Updates to the modern diagnosis of GERD: Lyon consensus 2.0

Key points

• Actionable GERD requires conclusive reflux-related pathology on endoscopy and/or abnormal reflux monitoring (Lyon thresholds) together with compatible troublesome symptoms.
• Los Angeles (LA) grade B oesophagitis is now conclusive evidence of GERD, alongside LA grades C and D, biopsy-proven Barrett's oesophagus and peptic stricture.
• In unproven GERD, testing is performed off antisecretory therapy; prolonged wireless pH monitoring (96 hours) is preferred when available.
• In proven GERD with persisting symptoms, pH-impedance monitoring is performed on optimised therapy; acid exposure time (AET) above 4% plus more than 80 reflux episodes per day is evidence of actionable refractory GERD.
• Criteria that performed poorly, such as the post-reflux swallow-induced peristaltic wave index and routine biopsy analysis, were retired.

Overview

Lyon Consensus 2.0 is an international expert update of the criteria for and against the diagnosis of gastro-oesophageal reflux disease (GERD). It distinguishes unproven from proven GERD to choose the testing strategy, and describes which symptoms are likely or unlikely to be related to reflux.

Methods and symptoms

A core and working group of 21 members (20 voting) rated statements with the RAND/UCLA Appropriateness Methodology on a 9-point scale; all final statements met the 80% agreement threshold. Typical symptoms are heartburn, oesophageal chest pain and regurgitation. Chronic cough and wheezing have a low but potential relationship to reflux, while hoarseness, globus, nausea, abdominal pain and other dyspeptic symptoms without typical symptoms have a low likelihood. Typical symptoms alone may justify an antisecretory trial, but up-front oesophageal testing is suggested for other symptom categories, for proton pump inhibitor (PPI) non-responders, and before invasive or long-term medical management. Because of a 10-25% placebo effect, response to an empiric PPI trial alone is insufficient for a conclusive diagnosis.

Endoscopy

LA grade A oesophagitis remains borderline evidence. In unproven GERD, endoscopy should be performed 2-4 weeks after stopping PPI therapy to maximise diagnostic yield. LA grade B, C or D oesophagitis or recurrent peptic stricture on optimised PPI therapy indicates refractory GERD. Hiatus hernia is supportive evidence. Routine oesophageal biopsies are not recommended unless there is dysphagia or endoscopic suspicion of eosinophilic oesophagitis.

Reflux monitoring thresholds

On wireless pH monitoring, AET below 4.0% on all days with a negative reflux-symptom association excludes GERD, while the same AET with a positive association meets criteria for reflux hypersensitivity. AET above 6.0% on at least 2 days is diagnostic of GERD; any other result is inconclusive. On pH-impedance monitoring off PPI, total AET above 6% is diagnostic. Fewer than 40 reflux episodes per day is adjunctive evidence against pathological GERD, 40-80 is inconclusive as a stand-alone metric, and more than 80 is adjunctive evidence for GERD. Mean nocturnal baseline impedance below 1500 ohms is adjunctive evidence for GERD, and above 2500 ohms is evidence against it. pH-impedance monitoring off therapy is particularly useful with excessive belching, suspected rumination or pulmonary symptoms.

Frequently asked questions

Is an empiric PPI trial enough to diagnose GERD?

An empiric trial is appropriate for typical symptoms without alarm symptoms, but a response alone does not establish a conclusive diagnosis.

What does an AET between 4% and 6% mean?

It is inconclusive; further clinical context and additional test data are needed to decide whether GERD management is required.

Is LA grade A oesophagitis conclusive?

No. It remains borderline evidence, and later studies found grade A oesophagitis in 5-7.5% of healthy subjects.

Source

Gyawali CP, Yadlapati R, Fass R, Katzka D, Pandolfino J, Savarino E, et al. Updates to the modern diagnosis of GERD: Lyon consensus 2.0. Gut 2024;73(2):361-371. doi:10.1136/gutjnl-2023-330616. Open access under CC BY-NC 4.0; the article was corrected after Online First publication. This summary was prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.