【medical-news】AJG：胃食管反流疾病的诊治指南

AJG: Guidelines for the Diagnosis and Management of Gastroesophageal RefluxDiseaseSummary andstrength of recommendations

Establishingthe diagnosis of Gastroesophageal Reflux Disease (GERD)

1. Apresumptive diagnosis of GERD can be established in the setting of typicalsymptoms of heartburn and regurgitation. Empiric medical therapy with a protonpump inhibitor (PPI) is recommended in this setting. (Strong recommendation,moderate level of evidence)

2. Patientswith non-cardiac chest pain suspected due to GERD should have diagnosticevaluation before institution of therapy. (Conditional recommendation, moderatelevel of evidence). A cardiac cause should be excluded in patients with chestpain before the commencement of a gastrointestinal evaluation (Strongrecommendation, low level of evidence)

3. Bariumradiographs should not be performed to diagnose GERD (Strong recommendation,high level of evidence)

4. Upper endoscopy is not required in thepresence of typical GERD symptoms. Endoscopy is recommended in the presence ofalarm symptoms and for screening of patients at high risk for complications.Repeat endoscopy is not indicated in patients without Barrett’s esophagus inthe absence of new symptoms. (Strong recommendation, moderate level ofevidence)

5. Routinebiopsies from the distal esophagus are not recommended specifically to diagnoseGERD. (Strong recommendation, moderate level of evidence)

6. Esophagealmanometry is recommended for preoperative evaluation, but has no role in thediagnosis of GERD. (Strong recommendation, low level of evidence)

7. Ambulatory esophageal reflux monitoring isindicated before consideration of endoscopic or surgical therapy in patientswith non-erosive disease, as part of the evaluation of patients refractory toPPI therapy, and in situations when the diagnosis of GERD is in question.(Strong recommendation, low level of evidence). Ambulatory reflux monitoring isthe only test that can assess reflux symptom association (strongrecommendation, low level of e vidence).

8. Ambulatory reflux monitoring is not requiredin the presence of short or long-segment Barrett’s esophagus to establish adiagnosis of GERD. (Strong recommendation, moderate level of evidence)

9. Screening for Helicobacter pylori infectionis not recommended in GERD patients. Treatment of H. pylori infection is notroutinely required as part of antireflux therapy. (Strong recommendation, lowlevel of evidence)

Management of GERD

1. Weight lossis recommended for GERD patients who are overweight or have had recent weightgain. (Conditional recommendation, moderate level of evidence)

2. Head of bed elevation and avoidance of meals2–3h before bedtime should be recommended for patients with nocturnal GERD.(Conditional recommendation, low level of evidence)

3. Routine global elimination of food that cantrigger reflux (including chocolate, caffeine, alcohol, acidic and / or spicyfoods) is not recommended in the treatment of GERD. (Conditionalrecommendation, low level of evidence)

4. An 8-week course of PPIs is the therapy ofchoice for symptom relief and healing of erosive esophagitis. There are nomajor differences in efficacy between the different PPIs. (Strongrecommendation, high level of evidence)

5. Traditional delayed release PPIs should beadministered 30–60 min before meal for maximal pH control. (Strongrecommendation, moderate level of evidence). Newer PPIs may offer dosingflexibility relative to meal timing. (Conditional recommendation, moderatelevel of evidence)

6. PPI therapy should be initiated at once a daydosing, before the first meal of the day. (Strong recommendation, moderatelevel of evidence). For patients with partial response to once daily therapy,tailored therapy with adjustment of dose timing and/or twice daily dosingshould be considered in patients with night-time symptoms, variable schedules,and/or sleep disturbance. (Strong recommendation, low level of evidence).

7.Non-responders to PPI should be referred for evaluation. (Conditionalrecommendation, low level of evidence, see refractory GERD section).

8. In patients with partial response to PPItherapy, increasing the dose to twice daily therapy or switching to a differentPPI may provide additional symptom relief. (Conditional recommendation, lowlevel evidence).

9. Maintenance PPI therapy should beadministered for GERD patients who continue to have symptoms after PPI isdiscontinued, and in patients with complications including erosive esophagitisand Barrett’s esophagus. (Strong recommendation, moderate level of evidence).For patients who require long-term PPI therapy, it should be administered inthe lowest effective dose, including on demand or intermittent therapy.(Conditional recommendation, low level of evidence)

10. H₂-receptorantagonist (H₂RA) therapy can be used as a maintenance option inpatients without erosive disease if patients experience heartburn relief.(Conditional recommendation, moderate level of evidence). Bedtime H₂RAtherapy can be added to daytime PPI therapy in selected patients with objectiveevidence of night-time reflux if needed, but may be associated with thedevelopment of tachyphlaxis after several weeks of use. (Conditionalrecommendation, low level of evidence)

11. Therapyfor GERD other than acid suppression, including prokinetic therapy and/orbaclofen, should not be used in GERD patients without diagnostic evaluation.(Conditional recommendation, moderate level of evidence)

12. There isno role for sucralfate in the non-pregnant GERD patient. (Conditionalrecommendation, moderate level of evidence)

13. PPIs aresafe in pregnant patients if clinically indicated. (Conditional recommendation,moderate level of evidence)

Surgical options for GERD

1. Surgicaltherapy is a treatment option for long-term therapy in GERD patients. (Strongrecommendation, high level of evidence)

2. Surgicaltherapy is generally not recommended in patients who do not respond to PPItherapy. (Strong recommendation, high level of evidence)

3. Preoperative ambulatory pH monitoring ismandatory in patients without evidence of erosive esophagitis. All patientsshould undergo preoperative manometry to rule out achalasia or scleroderma-likeesophagus. (Strong recommendation, moderate level of evidence)

4. Surgicaltherapy is as effective as medical therapy for carefully selected patients withchronic GERD when performed by an experienced surgeon. (Strong recommendation,high level of evidence)

5. Obesepatients contemplating surgical therapy for GERD should be considered forbariatric surgery. Gastric bypass would be the preferred operation in thesepatients. (Conditional recommendation, moderate level of evidence)

6. The usageof current endoscopic therapy or transoral incision less fundoplication cannotbe recommended as an alternative to medical or traditional surgical therapy. (Strongrecommendation, moderate level of evidence)

Potential risks associated with PPIs

1. SwitchingPPIs can be considered in the setting of side-effects. (Conditional recommendation,low level of evidence)

2. Patientswith known osteoporosis can remain on PPI therapy. Concern for hip fracturesand osteoporosis should not affect the decision to use PPI long-term except inpatients with other risk factors for hip fracture. (Conditional recommendation,moderate level of evidence)

3. PPI therapycan be a risk factor for Clostridium difficile infection, and should be usedwith care in patients at risk. (Moderate recommendation, moderate level ofevidence)

4. Short-termPPI usage may increase the risk of community-acquired pneumonia. The risk doesnot appear elevated in long-term users. (Conditional recommendation, moderatelevel of evidence)

5. PPI therapydoes not need to be altered in concomitant clopidogrel users as there does notappear to be an increased risk for a dverse cardiovascular events. (Strongrecommendation, high level of evidence)

Extraesophageal presentations of GERD:Asthma, chronic cough, and laryngitis

1. GERD can beconsidered as a potential co-factor in patients with asthma, chronic cough, orlaryngitis. Careful evaluation for n on-GERD causes should be undertaken in allof these patients. (Strong recommendation, moderate level of evidence).

2. A diagnosisof reflux laryngitis should not be made based solely upon laryngoscopyfindings. (Strong recommendation, moderat e level of evidence)

3. A PPI trialis recommended to treat extraesophageal symptoms in patients who also havetypical symptoms of GERD. (Strong recommendation, low level of evidence)

4. Upper endoscopy is not recommended as a meansto establish a diagnosis of GERD-related asthma, chronic cough, or laryngitis.(Strong recommendation, low level of evidence)

5. Refluxmonitoring should be considered before a PPI trial in patients withextraesophageal symptoms who do not have typical symptoms of GERD. (Conditionalrecommendation, low level of evidence)

6.Non-responders to a PPI trial should be considered for further diagnostictesting and are addressed in the refractory GERD section below. (Conditionalrecommendation, low level of evidence)

7. Surgeryshould generally not be performed to treat extraesophageal symptoms of GERD inpatients who do not respond to acid suppression with a PPI. (Strongrecommendation, moderate level of evidence)

GERD refractory to treatment with PPIs

1. The firststep in management of refractory GERD is optimization of PPI therapy. (Strongrecommendation, low level of evidence)

2. Upperendoscopy should be performed in refractory patients with typical or dyspepticsymptoms principally to exclude non-GERD etiologies. (Conditionalrecommendation, low level of evidence)

3. In patientsin whom extraesophageal symptoms of GERD persist despite PPI optimization,assessment for other etiologies should be pursued through concomitantevaluation by ENT, pulmonary, and allergy specialists. (Strong recommendation,low level of evidence)

4. Patientswith refractory GERD and negative evaluation by endoscopy (typical symptoms) orevaluation by ENT, pulmonary, and allergy specialists (extraesophagealsymptoms), should undergo ambulatory reflux monitoring. (Strong recommendation,low level of evidence)

5. Refluxmonitoring off medication can be performed by any available modality (pH orimpedance-pH). (Conditional recommendation, moderate level evidence).Testing on medication should beperformed with impedance-pH monitoring in order to enable measurement ofnonacid reflux. (Strong recommendation, moderate level of evidence).

6. Refractorypatients with objective evidence of ongoing reflux as the cause of symptomsshould be considered for additional antirefux therapies, which may includesurgery or TLESR inhibitors. (Conditional recommendation, low level ofevidence). Patients with negative testing are unlikely to have GERD and PPItherapy should be discontinued. (Strong recommendation, low level of evidence)

Complications Associated with GERD

1. The LosAngeles (LA) classification system should be used when describing theendoscopic appearance of erosive esophagitis. (Strong recommendations, moderatelevel of evidence). Patients with LA Grade A esophagitis should undergo furthertesting to confirm the presence of GERD. (Conditional recommendation, low levelof evidence)

2. Repeatendoscopy should be performed in patients with severe erosive reflux diseaseafter a course of antisecretory therapy to exclude underlying Barrett’sesophagus. (Conditional recommendation, low level of evidence)

3. ContinuousPPI therapy is recommended following peptic stricture dilation to improvedysphagia and reduce the need for repeated dilations. (Strong recommendation,moderate level of evidence)

4. Injectionof intralesional corticosteroids can be used in refractory, complex stricturesdue to GERD. (Conditional recommendation, low level of evidence)

5. Treatmentwith a PPI is suggested following dilation in patients with lower esophageal(Schatzki) rings. (Conditional recommendation, low level of evidence)

6. Screening for Barrett’s esophagus should beconsidered in patients with GERD who are at high risk based on epidemiologicprofile. (Conditional recommendation, moderate level of evidence)

7. Symptoms in patients with Barrett’s esophaguscan be treated in a similar fashion to patients with GERD who do not haveBarrett’s esophagus. (Strong recommendation, moderate level of evidence)

8. Patientswith Barrett’s esophagus found at endoscopy should undergo periodicsurveillance according to guidelines. (Strong recommendation, moderate levelof evidence)