New Guidelines on GERD

March 15, 2013

New Guidelines on GERD

  1. David A. Johnson, MD

The latest update on best practices from the American College of Gastroenterology

  1. David A. Johnson, MD

Epidemiologic data from the U.S. suggest that the prevalence of gastroesophageal reflux disease (GERD) is increasing at an average annual rate of 3%. Clearly, GERD represents a considerable burden to patients as well as an ongoing challenge for clinicians to identify best therapies. Now, the American College of Gastroenterology has updated their guidelines for the treatment of GERD.

The level of evidence supporting each recommendation was designated as high, moderate, or low. Recommendations were designated as strong (i.e., desirable effects of an intervention outweigh any undesirable effects) or conditional (i.e., uncertainty exists about trade-offs).

Notable recommendations are presented here (see table).

Comment

These guidelines provide the most up-to-date guidance on the diagnosis and management of gastroesophageal reflux disease. The omission of the most recent surgical magnetic ring device (JW Gastroenterol Feb 20 2013) is because of a time lag in the date of publication and does not indicate a dismissal of the technology. I strongly suggest that clinicians review all recommendations and weighted evidence in this comprehensive report.

Citation(s):

Reader Comments (2)

George Triadafilopoulos, MD

The recently published “Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease” did not properly address the role of radiofrequency endoscopic therapy for GERD (Stretta procedure) grouping it with other techniques abandoned for insufficient efficacy or concerns about safety.

Stretta has been widely used and studied over the past 13 years in several randomized controlled trials and long-term durability studies, as recently reviewed in a meta-analysis of 18 studies covering 1441 patients (Perry KA et al Surg Lap Endoscopy Perc Tech 2012; 22:283-288). In all these studies, Stretta significantly reduced esophageal acid exposure and normalized it in a proportion of patients. More importantly, Stretta was shown to be a safe, durable and effective procedure when considering the main endpoint of GERD treatment (i.e. symptom control).

Approximately one third of reflux patients today have inadequate response to PPI therapy and are not willing to undergo fundoplication. Stretta provides an invaluable adjunct in the treatment of GERD that spans the “gap” between PPI responders and surgical candidates.

As the precise physiologic dysfunction exhibited by GERD sufferers is not completely understood, it stands to reason that multiple therapeutic modalities – used alone or even in combination -may contribute to symptom control. The abundance of clinical data on Stretta confirms the following: 1) tissue destruction and creation of fibrosis does not occur; 2) symptom control in PPI dependent patients occurs consistently; 3) a variety of functional improvements occur in the distal esophagus including improved acid sensitivity and tissue compliance; and 4) the procedure is exceedingly safe and reproducible.

There is unquestionably an unmet need for the many sufferers of GERD, particularly the refractory ones, where Stretta has been shown to offer significant improvements by both objective and subjective criteria. Stretta is safe, effective, durable and repeatable if necessary. Further, it does not preclude any other alternative (repeat Stretta, PPI addition or fundoplication) and is the least expensive alternative to medical therapy.

Competing interests: None declared

MaryAnn Bradley

recently I have discontinued my long term PPI due to continuous nausea. Currently, I am taking digestive enzymes with HCL and for breakthrough Apple Cider Vinegar. Perhaps more natural methods need to be studied. I would have never believed this regimen would work but I was at a crossroad and needed help.

Competing interests: None declared

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