease to assess for disease progression is NOT recommended. (IV)
- Manometry is recommended to evaluate GERD patients who are candidates for anti-reflux surgery. (II)
- Ambulatory impedance-pH, catheter pH, or wireless pH monitoring is recommended to evaluate patients with a suspected esophageal GERD syndrome who have not responded to an empirical trial of PPI* therapy, have normal findings on endoscopy, and have no major abnormality on manometry.
- Wireless capsule pH monitoring for refractory GERD is suggested for 4 days (first day off treatment and the other 3 days on treatment). (II)