ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease

Key points

• Classic heartburn and regurgitation without alarm symptoms: an 8-week empiric trial of a proton pump inhibitor (PPI) once daily before a meal (strong recommendation, moderate evidence).
• If symptoms respond, an attempt to discontinue PPIs is recommended; if they do not respond or return, diagnostic endoscopy, ideally after PPIs are stopped for 2 to 4 weeks.
• When gastroesophageal reflux disease (GERD) is suspected but endoscopy shows no objective evidence, reflux monitoring off therapy establishes the diagnosis.
• Weight loss is recommended in overweight and obese patients; PPIs are preferred over H2-receptor antagonists (H2RA) for healing and maintaining healing of erosive esophagitis.
• Extraesophageal symptoms without typical GERD symptoms call for reflux testing before PPI therapy.

Overview

The American College of Gastroenterology (ACG) guideline gives evidence-based, GRADE-rated recommendations for the diagnosis and management of GERD, covering empiric therapy, diagnostic testing, lifestyle and medical treatment, extraesophageal symptoms, refractory disease and surgical and endoscopic options. The core approach is an empiric PPI trial for typical symptoms, with objective testing when the response is inadequate or the presentation is atypical.

Diagnosis

Endoscopy is recommended as the first test for dysphagia or other alarm symptoms (weight loss, GI bleeding) and for patients with multiple risk factors for Barrett's esophagus. In chest pain after adequate evaluation to exclude heart disease, objective testing for GERD (endoscopy and/or reflux monitoring) is recommended. A barium swallow is not recommended solely as a diagnostic test for GERD. Reflux monitoring off therapy is not suggested solely for diagnosis in patients already known to have Los Angeles (LA) grade C or D esophagitis or long-segment Barrett's esophagus.

Lifestyle and medical management

Conditional suggestions include avoiding meals within 2-3 hours of bedtime, avoiding tobacco and trigger foods, and elevating the head of the bed for nighttime symptoms. PPIs should be taken 30-60 minutes before a meal rather than at bedtime. Patients without erosive esophagitis or Barrett's esophagus whose symptoms resolved on PPIs should attempt to stop them; those who need maintenance should take the lowest effective dose. LA grade C or D esophagitis calls for indefinite maintenance PPI therapy or antireflux surgery. On-demand or intermittent PPI therapy is suggested for heartburn in non-erosive reflux disease. Baclofen is not recommended without objective evidence of GERD, prokinetics not unless there is objective evidence of gastroparesis, and sucralfate not except during pregnancy.

Extraesophageal symptoms

Non-GERD causes should be evaluated before possible extraesophageal manifestations are ascribed to GERD. Upper endoscopy should not be used to establish GERD-related asthma, chronic cough or laryngopharyngeal reflux (LPR), and LPR should not be diagnosed from laryngoscopy findings alone.

Refractory GERD and surgery

Optimization of PPI therapy is the first step in refractory GERD. For established GERD that has not responded adequately to twice-daily PPIs, esophageal impedance-pH monitoring on PPIs is recommended; manometry should be considered when endoscopy and pH monitoring are normal and before surgical or endoscopic treatment. Antireflux surgery by an experienced surgeon is an option for long-term treatment of patients with objective evidence of GERD, and magnetic sphincter augmentation (MSA) can be considered as an alternative to laparoscopic fundoplication for regurgitation that fails medical management.

Frequently asked questions

How long should an empiric PPI trial last?

The guideline recommends 8 weeks of a PPI once daily before a meal for classic symptoms without alarm features.

Is endoscopy needed to diagnose extraesophageal GERD?

No. Endoscopy should not be used to establish GERD-related asthma, chronic cough or LPR; patients without typical symptoms should have reflux testing before PPI therapy.

Should PPIs be continued long term?

Only when needed and at the lowest effective dose; indefinite maintenance or surgery is recommended for LA grade C or D esophagitis.

Source

American College of Gastroenterology. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. The American Journal of Gastroenterology 2022;117(1):27-56. Recommendations as summarized by Guideline Central (publication date November 22, 2021; last updated March 14, 2022). This summary was prepared by Medpresso from the original publication and is not a substitute for the full text or medical advice.