Guidance offered on management of extraesophageal GERD
The clinical practice update from the American Gastroenterological Association was based on a review of the evidence and expert opinion regarding extraesophageal symptoms of gastroesophageal reflux disease (GERD).
A clinical practice update outlined best practice advice on managing extraesophageal symptoms of gastroesophageal reflux disease (GERD), including medicine and lifestyle changes.
The American Gastroenterological Association reviewed evidence and expert advice regarding the clinical management of patients with suspected extraesophageal GERD. The clinical practice update was not based on a formal systematic review and does not have formal ratings of the quality or strength of evidence. It was published April 14 by Clinical Gastroenterology and Hepatology.
Gastroenterologists should be aware of potential extraesophageal manifestations of GERD and should ask about symptoms in the larynx, chronic cough, asthma, and dental erosions to determine whether GERD might be a contributing factor, the update said. It also recommended that clinicians take a multidisciplinary approach to symptoms, including those captured from non-GI specialties, such as bronchoscopy, thoracic imaging, or laryngoscopy. Because there is no single diagnostic tool that can diagnose GERD resulting in extraesophageal reflux, physicians should consider all symptoms, response to therapy, and results of endoscopy and reflux testing, according to the statement.
Physicians should consider diagnostic testing for reflux before starting proton-pump inhibitors (PPIs). A single-dose PPI trial, titrating up to twice daily in those with typical GERD symptoms, is reasonable, the statement said. Improved symptoms while on PPIs may result from something other than acid suppression and should not be regarded as confirmation of GERD, the statement noted. In patients who have not responded to up to 12 weeks of therapy with a PPI, clinicians should consider objective testing for pathologic GERD rather than switching to another drug, since trials of different PPIs are low yield, according to the statement.
Physicians should tailor testing to the clinical presentation, and testing can include upper endoscopy and ambulatory reflux monitoring studies of acid suppressive therapy. In addition, they can consider pH-impedance monitoring in the setting of acid suppression to evaluate the role of ongoing acid or nonacid reflux, the statement said.
Alternative treatments such as lifestyle modifications, alginate-containing antacids, an external upper esophageal sphincter compression device, cognitive behavioral therapy, and neuromodulators may serve a role in managing extraesophageal reflux symptoms.
Shared decision making should take place before referral for antireflux surgery for extraesophageal reflux when the patient has an established diagnosis of GERD, the statement said. “However, a lack of response to PPI therapy predicts lack of response to anti-reflux surgery and should be incorporated into the decision process,” the authors wrote.