From the AGA Journals

AGA Clinical Practice Update: Expert review on personalizing GERD management



In the section on personalization of disease management, the authors note that ambulatory reflux monitoring and upper gastrointestinal endoscopy can be used to guide management of GERD. When upper GI endoscopy reveals no erosive findings and esophageal acid exposure time (AET) is less than 4% throughout all days of prolonged wireless pH monitoring, the physician can conclude that the patient has no pathologic gastroesophageal reflux and is likely to have a functional esophageal disorder. In contrast, erosive findings during upper GI endoscopy and/or AET more than 4% across at least 1 day of wireless pH monitoring suggests a GERD diagnosis.

Optimization of PPI is important among patients with GERD, and the authors stress that patients should be educated about the safety of PPI use.

Adjunctive pharmacotherapy is useful and can include alginate antacids for breakthrough symptoms, H2RAs for nocturnal symptoms, baclofen to counter regurgitation or belching, and prokinetics for accompanying gastroparesis. The choice of medications depends on the phenotype, and they should not be used empirically.

For patients with functional heartburn or reflux disease linked to esophageal hypervigilance, reflux sensitivity, or behavioral disorders, options include pharmacologic neuromodulation, hypnotherapy provided by a behavioral therapist, cognitive behavioral therapy, and diaphragmatic breathing and relaxation.

If symptoms persist despite efforts at optimization of treatments and lifestyle factors, ambulatory 24-hour pH-impedance monitoring on PPI can be used to investigate mechanistic causes, especially when there is no known antireflux barrier abnormality, but the technique requires expertise to correctly interpret. This can ensure that the symptoms are not due to reflux hypersensitivity, rumination syndrome, or a belching disorder. When symptoms are confirmed to be treatment resistant, therapy should be escalated, using a strategy that incorporates a pattern of reflux, integrity of the antireflux barrier, obesity if present, and psychological factors.

Surgical options for confirmed GERD include laparoscopic fundoplication and magnetic sphincter augmentation. Transoral incisionless fundoplication can be performed endoscopically in selected patients. For obese patients with confirmed GERD, Roux-en-Y gastric bypass is effective at reducing reflux and can be used as a salvage treatment for nonobese patients. Sleeve gastrectomy may exacerbate GERD.

The authors reported relationships with Medtronic, Diversatek, Ironwood, and Takeda. The authors also reported funding from National Institutes of Health grants.


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