Management of Gastroesophageal Reflux Disease

Gyawali, C. Prakash; Fass, Ronnie

doi:10.1053/j.gastro.2017.07.049

Cited by 255 publications

(259 citation statements)

References 190 publications

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“…Further investigations are obviously indicated in case of red flag symptoms such as bloody stools, dysphagia, or severe weight loss, with extra caution in elderly who are at greater risk for malignancies . As a comparison, patients with gastrointestinal reflux are rarely referred directly to endoscopy without red flag symptoms . The diagnosis of refractory coeliac disease is based on poor clinical response and severe histopathologic findings despite the gluten‐free diet, and baseline biopsy results would not be helpful .…”

Section: Discussionmentioning

confidence: 99%

Serology‐based criteria for adult coeliac disease have excellent accuracy across the range of pre‐test probabilities

Fuchs

Kurppa

Huhtala

et al. 2018

Aliment Pharmacol Ther

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Summary Background The revised paediatric criteria for coeliac disease allow omission of duodenal biopsies in symptomatic children who have specific serology and coeliac disease‐associated genetics. It remains unclear whether this approach is also applicable for adults with various clinical presentations. Aim To evaluate the accuracy of serology‐based criteria in adults with variable pre‐test probabilities for coeliac disease. Methods Three study cohorts comprised adults with high‐risk clinical coeliac disease suspicion (n = 421), moderate‐risk family members of coeliac disease patients (n = 2357), and low‐risk subjects from the general population (n = 2722). Serological and clinical data were collected, and “triple criteria” for coeliac disease comprised transglutaminase 2 antibodies >10× the upper limit of normal, positive endomysium antibodies, and appropriate genetics without requirement of symptoms. The diagnosis was based on intestinal biopsy. Results The diagnosis of coeliac disease was established in 274 subjects. Of these, 59 high‐risk subjects, 17 moderate‐risk subjects, and 14 low‐risk subjects fulfilled the “triple criteria”. All had histologically proven coeliac disease, giving the criteria a positive predictive value of 100%. Altogether, 90 (33%) of all 274 newly diagnosed patients could have avoided biopsy, including 37% among high‐risk, 20% among moderate‐risk, and 48% among low‐risk patients. No histological findings other than coeliac disease were found in the biopsies of “triple positive” subjects. Conclusions Coeliac disease can reliably and safely be diagnosed without biopsy in adults fulfilling the “triple criteria” regardless of the pre‐test probability. Revised criteria would enable the number of endoscopies to be reduced by one‐third.

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Section: Discussionmentioning

confidence: 99%

Serology‐based criteria for adult coeliac disease have excellent accuracy across the range of pre‐test probabilities

Fuchs

Kurppa

Huhtala

et al. 2018

Aliment Pharmacol Ther

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“…A multidisciplinary committee (geriatrician, gastroenterologist, QI expert, and two general internists) created guideline‐based appropriateness criteria based on the American Geriatrics Society Beers Criteria®, American Gastroenterological Association, and American College of Gastroenterology Practice Guidelines . The committee reviewed each recommendation and strength of evidence; all recommendations were accepted based on group discussion and consensus.…”

Section: Methodsmentioning

confidence: 99%

Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Mafi

May

Kahn

et al. 2019

J American Geriatrics Society

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BACKGROUND Older adults are particularly vulnerable to complications from proton pump inhibitor (PPI) drugs. We sought to characterize the prevalence of potentially low‐value PPI prescriptions among older adults to inform a quality improvement (QI) intervention. METHODS We created a cohort of patients, aged 65 years or older, receiving primary care at a large academic health system in 2018. We identified patients currently prescribed any PPI using the electronic health record (EHR) medication list (current defined as September 1, 2018). A geriatrician, a gastroenterologist, a QI expert, and two primary care physicians (PCPs) created multidisciplinary PPI appropriateness criteria based on evidenced‐based guidelines. Supervised by a gastroenterologist and PCP, two internal medicine residents conducted manual chart reviews in a random sample of 399 patients prescribed PPIs. We considered prescriptions potentially low value if they lacked a guideline‐based (1) short‐term indication (gastroesophageal reflux disease [GERD]/peptic ulcer disease/Helicobacter pylori gastritis/dyspepsia) or (2) long‐term (>8 weeks) indication (severe/refractory GERD/erosive esophagitis/Barrett esophagus/esophageal adenocarcinoma/esophageal stricture/high gastrointestinal bleeding risk/Zollinger‐Ellison syndrome). We used the Wilson score method to calculate 95% confidence intervals (CIs) on low‐value PPI prescription prevalence. RESULTS Among 69 352 older adults, 8729 (12.6%) were prescribed a PPI. In the sample of 399 patients prescribed PPIs, 63.9% were female; their mean age was 76.2 years, and they were seen by 169 PCPs. Of the 399 prescriptions, 143 (35.8%; 95% CI = 31.3%‐40.7%) were potentially low value—of which 82% began appropriately (eg, GERD) but then continued long term without a guideline‐based indication. Among 169 PCPs, 32 (18.9%) contributed to 59.2% of potentially low‐value prescriptions. CONCLUSION One in eight older adults were prescribed a PPI, and over one‐third of prescriptions were potentially low‐value. Most often, appropriate short‐term prescriptions became potentially low value because they lacked long‐term indications. With most potentially low‐value prescribing concentrated among a small subset of PCPs, interventions targeting them and/or applying EHR‐based automatic stopping rules may protect older adults from harm. J Am Geriatr Soc 67:2600–2604, 2019

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“…Modern day management of GERD is patient‐centered and includes establishing a definitive diagnosis by diagnostic testing (endoscopy, esophageal manometry, and 24‐h pH/impedance testing), patient education, and reassurance, as well as dietary and lifestyle modifications. When NERD is diagnosed on the basis of abnormal reflux parameters on ambulatory reflux monitoring, management is identical to that of GERD . Therapeutic options vary depending on clinical presentation and underlying pathophysiology, and range from intermittent H 2 receptor antagonist use for symptomatic nonerosive disease, to daily PPI for erosive esophagitis, to hiatus hernia repair and ARS in selected patients .…”

Section: Management Considerationsmentioning

confidence: 99%

“…When NERD is diagnosed on the basis of abnormal reflux parameters on ambulatory reflux monitoring, management is identical to that of GERD . Therapeutic options vary depending on clinical presentation and underlying pathophysiology, and range from intermittent H 2 receptor antagonist use for symptomatic nonerosive disease, to daily PPI for erosive esophagitis, to hiatus hernia repair and ARS in selected patients . In patients with PPI‐refractory GERD, PPIs independent of the cytochrome P450 enzyme system, nighttime H 2 receptor antagonists, promotility agents, TLESR inhibitors, and mucosal protective agents are options …”

Section: Management Considerationsmentioning

confidence: 99%

“…Using endoscopy, GERD can be phenotyped into erosive and NERD. While the yield of endoscopy is low, the finding of erosive esophagitis is specific for GERD, and, consequently, management outcome is excellent with both medical management and ARS . Of symptomatic patients, 30–40% report incomplete relief with PPI therapy, and objective evidence of GERD on ambulatory reflux monitoring performed off PPI can identify phenotypes that benefit from antireflux therapy.…”

Section: Management Considerationsmentioning

confidence: 99%

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Nonerosive reflux disease: clinical concepts

Gyawali

Azagury

Chan

et al. 2018

Annals of the New York Academy of Sciences

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Esophageal symptoms can arise from gastroesophageal reflux disease (GERD) as well as other mucosal and motor processes, structural disease, and functional esophageal syndromes. GERD is the most common esophageal disorder, but diagnosis may not be straightforward when symptoms persist despite empiric acid suppressive therapy and when mucosal erosions are not seen on endoscopy (as for nonerosive reflux disease, NERD). Esophageal physiological tests (ambulatory pH or pH-impedance monitoring and manometry) can be of value in defining abnormal reflux burden and reflux-symptom association. NERD diagnosed on the basis of abnormal reflux burden on ambulatory reflux monitoring is associated with similar symptom response from antireflux therapy for erosive esophagitis. Acid suppression is the mainstay of therapy, and antireflux surgery has a definitive role in the management of persisting symptoms attributed to NERD, especially when the esophagogastric junction is compromised. Adjunctive approaches and complementary therapy may be of additional value in management. In this review, we describe the evaluation, diagnosis, differential diagnosis, and management of NERD.

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Management of Gastroesophageal Reflux Disease

Cited by 255 publications

References 190 publications

Serology‐based criteria for adult coeliac disease have excellent accuracy across the range of pre‐test probabilities

Serology‐based criteria for adult coeliac disease have excellent accuracy across the range of pre‐test probabilities

Low‐Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System

Nonerosive reflux disease: clinical concepts

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