Nearly half of the patients with suspected gastroesophageal reflux disease (GERD) do not seem to benefit from acid suppression. A review was done recently to define a personalized approach to the diagnosis and management of GERD symptoms.

Authors developed best practice advice statements based on expert review of published literature followed by comprehensive discussion and expert opinion. The review outlines the following best practice advice:

• A care plan must be developed to investigate the symptoms pointing to gastroesophageal reflux disease (GERD), to select appropriate treatment and long-term management, including de-escalation, with the involvement of the patients, in a shared-decision making model.
• Patients with reflux symptoms should be provided with standardized educational material on GERD mechanisms, weight management, lifestyle intervention and dietary behavior, relaxation techniques, as well as awareness on the brain-gut axis link.
• Clinicians must stress on the safety of proton pump inhibitors (PPIs) for the treatment of GERD.
• Patients with troubling heartburn, regurgitation and/or non-cardiac chest pain without any alarm symptoms should be given a 4 to 8 week trial of single dose PPI therapy. In case of inadequate response, twice a day dosing regimen can be given or the patient can be switched to a more effective acid suppressive agent once a day. Once there is adequate response, the agent should be tapered off to the lowest effective dose.
• If PPI therapy is continued in case of unproven GERD, the appropriateness and dosing must be assessed within 12 months of initiation. Clinicians should offer endoscopy with prolonged wireless reflux monitoring off PPI therapy in order to ascertain the appropriateness of long-term PPI therapy.
• In case the troublesome heartburn, regurgitation and/or non-cardiac chest pain fail to respond adequately to PPI trial or if alarm symptoms exist, investigations should be done with endoscopy. If there is no erosive reflux disease (Los Angeles B or greater) or long-segment (≥3cm) Barretts esophagus, prolonged wireless pH monitoring off medication (96 hour preferred if available) should be done to confirm and phenotype GERD or to exclude GERD.
• Complete endoscopic evaluation of symptoms of GERD involves inspection for erosive esophagitis, diaphragmatic hiatus, axial hiatus hernia length, and checking for Barretts esophagus.
• Objective reflux testing off medication should be done in patients with isolated extra-esophageal symptoms with suspected reflux etiology.
• In symptomatic patients with confirmed GERD, ambulatory 24 hour pH-impedance monitoring on PPI should be considered to ascertain the mechanism behind persisting esophageal symptoms in spite of treatment (if there is adequate expertise for interpretation).
• Adjunctive pharmacotherapy should be tailored according to the GERD phenotype, rather than empiric use of the agents. Adjunctive agents include nighttime H2 receptor antagonists for nocturnal symptoms, alginate antacids for breakthrough symptoms, baclofen for regurgitation, and prokinetics for coexisting gastroparesis.
• For patients with functional heartburn or reflux disease with esophageal hypervigilance reflux hypersensitivity and/or behavioral disorders, give pharmacologic neuromodulatory therapy, and/or refer to a behavioral therapist for hypnotherapy, provide cognitive behavioral therapy (CBT), diaphragmatic breathing and relaxation techniques.
• In patients with confirmed GERD, potential surgical therapy involves laparoscopic fundoplication and magnetic sphincter augmentation. Transoral incisionless fundoplication is an endoscopic option in carefully selected patients.
• Roux-en-Y gastric bypass is a potent primary anti-reflux intervention in obese patients with proven GERD, and a salvage option in patients who are not obese. Sleeve gastrectomy can potentially worsen GERD.
• Candidates for invasive anti-reflux procedures - confirmed pathologic GERD, exclusion of achalasia, and assessment of esophageal peristaltic function.

Source: Yadlapati R, Gyawali CP, Pandolfino JE. Personalized Approach to the Evaluation and Management of Gastroesophageal Reflux Disease. Clin Gastroenterol Hepatol. 2022 Feb 2;S1542-3565(22)00079-9.