AGA: Clinical practice update
Extraesophageal Symptoms and Diseases Attributed to GERD: Where is the Pendulum Swinging Now?

https://doi.org/10.1016/j.cgh.2018.02.001Get rights and content

The purpose of this review is to outline the recent developments in the field of extraesophageal reflux disease and provide clinically relevant recommendations.

The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations:

Best Practice Advice 1: The role of a gastroenterologist in patients referred for evaluation of suspected extra esophageal symptom is to assess for gastroesophageal etiologies that could contribute to the presenting symptoms.

Best Practice Advice 2: Non-GI evaluations by ENT, pulmonary and/or allergy are essential and often should be performed initially in most patients as the cause of the extraesophageal symptom is commonly multifactorial or not esophageal in origin.

Best Practice Advice 3: Empiric therapy with aggressive acid suppression for 6-8 weeks with special focus on response of the extraesophageal symptoms can help in assessing association between reflux and extraesophageal symptoms.

Best Practice Advice 4: No single testing methodology exists to definitively identify reflux as the etiology for the suspected extra esophageal symptoms.

Best Practice Advice 5: Constellation of patient presentation, diagnostic test results and response to therapy should be employed in the determination of reflux as a possible etiology in extra esophageal symptoms.

Best Practice Advice 6: Testing may need to be off or on proton pump inhibitor (PPI) therapy depending on patients’ presenting demographics and symptoms in assessing the likelihood of abnormal gastroesophageal reflux.

A. On therapy testing may be considered in those with high probability of baseline reflux (those with previous esophagitis, Barrett’s esophagus or abnormal pH).

B. Off therapy testing may be considered in those with low probability of baseline reflux with the goal of identifying moderate to severe reflux at baseline.

Best Practice Advice 7: Lack of response to aggressive acid suppressive therapy combined with normal pH testing off therapy or impedance-pH testing on therapy significantly reduces the likelihood that reflux is a contributing etiology in presenting extraesophageal symptoms.

Best Practice Advice 8: Surgical fundoplication is discouraged in those with extra esophageal reflux symptoms unresponsive to aggressive PPI therapy.

Best Practice Advice 9: Fundoplication should only be considered in those with a mechanical defect (e.g., hiatal hernia), moderate to severe reflux at baseline off PPI therapy who have continued reflux despite PPI therapy and have failed more conservative non-GI treatments.

Section snippets

Diagnostic Tests and Challenges Associated in Establishing Causal Link

There are no established diagnostic tests that unequivocally link any suspected extraesophageal symptom to GERD. Diagnostic tests used in evaluation of patients with extraesophageal symptoms (Table 2) suffer from either lack of sensitivity or specificity and have limited associated treatment outcomes. Nevertheless, testing is needed, and often in combination, to support or refute this diagnosis. We do not discuss the use of barium esophagography because of its reduced sensitivity in GERD

Treatment Challenges

The goals of treatment in reflux disease, independent of presenting symptom, are to relieve symptoms, heal esophagitis, and prevent recurrence of symptoms and future complications. The options to achieve these goals include lifestyle modification, medical therapy, endoscopic antireflux procedures, and surgical interventions (Table 3). Endoscopic antireflux procedures are not discussed given limited available data in those with extraesophageal reflux.

Conclusions

Emerging new data in diagnostic tests and treatment outcome suggests that reflux could be causal in a subgroup of patients with extraesophageal reflux, although the degree has been overestimated. Furthermore, the cause of extraesophageal symptoms in many patients is often multifactorial rather than from reflux alone. The role of diagnostic testing in this group is to establish presence and degree of reflux and assess the likelihood that it may be linked to patients’ symptoms. Figure 1 outlines

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    Conflicts of interest This author discloses the following: Frank Zerbib received devices for research purpose from Medtronic and Sandhill Scientific. The remaining authors disclose no conflicts. Vanderbilt University and Diversatek Healthcare Inc jointly hold a patent on the mucosal impedance concept and device discussed in this review.

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