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ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2022; 117:27-56. [PMID: 34807007 PMCID: PMC8754510 DOI: 10.14309/ajg.0000000000001538] [Citation(s) in RCA: 265] [Impact Index Per Article: 132.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/30/2021] [Indexed: 01/30/2023]
Abstract
Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.
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Kim JY, Shin IS, Min YW, Kim K, Lee H, Min BH, Lee JH, Kim JJ, Rhee PL. Endoscopic Prediction for Acid Reflux in Patients without Hiatus Hernia. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 76:134-141. [PMID: 32969361 DOI: 10.4166/kjg.2020.76.3.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/25/2020] [Accepted: 06/04/2020] [Indexed: 11/03/2022]
Abstract
Background/Aims A diagnosis of gastroesophageal reflux disease is challenging in patients who have reflux symptoms but do not respond to proton pump inhibitors nor have reflux esophagitis and hiatal hernia (HH) on endoscopy. This study examined the predictive role of the endoscopic findings, including the flap valve grade for pathologic acid exposure (PAE) to establish an endoscopic prediction model in patients with neither reflux esophagitis nor HH. Methods Five hundred seventy-eight patients who underwent upper endoscopy and 24 hours pH monitoring for reflux esophageal symptoms without evidence of reflux esophagitis and HH were analyzed. The gastroesophageal flap valve (GEFV), esophageal metaplasia, and chronic atrophic gastritis were assessed. The association between the endoscopic parameters and PAE was evaluated. Results Four hundred ninety-four patients were enrolled. The most common complaint was chest discomfort (42.3%) followed by globus (31.8%), dysphagia (7.9%), and heartburn (7.7%). PAE was present in 43 patients (8.7%). Multivariable analysis revealed PAE to be associated with the GEFV grade (p<0.001) and inversely associated with the chronic atrophic gastritis grade (p=0.005). Using these features, a predictive model was established and showed an area under the receiver operating characteristic curve of 0.705 (95% CI 0.619-0.790). The cutoff value of 12.0 had a sensitivity and specificity of 44.0% and 84.0%, respectively. Conclusions A loosened GEFV is associated with a risk of PAE in patients with neither reflux esophagitis nor HH, while atrophic gastritis is preventive. On the other hand, the endoscopic predictive model revealed a low sensitivity for detecting PAE. Thus, reflux testing needs to be performed further when gastroesophageal reflux disease is suspected, even without endoscopic evidence.
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Affiliation(s)
- Jun Young Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - In Seub Shin
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyunga Kim
- Biostatistics and Clinical Epidemiology Center, Research Institute for Future Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae J Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Esophageal symptoms are common and may indicate the presence of gastroesophageal reflux disease (GERD), structural processes, motor dysfunction, behavioral conditions, or functional disorders. Esophageal physiologic tests are often performed when initial endoscopic evaluation is unrevealing, especially when symptoms persist despite empiric management. Commonly used esophageal physiologic tests include esophageal manometry, ambulatory reflux monitoring, and barium esophagram. Functional lumen imaging probe (FLIP) has recently been approved for the evaluation of esophageal pressure and dimensions using volumetric distension of a catheter-mounted balloon and as an adjunctive test for the evaluation of symptoms suggestive of motor dysfunction. Targeted utilization of esophageal physiologic tests can lead to definitive diagnosis of esophageal disorders but can also help rule out organic disorders while making a diagnosis of functional esophageal disorders. Esophageal physiologic tests can evaluate obstructive symptoms (dysphagia and regurgitation), typical and atypical GERD symptoms, and behavioral symptoms (belching and rumination). Certain parameters from esophageal physiologic tests can help guide the management of GERD and predict outcomes. In this ACG clinical guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to describe performance characteristics and clinical value of esophageal physiologic tests and provide recommendations for their utilization in routine clinical practice.
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Li X, Ding F, Luo P, Yang J, Liu Z, Liu J, Zhang Y, Leng A, Wu K. Study on the Therapeutic Effects of Drug and Cognitive-Behavioral Therapy on Non-Erosive Reflux Disease Patients With Emotional Disorders. Front Psychiatry 2018; 9:115. [PMID: 29867593 PMCID: PMC5954135 DOI: 10.3389/fpsyt.2018.00115] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/20/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To assess the correlation between the incidence of non-erosive reflux disease (NERD) and mental and psychological factors, deepen the understanding of the pathogenesis of NERD and explore effective treatments. METHODS NERD patients with mood disorders who met the inclusion criteria were randomly divided into a drug treatment group, a psychotherapy group, and a psychotherapy combined with drug treatment group. Before and after treatment, the patients were retrospectively analyzed using the gastroesophageal reflux disease Questionnaire, Hamilton Depression Scale, Hamilton Anxiety Scale, and SF-36 Quality of Life Scale. RESULTS All three treatments were found to relieve patients' symptoms and improve their quality of life to some extent. The psychotherapy combined with drug treatment group showed the best overall curative effect. The Hamilton Depression and Anxiety Scale scores were significantly lower in the psychotherapy-alone group and psychotherapy combined with drug treatment group than in the drug treatment alone group at 4, 8, and 12 weeks (P < 0.05). CONCLUSION Medication, psychotherapy, and psychotherapy combined with medication can relieve clinical symptoms and improve quality of life to varying degrees in patients with NERD.
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Affiliation(s)
- Xiuhua Li
- Department of Gastroenterology, Yiyang Central Hospital, Yiyang, China
| | | | | | - Jing Yang
- Department of Gastroenterology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Zhenhua Liu
- Department of Nephrology, Yiyang Central Hospital, Yiyang, China
| | - Jinwei Liu
- Department of Intensive Care Unit, Yiyang Central Hospital, Yiyang, China
| | - Yali Zhang
- Department of Gastroenterology, Yiyang Central Hospital, Yiyang, China
| | - Aimin Leng
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, China
| | - Kuangming Wu
- Department of Gastroenterology, Yiyang Central Hospital, Yiyang, China
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Alkhathami AM, Alzahrani AA, Alzhrani MA, Alsuwat OB, Mahfouz MEM. Risk Factors for Gastroesophageal Reflux Disease in Saudi Arabia. Gastroenterology Res 2017; 10:294-300. [PMID: 29118870 PMCID: PMC5667695 DOI: 10.14740/gr906w] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 09/25/2017] [Indexed: 12/12/2022] Open
Abstract
Background Gastroesophageal reflux disease (GERD) is one of the most prevalent gastrointestinal tract diseases worldwide. GERD has an effect on the patients' quality of life as well as the health care system that can be prevented by identifying its risk factors among the population. Hence, we applied this study to assess the GERD's risk factors in Saudi Arabia. Methods A cross-sectional study was designed to assess the GERD's risk factors among the community of Saudi Arabia. The sample was collected randomly during the period from November to December 2016. Through a self-administered validated GERD questionnaire (GerdQ), GERD was diagnosed. Then, the GERD's risk factors were assessed among all participants. The data were analyzed using Statistical Package for Social Sciences version 21.0; the Student's t-test was used to assess the association of GERD and risk factors. Results A total of 2,043 subjects participated in the study. The characteristics and behaviors of participants statistically significant with GERD were positive family history (39.3%), obese (body mass index > 30 kg/m2) (39.4%), not performing weekly regular physical activities ≥ 30 min (31.1%) and smoking (39.3%). GERD was commonly noticed in participants on analgesics (38.4%), not taking fibers (37.4%), drinking tea (33.4%), eating greasy (31.2%) and fast food (32.7%), and these were statistically significant with GERD (P ≤ 0.05). Conclusion The characteristics and behaviors associated with GERD in Saudi population are family history of GERD, obesity, sedentary lifestyle and smoking. Other common risk factors correlated with GERD are analgesics intake, no fibers intake, drinking tea, greasy and fast food intake.
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Affiliation(s)
| | | | | | | | - Mohammad Eid Mahmoud Mahfouz
- College of Medicine, Taif University, Taif, Saudi Arabia.,King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia
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Mahoney LB, Nurko S, Rosen R. The Prevalence of Rome IV Nonerosive Esophageal Phenotypes in Children. J Pediatr 2017; 189:86-91. [PMID: 28711175 PMCID: PMC6158020 DOI: 10.1016/j.jpeds.2017.06.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/15/2017] [Accepted: 06/07/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To assess the prevalence of Rome IV nonerosive esophageal phenotypes in children using multichannel intraluminal impedance testing and to describe the rates of proton pump inhibitor (PPI) responsiveness and the frequency of microscopic esophagitis in these patients. STUDY DESIGN We conducted a retrospective review of all children ≥5 years of age who underwent esophagogastroduodenoscopy and multichannel intraluminal impedance testing off PPI therapy for evaluation of typical gastroesophageal reflux symptoms. Only children with symptoms during the multichannel intraluminal impedance testing were included. Children were categorized into the following nonerosive esophageal phenotypes using Rome IV criteria: nonerosive reflux disease, reflux hypersensitivity, and functional heartburn. Rates of esophagitis and responsiveness to acid suppression therapy were assessed. RESULTS Forty-five children were included: 27% were categorized as having nonerosive reflux disease, 29% with reflux hypersensitivity (27% acid and 2% nonacid), and 44% with functional heartburn. Older children reported significantly more heartburn (P < .001) than younger children, whereas younger children were more likely to report nonspecific pain (P = .047). There were no differences between groups in other reflux symptoms, rates of responsiveness to PPIs, or the presence of microscopic esophagitis on biopsy. CONCLUSIONS Functional heartburn is the most common Rome IV nonerosive esophageal phenotype in children. Neither microscopic esophagitis nor PPI responsiveness can predict phenotype in pediatric patients.
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Affiliation(s)
- Lisa B Mahoney
- Aerodigestive and Motility and Functional Gastrointestinal Disorders Centers, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Samuel Nurko
- Aerodigestive and Motility and Functional Gastrointestinal Disorders Centers, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Rachel Rosen
- Aerodigestive and Motility and Functional Gastrointestinal Disorders Centers, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA.
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Abstract
The prevalence of gastroesophageal reflux disease (GERD) and the incidence of some of its complications have risen strikingly over the last few decades. With the accumulation in our understanding on the pathophysiology of GERD along with the development of proton pump inhibitors, the diagnostic and therapeutic approaches to the GERD have changed dramatically over the past decade. However, The GERD still poses a problem to many clinicians since the spectrum of the disease has evolved to encompass more challenging presentations such as refractory GERD and extraesophageal manifestations. The aim of this article was to provide a review of available current diagnostic tests of the GERD, includes proton pump inhibitor test, ambulatory pH monitoring, impedance pH monitoring, mucosa impedance, and high resolution manometry. This review discusses different modalities for the work up of GERD.
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Affiliation(s)
- In Du Jeong
- Division of Gastroenterology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Jeong ID, Park MI. [Current Status of Translational Research on Gastroesophageal Reflux Disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2016; 68:127-31. [PMID: 27646580 DOI: 10.4166/kjg.2016.68.3.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The prevalence of gastroesophageal reflux disease (GERD) and the incidence of some of its complications have risen strikingly over the last few decades. With the increase in our understanding of the pathophysiology of GERD along with the development of proton pump inhibitors, the diagnostic and therapeutic approaches to GERD have changed dramatically over the past decade. However, GERD still poses a problem to many clinicians since the spectrum of the disease has evolved to encompass more challenging presentations such as refractory GERD and extra-esophageal manifestations. The aim of this article is to provide a review of available current translational research on GERD. This review includes acid pocket, ambulatory pH monitoring, impedance pH monitoring, mucosa impedance, and high resolution manometry. This article discusses current translational research on GERD.
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Affiliation(s)
- In Du Jeong
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
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