Gastroesophageal reflux disease (GERD) is one of the first reasons patients consult a primary care physician or gastroenterologist, worldwide. GERD is currently recognized as a very heterogeneous entity, obliging treating physicians to employ different diagnostic and therapeutic approaches. In an effort to provide a homogeneous approach, different international guidelines for the management of GERD have been developed1–5. Importantly, the majority of those guidelines are designed for patients from Europe, the United States, and Canada, and the sociocultural factors regarding GERD, such as mealtimes, diet, and associated comorbidities, are different in every country. Even though there are Latin American guidelines on the management of GERD that have come out of Mexico, Central America, and the Caribbean6,7, the heterogeneity in the region, with respect to habits and customs, as well as availability of resources and diagnostic tests, makes the applicability of said guidelines quite variable.

In addition, many gastroenterologists commonly adopt measures in their clinical practice based on their personal experience acquired over the course of treating many patients with GERD, and do not follow the guidelines or established recommendations.

The aim of the present study was to determine the degree of concordance (agreement or disagreement) among a selected group of specialists from Latin America on a series of diagnostic and therapeutic postulates, in accordance with their personal management of patients with GERD.

In the present study, we showed that even though close to 70% of the Latin American specialists surveyed followed international recommendations, with respect to the diagnostic and therapeutic approach to GERD, there was concordance in less than one-third of them (28%). Given our survey results, the low concordance among the participants in the majority of the statements is most likely influenced by the place of work, personal experience with different diagnostic methods, the available resources, and of course, by each specialist’s professional experience, which does not necessarily coincide with recommendations of the international guidelines. In the majority of cases, the approach of the participants was based on published evidence or their expert opinion.

Making the appropriate diagnosis is essential for the management of GERD, given that an accurate diagnosis guides the treatment and has cost-benefit implications. The variability found in the responses to those corresponding statements was very heterogeneous and striking. Whereas only 22% of the participants completely agreed that no diagnostic test was required in patients with no alarm symptoms and good response to treatment (statement 1), 69% responded that at least one endoscopy should be performed in nonresponders to treatment (statement 8). Regarding the approach variability, certainly the availability of and access to diagnostic tests varies throughout the continent10,11. Our results suggest that conducts cannot always be the same in all cases, and even though the guidelines provide orientation, they cannot always be uniformly applied to all patients or all countries.

Extraesophageal manifestations are one of the most controversial areas in GERD. According to the guidelines3 and published studies12–15, in patients with no symptoms or history of GERD, the causes that are unrelated to GERD (postnasal syndrome, allergies, allergic laryngitis, angiotensin-converting enzyme (ACE) inhibitor use, sinus disorders) must first be ruled out, and indicating PPIs or carrying out reflux monitoring should not be the first course of action.3 In the opinion of the specialists surveyed, the first step would be to begin with double-dose PPI (58.7%, agreement of 23.9%) or carry out reflux monitoring (67.4%, agreement of 34.8%), whereas only 37% (agreement of 11%) would refer patients to rule out causes unrelated to gastroesophageal reflux. Even though the initial approach varied, it should be underlined that 76% of the survey participants agreed that when symptoms of GERD persisted in patients with extraesophageal symptoms, they should be evaluated through pH study with impedance monitoring under treatment. That could reflect the fact that the majority of the participants surveyed follow the international recommendations or that they are a group of specialists with a high level of knowledge of how and when to utilize diagnostic tests, which is also supported by the fact that the statements related to the technical questions of pH-study with impedance monitoring (statements 15–18) had high concordance (above 75%).

Likewise, with respect to treatment, there was heterogeneous variability among the survey participants. A high percentage (83%) were of the opinion that weight loss is one of the most effective lifestyle modifications for reducing symptoms of GERD,16 and very few (20%) did not consider dietary recommendations useful.

The lack of treatment response is currently 40% in patients that take a standard-dose PPI once a day. It is more frequent in patients with nonerosive reflux17,18, and is currently considered multifactorial19–25. In general, the responses of the survey participants coincided with the suggestions in the guidelines and articles3,18, that when there is a lack of response to treatment, correct medication administration should first be verified, and if adequate, the dose should be doubled (statement 21, agreement of 73%)3. Nevertheless, there was lower complete agreement (30%), with respect to changing the PPI. Again, those findings can be influenced by drug availability and cost, which vary in Latin America. The international guidelines recommend that prokinetics not be used in patients with GERD that have not undergone a diagnostic test and advise their indication only in the presence of gastroparesis3. However, in our study, 45.7% of the gastroenterologists stated that prokinetics improved the symptoms of gastroesophageal reflux when they were combined with a PPI, even though agreement was partial in 43.5%. Hypothetically, we believe that said conduct could be influenced by the wide availability of prokinetics in Latin America. Another course of action that is not supported in the guidelines, but was a frequent survey response (87%), was the combination of PPIs and alginates.

On the other hand, the majority of specialists surveyed agreed with the recommendations regarding the differentiation of GERD, esophageal hypersensitivity (EH), and functional heartburn (FH)26, reaffirming the fact that the survey participants were made up of specialists that continuously keep up-to-date on the topic. The majority of the participants (97.8%) were in agreement that adding neuromodulators (tricyclic antidepressants, selective serotonin reuptake inhibitors, etc.) to acid secretion inhibiting therapy was the best management for patients with EH, as recommended in the literature27,28. They also agreed about not using anxiolytics or PPIs in FH (80.4%), again choosing the use of neuromodulators (preferably tricyclic antidepressants, psychotherapy, and relaxation techniques and hypnotherapy) (Fig. 1).

Figure 1.

Level of partial concordance of those surveyed regarding possible treatments to employ in functional heartburn. The negative numbers signify the responses are against the use of the medication alternatives and the positive numbers signify they are in favor of their use.

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At present, although some studies consider that the presence of H. pylori can have a beneficial or protective role in GERD29,30, others have shown the opposite31. The bacterium has even been associated with Barrett’s esophagus, as well as adenocarcinoma of the esophagus32. In the present survey, the gastroenterologists were asked if they considered H. pylori eradication useful in patients with GERD, and 91.3% answered in the negative (agreement of 63%).

Importantly, the primary aim of the present study was not to determine whether the approaches adopted by the specialists were the correct ones, but rather to know the “real world” manner of working of a selected group of gastroenterologists in Latin America. We also took into account the fact that in some cases, the international guidelines are based on scenarios that are not precisely the same as those in developing countries, which are the majority of Latin American countries.

Among the limitations of the present study was the survey design of statements with four possible response categories that could be perceived as unclear and produce doubts. That could possibly explain the poor agreement among the survey participants, indicating a marked dispersion in the responses. Twenty-three of the survey statements were based on international guidelines, whereas, although it could appear arbitrary, the authors of the survey statements agreed that the other 19 statements were conducts frequently seen in their clinical experience. An effort was made to represent all Latin American countries but not all survey invitations were accepted. In addition, whether the survey participants were all gastroenterologists, neurogastroenterologists, or surgeons, was not determined. Our study is not exempt from bias, specifically in the statements that are expressed subjectively that describe two conditional interventions (e.g., statements 36, 37, and 38). Other factors unrelated to the disease can also explain the different responses of the participants, such as the cost-effectiveness of endoscopy and functional studies in each country or region and the manner in which the physicians are paid (by private patients, determined by a healthcare system, as capitation, or as a fixed salary). Those considerations are also reflected in the observations in the World Gastroenterology Organisation (WGO) guidelines2 that differ from those in the American Gastroenterological Association (AGA) guidelines3.

The main strength of the present study is that it is a Latin American study that reflects reality in the management of a disease as complex as GERD. The majority of management guidelines on the disease come from the medical societies of developed countries, and so whether the same recommendations are applied by neurogastroenterologists in Latin America is not known. Even though our findings are important, their validation through similar studies conducted by associations and colleges involved in the management of GERD in Latin America would be very beneficial. Such further study would enable guidelines and/or consensuses to be developed that can be applied to the Latin American reality and said information could be conveyed through various strategies of continuing medical education.

The present study revealed that the diagnostic and therapeutic approach to GERD in Latin America is highly variable and concordance between conducts is low. That poor agreement may be linked to the availability of diagnostic tools and medications, as well as to the different prevalence of the GERD phenotypes in each country.

No financial support was received in relation to this study/article.

Luis Oscar Soifer, has been a consultant for AstraZeneca, Bayer, Bagó, Roemmers, and Novartis and has given talks for Biofarma, Novartis, Sanofi, and Domínguez.

José Tawil is a member of the advisory board of Takeda and has given talks for the Craveri, Temis Lostalo, and Eczane laboratories.

Jose María Remes Troche is a member of the advisory board of Takeda, Asofarma, and Biocodex and has given talks for Takeda, Asofarma, Medtronic, Carnot, and Alfasigma.

Miguel Ángel Valdovinos Díaz is a member of the advisory board of Takeda and has given talks for Takeda, Asofarma, Medtronic, Carnot, and Grünenthal.

Max Julio Schmulson is a research consultant for Alfasigma, a consultant for Gemelli Biotech, and gives talks for Takeda México.

The GERD Collaboration Group of the Sociedad Latinoamericana de Neurogastroenterologia: Soto JC, Sobrino S, Abreu AT, Coss-Adame E, Gomez Escudero O, Amieva Balmori M, Huerta F, Teramoto M (México), Hanna I, Coello Jaramillo R, Montalvo R (Ecuador), Rosas E, Vesco E, Monge V (Peru), Francisconi C, Bievig R, Prado de Moraes Filho J, Resende Neto J, Carvalho P, Bravim M (Brazil), Defilippi C, Monrroy H, Cisternas D, Madrid AM (Chile), Leguisamon AM, Ardila AF, Costa V, Hani A (Colombia), Cohen H, Dacoll C (Uruguay), Aguilar Paiz L, Garcia Martinez I, Jerez González L (Guatemala), Mejía M (Nicaragua), Solé L, Bustos Fernández LM, Ramos RM, Pascual A, Peralta DA, Alach J, Rodriguez S, Defagó MR, Arguero J, Guzmán JM, Ventura A, Salis G (Argentina), with the special collaboration of Sifrim D (Belgium)