GERD

Question 1

Recommend an 8-wk trial of empiric PPIs once daily before a meal for patients w/ classic GERD symptoms w/o alarm symptoms

Answer 1

strong, moderate evidence

Question 2

Recommend attempting to DC the PPIs in patients whose classic GERD symptoms respond to 8wk empiric trial

Answer 2

conditional, low evidence

Question 4

Do NOT recommend the use of a barium swallow solely as a diagnostic test for GERD

Answer 4

conditional, low evidence

Question 5

Recommend endoscopy as first test for evaluation of patients presenting w/ dysphagia or other alarm symptoms (weight loss and GI bleeding) and for patients w/ multiple risk factors for Barrett’s esophagus

Answer 5

strong, low evidence

Question 6

When diagnosis of GERD is suspected but not clear, and endoscopy shows no objective evidence of GERD, recommend reflux monitoring be performed off therapy to establish the diagnosis

Answer 6

strong, low evidence

Question 7

Suggest against performing reflux monitoring off therapy solely as a diagnostic test for GERD in patients known to have endoscopic evidence of LA grade C or D reflux esophagitis or in patients known to have long-segment Barrett’s esophagus

Answer 7

strong, low evidence

Question 8

Suggest avoiding meals within 2-3 hr of bedtime

Answer 8

conditional, low evidence

Question 9

Suggest elevating head of bed for nighttime GERD symptoms

Answer 9

conditional, low evidence

Question 10

Recommend treatment w/ PPIs over treatment w/ H2RA for healing EE

Answer 10

strong, high evidence

Question 11

Recommend treatment w/ PPIs over H2RA for maintenance of healing for EE

Answer 11

strong, moderate evidence

Question 12

Recommend PPI administration 30-60 min before a meal rather than at bedtime for GERD symptom control

Answer 12

strong, moderate evidence

Question 13

For patients w/ GERD who don’t have EE or Barrett’s, and whose symptoms have resolved w/ PPI therapy, an attempt should be made to discontinue PPIs

Answer 13

conditional, low evidence

Question 14

For maintenance therapy, PPIs should be administered at the lowest dose that effectively controls GERD symptoms and maintains healing of reflux esophagitis

Answer 14

conditional, low evidence

Question 15

Recommend against routine addition of medical therapies in PPI non-responders

Answer 15

conditional, moderate evidence

Question 16

Recommend maintenance PPI therapy indefinitely or anti reflux surgery for patients w/ LA grade C or D esophagitis

Answer 16

strong, moderate evidence

Question 17

Do NOT recommend baclofen in the absence of objective evidence of GERD

Answer 17

strong, moderate evidence

Question 18

Recommend against treatment w/ a pro kinetic agent of any kind for GERD therapy unless there is objective evidence of gastroparesis

Answer 18

strong, moderate evidence

Question 19

Do NOT recommend sucralfate for GERD therapy except during pregnancy

Answer 19

strong, low evidence

Question 20

Suggest on-demand/or intermittent PPI therapy for heartburn symptom control in patients w/ non-erosive reflux disease

Answer 20

conditional, low evidence

Question 21

Recommend evaluation for non-GERD causes in patients w/ possible extra esophageal manifestations before ascribing symptoms to GERD

Answer 21

strong, moderate evidence

Question 22

Recommend that patients who have extra esophageal manifestations of GERD w/o typical GERD symptoms undergo reflux testing for evaluation before PPI therapy

Answer 22

strong, moderate evidence

Question 23

For patients who have both extra esophageal and typical GERD symptoms, suggest considering a trial of BID PPI therapy for 8-12 wks before additional testing

Answer 23

conditional, low evidence

Question 24

Suggest that EGD shouldn’t be used as the method to establish a diagnosis of GERD-related asthma, chronic cough, or laryngopharyngeal reflux (LPR)

Answer 24

conditional, low evidence

Question 25

Suggest against a diagnosis of LPR based on laryngoscopy findings alone and recommended additional testing should be considered

Answer 25

conditional, low evidence

Question 26

In patients treated for extra esophageal reflux disease, surgical or endoscopic anti reflux procedures are only recommended in patients w/ objective evidence of reflux

Answer 26

conditional, low evidence

Question 27

Recommend optimizing PPI therapy as first step in management of refractory GERD

Answer 27

strong, moderate evidence

Question 28

Recommend esophageal pH monitoring (Bravo, catheter-based, or combined impedance-pH. monitoring) performed OFF PPIs if the diagnosis of GERD has not been established by a previous pH monitoring study or an endoscopy showing long-segment Barrett's esophagus or severe reflux esophagitis (grade C or D)

Answer 28

conditional, low evidence

Question 29

Recommend esophageal impedance-pH monitoring performed ON PPIs for patients w/ an established diagnosis of GERD whose symptoms have not responded adequately to BID PPI therapy

Answer 29

conditional, low evidence

Question 30

For patients w/ regurgitation as their primary PPI-refractory symptom and who have had abnormal reflux documented by objective testing, recommend consideration of anti reflux surgery or trans oral incision less fundoplication (TIF)

Answer 30

conditional, low evidence

Question 31

Recommend anti reflux surgery performed by an experienced surgeon as an option for long-term treatment of patients w/ objective evidence of GERD. Those who have severe reflux esophagitis (LA grade C or D), large hiatal hernias, and/or persistent, troublesome GERD symptoms who are likely to benefit most from surgery.

Answer 31

strong, moderate evidence

Question 32

Recommend consideration of magnetic sphincter augmentation (MSA) as an alternative to laparoscopic fundoplication for patients w/ regurgitation who fail medical management

Answer 32

strong, moderate evidence

Question 33

Recommend consideration of RYGB as an option to treat GERD in obese patients who are candidates for this procedure and who are willing to accept its risks and requirements for lifestyle alterations

Answer 33

conditional, low evidence

Question 34

Because data on the efficacy of radio frequency energy (Stretta) as an anti reflux procedure is inconsistent and highly variable, we cannot recommend its use as an alternative to medical or surgical anti reflux therapies

Answer 34

conditional, low evidence

Question 35

Suggest consideration of TIF for patients w/ troublesome regurgitation or heartburn who do not wish to undergo anti reflux surgery and who do not have severe reflux esophagitis (LA grade C or D) or hiatal hernias > 2cm

Answer 35

conditional, low evidence