New diagnostic criteria for GERD aim to curb overtreatment

Last Updated: 2018-05-31

By Will Boggs MD

NEW YORK (Reuters Health) - A consensus of international experts has introduced endoscopic criteria and altered other criteria for diagnosing gastroesophageal reflux disease (GERD).

"GERD is common, but is under-investigated and often over-treated," Dr. C. Prakash Gyawali from Washington University School of Medicine, St. Louis, Missouri told Reuters Health. "Using objective evidence of GERD to guide therapy can reduce overutilization of acid-suppressive medications and ensure appropriate utilization of GERD therapies available, including proton pump inhibitors (PPIs)."

Until now, the diagnosis of GERD has been based on the identification of esophageal mucosal lesions or troublesome symptoms caused by gastroesophageal reflux, and a favorable response to PPI therapy has bolstered a putative GERD diagnosis.

Dr. Gyawali and other experts met at the Lyon GERD consensus meeting in November 2017 to finalize modern indications for esophageal testing in GERD and to define criteria for a clinical diagnosis.

Rather than relying on clinical history and response to PPI therapy, the new criteria require conclusive endoscopic evidence, including Los Angeles (LA) grade C or D esophagitis, biopsy-proven Barrett's esophagus, or peptic strictures, or distal esophageal acid-exposure time >6% on ambulatory pH or pH-impedance monitoring.

The criteria were published online May 16 in Gut.

"The fact that an international consensus of GERD experts considers LA grade B reflux esophagitis on endoscopy insufficient evidence for a conclusive diagnosis of GERD might be considered controversial," Dr. Gyawali said. "This issue was extensively debated during the consensus process, and we concluded that there is a lot of variability and interobserver variation in how Grade B esophagitis is reported, and both grade B and grade A esophagitis can be seen in healthy volunteers. Therefore, while grade B esophagitis may be enough to start PPI therapy, we concluded that this grade of esophagitis is not enough to send a patient for fundoplication or other invasive therapies, hence this did not make the 'conclusive evidence' designation."

The approach to GERD testing requires individualization, according to the authors.

"The Lyon consensus utilizes the concepts of 'proven' and 'unproven' GERD in decisions regarding how to investigate GERD," Dr. Gyawali explained. "Therefore, a patient with possible GERD symptoms who does not respond to a trial of a PPI and has a normal endoscopy (unproven GERD) will undergo ambulatory reflux monitoring off PPI therapy. In contrast, a patient with previously documented GERD (proven GERD) with persisting symptoms on PPI therapy will be studied with an ambulatory pH impedance study on PPI."

Unlike the earlier Porto consensus, the Lyons consensus does not find esophageal high-resolution manometry useful for direct diagnosis of GERD (but recognizes that it can provide adjunctive information), and the Bilitec monitoring system is no longer considered a reliable diagnostic tool for GERD.

"GERD does not have a gold standard for a definitive diagnosis, and therefore, it is important to understand the advantages, as well as limitations, of current diagnostic tests available for evaluation of GERD symptoms," Dr. Gyawali concluded. "The Lyon consensus attempts to categorize findings on diagnostic tests to help define which findings can be used as definitive evidence for GERD, which findings refute a diagnosis of GERD, and which findings are borderline evidence, where additional test findings can sway the diagnosis toward or away from GERD."

SOURCE: https://bit.ly/2J4sOTo

Gut 2018.