Update on GERD: New Guidelines From the

ACG
April 12, 2013 | Gastrointestinal Disorders, Asthma, Obesity, Infection
By Jeffrey Hertzberg, MD, MS
The American College of Gastroenterology (ACG's) last update to its gastroesophageal
reflux disease (GERD) guideline was published in 2005, so Februarys publication of Katz
(Einstein-Philadelphia), Gerson (Stanford), and Velas (Baylor) synthesis of more current
treatment standards is welcomethis is the ACG's new guideline.1 Heres whats new
compared with the 2005 guideline:

1. Lifestyle recommendations: Weight loss is recommended as an effective lifestyle approach to

the treatment of GERD (moderate level of evidence). In the context of our continuing obesity epidemic
and parallel increases in GERD, this comes as no surprise. Head of bed elevation for patients with
nocturnal GERD symptoms was also recommended, but note that the authors cited only low level of
evidence. As for the other key lifestyle modification often recommended, the group did not recommend
avoidance of foods conventionally thought to provoke refluxthis is not routinely advised for most
GERD patients because of the lack of an evidence base.

2. Helicobacter pylori testing and treatment? Routine screening and treatment for infection
are not recommendedevidence is insufficient to support the expectation that testing and treatment will
affect GERD symptoms. This despite a European recommendation in favor of testing in this group
because of concerns about the risk of atrophic gastritis in infected patients; the current US guideline
committee considered the evidence in favor of testing to be weak and based on a single flawed study.

3. Biopsy the distal and mid-esophagus for eosinophilic esophagitis (EoE) if your
index of suspicion is high: The guideline continues to advise against routine biopsies of the distal
esophagus to diagnose GERD. But the recommendation shifts when EoE is suspected (for example, in
patients with GERD and dysphagia or patients with refractory GERD). EoE has become more common
since the publication of previous guidelines (or awareness of it has increasedthe authors cannot
distinguish based on current evidence).

4. Safety of long-term proton pump inhibitors (PPIs): This has been a crucial question
because PPIs remain the mainstay of therapy for GERD.
a. Fracture risk with long-term PPIs? The current guideline downplays the likelihood that
PPIs are associated with fractures (citing strong evidence against avoidance of PPIs), but the group
noted one exception: patients with other risk factors for hip fracture. This is consistent with 2012 findings
from the Canadian Multicentre Osteoporosis Study reviewed in ConsultantLive.
b. Risk of cardiovascular events in patients using PPIs and clopidogrel? The
group did not find strong evidence for increased risk.
c. Clostridium difficile infection: PPI therapy does appear to be a risk factor (moderate
level of evidence).

Given their effectiveness and lack of evidence suggesting long-term risk for most of the serious side
effects, PPIs remain the mainstay of therapy for GERD. Maintenance therapy is appropriate for patients
with GERD-associated complications. There is no evidence for superiority of any of the currently
available productsthey can be considered equivalent and all should be used in the lowest effective
dose for patients who require long-term therapy, with consideration of on-demand or intermittent use.

5. Extra-esophageal symptoms: GERD is a co-factor in patients with cough, laryngitis, and

asthma. While a PPI trial can be recommended in patients who also have typical GERD symptoms,
reflux monitoring should be considered before a PPI trial in patients without GERD symptoms.
Evaluation for non-GERD causes should occur in all patients.

6. Endoscopic therapy is not recommended for GERD.

7. Obese patients with GERD should consider gastric bypass surgery as
treatment for heartburn symptoms.
Given the realities of the obesity epidemic, GERD will increase in prevalence with the aging of the
baby boomers. Appropriate and cost-effective use of PPIs will continue to be major tasks for primary
care clinicians.

Reference

1. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of
gastroesophageal reflux disease. Am J Gastroenterol. 2013;108:308-328.

Medscape
Approach Considerations
Treatment of gastroesophageal reflux disease (GERD) involves a
stepwise approach. The goals are to control symptoms, to heal
esophagitis, and to prevent recurrent esophagitis or other
complications. The treatment is based on (1) lifestyle modification
and (2) control of gastric acid secretion through medical therapy
with antacids or PPIs or surgical treatment with corrective antireflux
surgery. [1, 2, 3, 4, 5, 6]
Approximately 80% of patients have a recurrent but nonprogressive
form of GERD that is controlled with medications. (See Medical
Therapy.) Identifying the 20% of patients who have a progressive
form of the disease is important, because they may develop severe
complications, such as strictures or Barrett esophagus. For patients
who develop complications, surgical treatment should be considered
at an earlier stage to avoid the sequelae of the disease that can
have serious consequences. (See Surgical Therapy.)
Use of a patient management tool such as the self-administered
GERD Questionnaire (GerdQ) to stratify patients may improve the
management of GERD patients in primary care settings. [28]

Lifestyle Modifications

Lifestyle modifications include the following:

Losing weight (if overweight)

Avoiding alcohol, chocolate, citrus juice, and tomato-based
products (2005 guidelines from the American College of
Gastroenterology [ACG] also suggest avoiding peppermint,
coffee, and possibly the onion family [7] )
Avoiding large meals
Waiting 3 hours after a meal before lying down
 Elevating the head of the bed by 8 inches

According to the ACG 2005 guidelines, studies have shown

decreased distal esophageal acid exposure after these changes are
made, but few data are available to confirm these findings. [7]

Lifestyle modifications are the first line of management in pregnant

women with GERD. Advise patients to elevate the head of the bed;
avoid bending or stooping positions; eat small, frequent meals; and
refrain from ingesting food (except liquids) within 3 hours of bedtime.

Pharmacologic Therapy
Antacids

Antacids were the standard treatment in the 1970s and are still
effective in controlling mild symptoms of GERD. Antacids should be
taken after each meal and at bedtime.

H2 receptor antagonists and H2 blocker therapy

H2 receptor antagonists are the first-line agents for patients with mild
to moderate symptoms and grades I-II esophagitis. Options include
ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid), and
nizatidine (Axid).

H2 receptor antagonists are effective for healing only mild

esophagitis in 70-80% of patients with GERD and for providing
maintenance therapy to prevent relapse. Tachyphylaxis has been
observed, suggesting that pharmacologic tolerance can reduce the
long-term efficacy of these drugs.

Additional H2 blocker therapy has been reported to be useful in

patients with severe disease (particularly those with Barrett
esophagus) who have nocturnal acid breakthrough.

Proton pump inhibitors

PPIs are the most powerful medications available for treating GERD.
These agents should be used only when this condition has been
objectively documented. They have few adverse effects and are well
tolerated for long-term use. However, data have shown that PPIs can
interfere with calcium homeostasis and aggravate cardiac conduction
defects. These agents have also been responsible for hip fracture in
postmenopausal women. [29]
Available PPIs include omeprazole (Prilosec), lansoprazole
(Prevacid), rabeprazole (Aciphex), and esomeprazole (Nexium). In
November 2013, the FDA approved the first generic versions of
rabeprazole sodium delayed-release tablets for the treatment of
GERD in adults and adolescents ages 12 and up. In clinical trials, the
most commonly reported adverse reactions to rabeprazole were sore
throat, flatulence, infection, and constipation in adults, and abdominal
pain, diarrhea, and headache in adolescents. [30]

A research review by the Agency for Healthcare Research and

Quality (AHRQ) concluded, on the basis of grade A evidence, that
PPIs were superior to H2 receptor antagonists for the resolution of
GERD symptoms at 4 weeks and healing of esophagitis at 8
weeks. [31] In addition, the AHRQ found no difference between
individual PPIs (omeprazole, lansoprazole, pantoprazole, and
rabeprazole) for relief of symptoms at 8 weeks. For symptom relief at
4 weeks, esomeprazole 20 mg was equivalent, but esomeprazole 40
mg superior, to omeprazole 20 mg. [31]

A systematic review and meta-analysis of two randomized trials and

four prospective cohort studies on the effects of PPI in obstructive
sleep apnea in patients with GERD found a lack of definitive data. [32]

Prokinetic medications and reflux inhibitors

Prokinetic agents are somewhat effective but only in patients with mild symptoms; other
patients usually require additional acid-suppressing medications, such as PPIs. The usual
regimen in adults is metoclopramide, 10 mg/day orally. Long-term use of prokinetic agents
may have serious, even potentially fatal, complications and should be discouraged.

Indications for Surgical Treatment

As in many other fields, surgical therapy for gastroesophageal reflux

has evolved a great deal. A few historical procedures of note include
the Allison crural repair, the Boerema anterior gastropexy, and the
Angelchik prosthesis. Both the Allison and the Boerema repairs have
high failure rates and are rarely, if ever, used. [33, 34] The Angelchik
prosthesis is a silicone ring that is positioned at the gastroesophageal
junction and prevents reflux. The Angelchik prosthesis was rarely
used in children and has been largely abandoned because of a high
rate of complications. [35]

Today, both transthoracic and transabdominal fundoplications are

performed, including partial (anterior or posterior) and circumferential
wraps. The most commonly performed operation today in both
children and adults is the Nissen fundoplication, which is a 360
transabdominal fundoplication (see the image below). [36, 37] First
reported in 1991, laparoscopic fundoplication is well studied in adult
populations. Laparoscopic fundoplication has also quickly gained
acceptance for use in children. [38, 39, 40, 41, 42, 43] However, in one study
in which 119 children underwent fundoplication for severe GERD,
7.6% required a redo fundoplication and 53.8% needed to restart
their antireflux medications within 6 months of surgery. [44]

Indications for fundoplication include the following:

Patients with symptoms that are not completely controlled by PPI therapy can be
considered for surgery; surgery can also be considered in patients with well-controlled
GERD who desire definitive, one-time treatment
The presence of Barrett esophagus is an indication for surgery (whether acid
suppression improves the outcome or prevents the progression of Barrett esophagus
remains unknown, but most authorities recommend complete acid suppression in
patients with histologically proven Barrett esophagus)
The presence of extraesophageal manifestations of GERD may indicate the need for
surgery; these include the following: (1) respiratory manifestations (eg, cough,
wheezing, aspiration); (2) ear, nose, and throat manifestations (eg, hoarseness, sore
throat, otitis media); and (3) dental manifestations (eg, enamel erosion)
Young patients
Poor patient compliance with regard to medications
Postmenopausal women with osteoporosis
Patients with cardiac conduction defects
Cost of medical therapy
Several randomized clinical trials have challenged the benefits of surgery in controlling
GERD. Lundell followed up his cohort of patients for 5 years and did not find surgery to be
superior to PPI therapy. [45]Spechler found that, at 10 years after surgery, 62% of patients were
back on antireflux medications. [46] A very rigorous, randomized study by Anvari et al
reestablished surgery as the criterion standard in treating GERD. [47] The investigators showed
that, at 1 year, the outcome and the symptom control in the surgical group was better than
that in the medical group. [47]
A British multicenter randomized study conducted by Grant et al also compared surgical
treatment versus medical therapy in patients with documented evidence of GERD. [48] The type
of laparoscopic fundoplication was decided by the respective surgeons. Individuals who had
received medication for their condition had taken them for a median of 32 months before
participating in the study. The investigators reported that by 12 months, 38% of those who had
undergone surgery were taking reflux medication, compared with 90% of the individuals
randomized to medical management. [48]
Long-term results of laparoscopic antireflux surgery have shown that, at 10 years, 90% of
patients are symptom free and only a minority still take PPIs. [49]
Long-term follow-up results from a multicenter, randomized trial showed that, relative to
pharmacotherapy, fundoplication maintained better symptomatic relief in the management of
gastroesophageal reflux disease without evidence of long-term postsurgical adverse
symptoms. At 5 years, among patients with a treatment response, almost twice as many of
those randomized to medical management (82%) were taking antireflux agents relative to
those who had been randomized to surgery (44%). [50]

Laparoscopic fundoplication

Laparoscopic fundoplication is performed under general endotracheal anesthesia. Five small

(5-mm to 10-mm) incisions are used (see image below). The fundus of the stomach is
wrapped around the esophagus to create a new valve at the level of the esophagogastric
junction.

The essential elements of the operation are as follows:

Complete mobilization of the fundus of the stomach with division of the

short gastric vessels
Reduction of the hiatal hernia
Narrowing of the esophageal hiatus
Creation of a 360 fundoplication over a large intraesophageal dilator
(Nissen fundoplication)

Laparoscopic fundoplication procedure takes about 2-2.5 hours. The hospital stay is
approximately 2 days. Patients resume regular activities within 2-3 weeks. Approximately 92%
of patients obtain resolution of symptoms after undergoing laparoscopic fundoplication.

The AHRQ found, on the basis of limited evidence, that laparoscopic fundoplication was as
effective as open fundoplication in relieving heartburn and regurgitation, improving quality of
life, and decreasing the use of antisecretory medications. [31]

Although a prospective, randomized trial has never been performed to compare PPIs to
laparoscopic fundoplication, the authors believe fundoplication is preferable for the following
reasons:
 PPIs, although effective in controlling the acid component of the
refluxate, do not eliminate the reflux of bile, which some believe to be a
major contributor to the pathogenesis of Barrett epithelium
Patients with Barrett esophagus tend to have lower LES pressure and
worse esophageal peristalsis than patients without Barrett esophagus;
patients with Barrett esophagus are also exposed to a larger amount of
reflux
A fundoplication offers the only possibility of stopping any kind of reflux
by creating a competent LES; however, until the definitive answer is
known, the authors recommend that patients with Barrett esophagus
should continue to undergo periodic endoscopic surveillance even after
laparoscopic fundoplication
Sleeve gastrectomy

In a study that evaluated laparascopic sleeve gastrectomy for GERD in 71 morbidly obese
patients, symptomatic and reflux control improved in most patients following the
procedure. [51] However, a systematic review and meta-analysis of 33 studies was unable to
determine the effect of sleeve gastrectomy on the prevalence of GERD owing to the high
heterogeneity among available studies and paradoxical outcomes of objective esophageal
function tests. [52]

Devices

The US Food and Drug Administration approved the LINX Reflux Management System in
March 2012. This device is designed to augment the lower esophageal sphincter. The system
is a small flexible band that is placed laparoscopically around the esophagus just above the
stomach to create a natural barrier to reflux. The band consists of interlinked titanium beads
with magnetic cores. The act of swallowing temporarily breaks the magnetic bond, allowing
food and liquid to pass normally. [53]

In a systematic review, magnetic sphincter augmentation appeared to reinforce the lower

esophageal sphincter to antireflux, effectively reducing the time percentage of esophageal
acid exposure (pH <4), improving the GERD health-related quality of life score, reducing the
operative time (vs Nissen fundoplication), and achieving similar treatment success as that of
fundoplication. [54] These findings suggest that magnetic sphincter augmentation may have
potential as an alternative surgical option for patients with conservative GERD treatment
failure. [54]