A Deep Dive Into the 2022 ACG GERD Guideline Update

Gastroesophageal reflux disease (GERD) remains among the leading diagnoses given to patients, especially in an ever growing obesity epidemic.

Our understanding of the different presentations of GERD, its diagnosis and treatment, as well as side effects of GERD-directed therapy, have been changing. An updated American College of Gastroenterology (ACG) Clinical Guideline for the Diagnosis and Management of GERD effectively summarizes the current advances in GERD.¹

Compared to the previous clinical guidelines, much remains the same in the diagnosis and treatment of typical GERD.

An 8-week empiric trial of proton pump inhibitors (PPI) is recommended for patients who do not have alarm symptoms. Diagnostic endoscopy is recommended to be done off of PPI therapy for patients who do not respond to PPI, hose with red flag symptoms, and those at risk of Barrett’s esophagus. Ambulatory reflux testing is indicated in patients without objective evidence of GERD on endoscopy prior to establishing a diagnosis of GERD.

When indicated, PPIs are recommended to be continued at the lowest effective dose. This change stems from pressures of research suggesting an association of many side-effects to PPI use.

However, it is emphasized that the evidence for these associations are based on observational studies, not designed to prove causality.

The only randomized controlled trial has not shown evidence of causation for many of these side effects, with the exception of increased risk of enteric infections. Therefore, continued use of PPIs is still recommended for those with indications such as erosive esophagitis and Barrett’s esophagus.

The dietary and lifestyle recommendations for GERD have not changed. Optimization of PPI therapy is still the first line of management in patients with refractory GERD.

Most PPIs (with the exception of dexlansoprazole) are recommended to be taken 30 minutes before a meal, not at bed time. Although all PPIs are effective at healing esophagitis, they have differences in their potency of acid-suppression.

Ranked in potency from least to highest, are pantoprazole, lansoprazole, omeprazole, esomeprazole, and rabeprazole. Therefore, switching to another PPI in patients with incomplete response can be considered. In line with previous recommendations, PPIs are recommended over H2-receptor antagonists (HR2As) for their superiority at healing esophagitis.

While H2RAs can be used on an as-needed basis, they have been shown to lose effectiveness if continuously used for >1 month.

Prior to consideration of invasive therapies for reflux, a solid diagnosis of GERD and a clear association to symptoms, should be established either by pH monitoring, or endoscopy (i.e. for large hiatal hernias and erosive esophagitis). High resolution manometry is indicated preoperatively to rule out major disorders of esophageal motility such as achalasia or absent contractility. The new addition to these recommendations, is that provocative testing for contractile reserve via multiple rapid swallows should be done to assess for risk of post-fundoplication dysphagia.

For the carefully selected patient with indications for anti-reflux surgery, the guidelines recommend surgical fundoplication or Roux-en-Y gastric bypass. Newer, less invasive alternatives to consider include magnetic sphincter augmentation and trans-oral incisionless fundoplication (in the absence of hiatal hernias > 2 cm, and erosive esophagitis).

With the advances of ambulatory pH and impedance monitoring, the diagnosis of extraesophageal symptoms of GERD is another new focus of the updated guidelines.

For patients who do not have heartburn or regurgitation, but have atypical GERD symptoms such as cough, throat clearing, hoarseness, globus, asthma, laryngitis, it is recommended that ambulatory reflux testing be done prior to a trial of PPI.

For those who have both typical symptoms of GERD, as well as extraesophageal GERD symptoms, a trial of PPI can be considered. It is important to note that endoscopic evidence of GERD does not prove causality for GERD as the driver of extraesophageal symptoms.

Therefore, ambulatory pH and impedance testing has more of a role in the evaluation of patients with extraesophageal GERD symptoms than endoscopy alone.

Not much has changed in the management of extraesophageal GERD symptoms, but the guidelines have summarized the efficacy of different treatment modalities.

PPIs have shown varying results in the treatment of asthma and chronic cough. Antireflux surgery seems to be inferior in the treatment of patients with extraesophageal GERD symptoms, compared to those with typical GERD symptoms.

Predictors of a positive response to surgery include the presence of typical GERD symptoms, abnormal acid exposure time on pH monitoring, and positive response to PPI. Therefore, patients with only extraesophageal GERD symptoms who do not respond to PPIs, should be advised against invasive therapies for reflux.

Overall, the 2022 ACG guidelines serve as an excellent refresher on everything GERD-related, as well as a comprehensive summary on newer developments in the diagnosis and management of GERD. With the current rate of evolution in the field of GERD research (i.e, esophageal function testing, alternatives to PPIs, and endoscopic therapies for GERD), much more remains to be anticipated from the next update on GERD.

References

Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2022;117(1):27-56. doi:10.14309/ajg.0000000000001538