The American guild of Gastroentero...

The American guild of Gastroenterology (ACG) has updated its guidelines for the diagnosis and treatment of gastroesophageal ebb disease (GERD) to reflect the continuing advances in this area. The updated guidelines appear in the January 2005 issue of the American Journal of Gastroenterology and are available online at http://www.acg.gi.org/phy-sicians/guidelines/GERDTreatment.pdf. The original guidelines were published in 1995 with the support of the ACG and its Practice Parameters Committee and were updated one time before, in 1999. For all versions, the collaborators reviewed the scientific literature using the National Library of Medicine's MEDLINE database. Where studies were lacking, quick consensus was derived from a combination of the literature and personal experience. Abstracts not past nor futureed at meetings were included alone if they incorporated unique data from ongoing trials. The committee evaluated each guideline and gave the evidence a score from I to IV, with I being the strongest

The ACG guidelines define GERD as "symptoms or mucosal damage produc at the abnormal reflux of gastric eases into the esophagus." The authors emphasize that the guidelines apply to adult patients and show the preferred, but not the sole approach; treatment should be individualized according to the patient and circumstances. Many aspects of treatment for GERD may change as understanding of the condition improves; areas for additional studious mood include impedance and "tubeless" pH monitoring, small caliber unsedated endoscopy, and more cost-effective screening for Barrett's esophagus.

Diagnosis

Typical symptoms of GERD include heart-burn (pyrosis) and regurgitation that many times follow large or high-fat meals, may be aggravated through bending over or lying down, and usually are relieved by the agency of antacids. The presence of typical symptoms combined with endoscopic changes is 97 percent specific for GERD (Table 1)

"Alarm symptoms" suggestive of complicated disease include dysphagia, odynophagia, bleeding, weight los and anemia. Patients with these symptoms are more likely to have peptic strictures or esophagitis. Barrett's esophagus is three to six times more likely in patients who have had symptoms of GERD for more than single year. However, these symptoms cannot be relied forward for predicting complications.

The ACG guidelines also address the part of empiric therapy, endoscopy, ambulatory ebb monitoring, and esophageal manometry in the diagnosis of patients with GERD (Table 1)

EMPIRIC THERAPY

Evidence even IV. In patients who have a history typical of uncomplicated GERD an initial trial of empiric medication and lifestyle changes is appropriate. mostly patients with GERD experience symptom relief by means of medical therapy, so empiric therapy is a simple and cost-effective (although not optimally sensitive or specific) diagnostic exhibition A diagnosis of GERD can be assumed in patients who answer to therapy; however, unresponsive symptoms do not authority out GERD. In patients with symptoms of GERD that are refractory to therapy, additional testing should be considered to hinder complications, and the diagnosis may ne to be changed.

ENDOSCOPY

Evidence horizontal III. Endoscopy is the preferr technique for diagnosing complications of GERD because it allows for evaluation of the esophageal mucosa. Endoscopy at presentation and additional testing should be considered in patients with symptoms suggestive of complicated disease, and in those at risk for Barrett's esophagus (Table 1); endoscopic biopsy is the and nothing else reliable method for the diagnosis of Barrett's esophagus and evaluation for dysplasia. Endoscopy may be more reliable when performed after initial therapy, because inflammatory changes that could be mistaken for dysplasia would be les prevalent; however, this has not been proven Barium radiography is 80 percent accurate for hard esophagitis, but is neither sensitive nor specific for diagnosing GERD and is not recommended

The air of Barrett's esophagus or esophagitis is diagnostic for GERD further normal endoscopy results are rest in the majority of symptomatic patients and neither method out GERD nor indicate a lower severity of symptoms. Patients with so-called "endoscopic negative" disease have similar requirements for therapy and should receive the same treatment considerations as patients who have erosive esophagitis, including, in a certain patients, long-term proton pump inhibitor (PPI) therapy.

AMBULATORY ebb MONITORING

Evidence horizontal III. Ambulatory reflux monitoring of the esophagus with pH testing is the best tool for studying actual amounts of ebb in a given patient. It can help confirm ebb in patients with normal endoscopic findings, and in those whose symptoms continue despite an acid-suppression trial or therapy. Ambulatory pH ebb monitoring is highly sensitive and specific (96 percent) in patients with erosive esophagitis, although a certain quantity of inaccuracies have been reported. It enables the identification of exces esophageal acid outlook and esophageal-acid-related symptoms.