A new approach to diagnosis of gastroesophageal reflux disease (GERD) aims to put more focus on oesophageal testing rather than relying on symptoms and the response to acid suppression.
Enshrined in the Lyon Consensus, the new principles drawn up by gastroenterologists from Europe and the US, define new standards for oesophageal testing to more precisely identify the phenotype of GERD in an individual patient.
Published in Gut the new guide to the diagnosis of GERD states that the traditional starting points of clinical history and response to PPIs have poor specificity and sensitivity for diagnosing GERD.
“Because simple algorithms starting with a PPI trial do not consider these complex phenotypes of GERD, they often lead to inappropriate PPI utilisation, delayed diagnosis and inaccurate diagnoses,” they note.
According to the Lyon Consensus, initial testing for PPI non-responders with no prior endoscopic or pH-metry demonstration of GERD should include pH or pH-impedance monitoring done withholding antisecretory therapy.
“A key potential outcome of that testing is to rule out GERD and to redirect management towards weaning off PPIs, using neuromodulators and/or cognitive behavioural therapy as appropriate,” it states.
For poorly responsive patients with a prior demonstration of GERD, the Lyon Consensus recommends a combination of upper endoscopy, high-resolution manometry (HRM) and pH-impedance monitoring done on twice-daily PPI therapy.
“This combination of tests serves both to redirect therapy towards alternative diagnoses and to mechanistically subtype patients in terms of poor clearance, excessive reflux episodes and hypersensitivity, each of which can trigger specific management options,” it says.
The statements were developed over two years by a group of gastroenterologists who started with a review of the latest evidence, and who met in Lyon in 2017 to adapt the recommendations for practising gastroenterologists.
They say the new consensus statements represent a progression from the previous Porto Consensus of 2002 by including discussion of areas such as endoscopic criteria for GORD, and updated recommendations on reflux monitoring.
They also provide a definition of normal values, with an Acid Exposure Time (AET) of <4% being normal, and >6% abnormal. For reflux episodes, >80/24 hours is defined as abnormal and <40 is defined as physiological when reflux is monitored on or off PPI.
The new consensus statement also proposes that novel metrics such as the PSPW (Post-reflux Swallow-induced Peristaltic Wave) index and baseline impedence should allow a more tailored approach to be taken.
“As the GERD diagnostic paradigm evolves, using diagnostic testing to define a precision approach tailored to the individual patient becomes possible. The goals of evaluation should therefore transition towards defining GERD phenotypes to facilitate tailored treatment.”
Professor Geoff Hebbard, Director, Gastroenterology and Hepatology at the Royal Melbourne Hospital, said the consensus statement represented a good summary of current thinking in terms of diagnosing reflux disease and its relationship to symptoms
It applied most specifically to patients in whom an initial trial of PPI has not been helpful, and where the clinicians wished either to discount reflux as a cause of symptoms or was considering other interventions such as surgery,” he told the limbic.
“I do not think it is advocating use of pH testing before or instead of an initial trial of PPI, but does make the suggestion that where patients have failed PPI, pH testing is a reasonable option to strengthen the case against reflux.”
“I think in this group most gastroenterologists would – based on availability and ability to look for a wider range of conditions – opt for an endoscopy at that point despite poorer performance characteristics in diagnosing reflux compared to pH monitoring.” he added.