Evidence-based clinical practice guidelines for gastroesophageal reflux disease 2015

Abstract

As an increase in gastroesophageal reflux disease (GERD) has been reported in Japan, and public interest in GERD has been increasing, the Japanese Society of Gastroenterology published the Evidence-based Clinical Practice Guidelines for GERD (1st edition) in 2009. Six years have passed since its publication, and there have been a large number of reports in Japan concerning the epidemiology, pathophysiology, treatment, and Barrett's esophagus during this period. By incorporating the contents of these reports, the guidelines were completely revised, and a new edition was published in October 2015. The revised edition consists of eight items: epidemiology, pathophysiology, diagnosis, internal treatment, surgical treatment, esophagitis after surgery of the upper gastrointestinal tract, extraesophageal symptoms, and Barrett's esophagus. This paper summarizes these guidelines, particularly the parts related to the treatment for GERD. In the present revision, aggressive proton pump inhibitor (PPI) maintenance therapy is recommended for severe erosive GERD, and on-demand therapy or continuous maintenance therapy is recommended for mild erosive GERD or PPI-responsive non-erosive GERD. Moreover, PPI-resistant GERD (insufficient symptomatic improvement and/or esophageal mucosal break persisting despite the administration of PPI at a standard dose for 8 weeks) is defined, and a standard-dose PPI twice a day, change in PPI, change in the PPI timing of dosing, addition of a prokinetic drug, addition of rikkunshito (traditional Japanese herbal medicine), and addition of histamine H2-receptor antagonist are recommended for its treatment. If no improvement is observed even after these treatments, pathophysiological evaluation with esophageal impedancepH monitoring or esophageal manometry at an expert facility for diseases of the esophagus is recommended.

Benign diseases of the gastro-oesophageal junction

“…If the complaints persist over this period it is recommended to double the PPI dose, change to another preparation, or add other drugs which neutralise hydrochloric acid, e.g. histamine H2 (H2RA) receptor blocker [6]. The main cause of treatment of oesophageal reflux disease is prevention of its complications, and consequently the development of Barrett's oesophagus and cancer associated with it, as well as an improvement in the quality of life of the patients.…”

“…In the case of the Toupet fundoplication procedure, the outcomes of treatment depend, to a great extent, on the length of the sutured wrap. With respect to controlling the symptoms of the disease, Toupet fundoplication seems to be an interesting alternative to the Nissen fundoplication procedure [6]. In each of these procedures it is possible to perform the surgery by the LESS method (laparoendoscopic single-site surgery), in which a single incision is made in the umbilicus region.…”

New Minimally Invasive Endoscopic and Surgical Therapies for Gastroesophageal Reflux Disease (GERD)

“…PPIs are the most effective, as they block the acid pump (7). PPI therapy is effective, especially in those with EE, well tolerated, but also presents some hard to dismiss inconveniences (8,9,10):…”

Vonoprazan 10 mg daily is effective for the treatment of patients with proton pump inhibitor-resistant gastroesophageal reflux disease

“…Proton pump inhibitors (PPI) have been the mainstay of GERD treatment for two decades, and are recommended in Japanese guidelines (2). Despite evidence confirming the efficacy of PPI treatment, a Japanese survey reported over-the-counter medication use in patients who received prescriptions for GERD (3).…”

“…Some patients with GERD are refractory to standard PPI treatment. Japanese guidelines define PPI-resistant GERD as a condition in which, i) an esophageal mucosal break did not heal and/or ii) reflux symptoms considered to be due to GERD are not sufficiently mitigated even after oral administration of PPI at a standard dose for eight weeks (2). To overcome treatment difficulties, double-dose PPI and/or additional administration of a prokinetic drug and herbal medicine were suggested.…”