New American Gastroenterological Association Clinical Practice Update for Evaluation and Management of Gastroesophageal reflux disease (GERD) focuses on providing personalized diagnostic and therapeutic strategies.
This document contains new advice on the use of prior objective tests for isolated extraesophageal symptoms, confirmation of GERD diagnosis prior to long-term GERD treatment even with PPI responders, and key elements focused on individualization of treatment. I am.
Gastroesophageal reflux disease is common, but an estimated 30% of people in the United States experience symptoms, but up to half of those receiving proton pump inhibitor (PPI) therapy improve incomplete symptoms. I am reporting. This can be due to the uneven nature of the symptoms, such as heartburn, regurgitation, chest pain, coughing and sore throat. Other conditions can cause similar symptoms and can be exacerbated by the presence of GERD.
Author of expert reviews, Release It should be noted that in clinical gastrointestinal illness and hepatology, these considerations have increased interest in individual approaches to the management of GERD. The latest clinical information includes sections on how to approach GERD symptoms in the clinic, personalized diagnosis related to GERD symptoms, and accurate management.
In initial management, the authors enrolled patients with heartburn, regurgitation, or non-cardiac chest pain in care planning, patient education, and conducting 4- to 8-week PPI trials without alarm signals. Provides advice on getting involved. If symptoms do not improve patient satisfaction, the dose can be increased to twice daily or replaced with a more effective acid suppressant and continued once daily. If the response to PPI is appropriate, the dose should be reduced until the minimum effective dose is reached. Otherwise, patients may move to H2 receptor antagonists or other antacids.However, patients with erosive esophagitis, confirmed by biopsy Barrett’s esophagusOr gastrointestinal stricture requires long-term PPI therapy.
The author also gave advice on when to perform an objective test. If the PPI trial does not adequately address nasty heartburn, reflux, and / or non-cardiac chest pain, or if an alarm system is present, use endoscopy to gastroesophageal reflux disease or long-segment Barrett. The esophagus should be looked for as definitive evidence of GERD. In the absence of these, it is advisable to extend wireless pH monitoring while the patient is not receiving medication. In addition, patients with extraesophageal symptoms suspected to be due to reflux should undergo a prior objective reflux test while discontinuing PPI therapy rather than conducting an empirical PPI study.
The authors advise that if the patient has not proven GERD and is continuing PPI therapy, it should be evaluated within 12 months to ensure that the therapy and dose are appropriate. I am. Physicians provide endoscopy with long-term wireless reflux monitoring in the absence of PPI therapy (ideally after 2-4 weeks of withdrawal) to confirm the need for long-term PPI therapy need to do it.
In the section on personalization of disease management, the authors note that portable reflux disease monitoring and upper gastrointestinal endoscopy can be used to guide the management of GERD. If there are no erosive findings on upper gastrointestinal endoscopy and the esophageal acid exposure time (AET) is less than 4% throughout the day of long-term wireless pH monitoring, the doctor will tell the patient that the patient has no pathological gastroesophageal reflux disease. It can be concluded that there is likely to be a functional esophagus. hindrance. In contrast, upper gastrointestinal endoscopy and / or erosive findings during AET exceed 4% with at least 1 day of wireless pH monitoring, suggesting a GERD diagnosis.
PPI optimization is important among patients with GERD, and the authors emphasize that patients should be educated about the safety of PPI use.
Adjuvant drug therapy is useful, alginate antacids for breakthrough symptoms, H2RA for nocturnal symptoms, Baclofen To combat the promotion of regurgitation or belching, and associated gastroparesis. The choice of drug depends on the phenotype and should not be used empirically.
For patients with functional heart burns or reflux disease associated with esophageal hypersensitivity, reflux disease, or behavioral disorders, options include pharmacological neuromodulation, behavioral therapist hypnotherapy, cognitive behavioral therapy, and diaphragmatic breathing. Includes relaxation.
If symptoms persist after efforts to optimize treatment and lifestyle factors, PPI’s 24-hour portable pH impedance monitoring can be used to investigate the cause of the mechanism, especially in the absence of known antireflux barrier abnormalities. However, specialized expertise is required to correctly interpret this technique. This confirms that the symptoms are not due to reflux hypersensitivity. Ruminant Syndrome or belching disorder. Once the symptoms are confirmed to be refractory, treatment should be escalated using a strategy that incorporates a pattern of regurgitation, the integrity of the anti-reflux barrier. obesity If present, and psychological factors.
Confirmed GERD surgical options include laparoscopic cardiaplasty and magnetic sphincter augmentation. Cardiac plasty without an oral incision can be performed endoscopically in selected patients.Roux-en-Yostomy for obese patients with confirmed gastroesophageal reflux disease Gastric bypass It is effective in reducing regurgitation and can be used as a remedy for non-obese patients. Sleeve gastrectomy can exacerbate GERD.
The author reported relationships with Medtronic, Diversatech, Ironwood, and Takeda. The author also reported funding from a grant from the National Institutes of Health.
This article was originally MDedge.comIs part of the Medscape Professional Network.
