Gastroesophageal reflux disease (GERD) is estimated to affect nearly 20% of Americans. Recent advances in our understanding of GERD have changed clinical practice. Therefore, in February 2022, the American College of Gastroenterology (ACG) released an updated set of guidelines for the diagnosis and management of GERD. Research from Baylor University Medical Center (Baylor Dallas), part of Baylor Scott & White Health, helped shape these new practice guidelines.
Highlights of the ACG Guidelines for GERD
The new guidelines, published in the American Journal of Gastroenterology, represent the first update in nearly a decade. According to Stuart Spechler, MD, chief of the division of gastroenterology at Baylor Dallas, co-director of the Center for Esophageal Research, and senior author on the manuscript, “One of the major changes to the guidelines came from work done here at Baylor Dallas. We were the first to point out that if patients are taking proton pump inhibitors (PPIs) at the time of endoscopy, the PPIs can mask the presence of eosinophilic esophagitis, an allergic disorder of the esophagus that can be confused with GERD. So, for patients who have not responded well to PPIs, it is now recommended to stop the PPIs for two weeks before diagnostic endoscopy. This was not a common clinical practice prior to the publication of our findings, and it is now standard clinical practice around the world.”
The new information about PPI use came from updated research on PPI-responsive esophageal eosinophilia. According to Dr. Spechler, “We used to think that the only effect of PPIs was to stop acid production from the stomach. So, the only esophageal disease that should be responsive to PPIs was GERD, which is caused by acid that refluxes from the stomach into the esophagus. Work from our laboratory showed that eosinophilic esophagitis responds to PPIs through a completely different mechanism.” It is now known that PPIs have an anti-inflammatory function in eosinophilic esophagitis through a mechanism involving the secretion of cytokines by esophageal epithelial cells.
The new guidelines also highlight novel surgical treatments for GERD, including magnetic sphincter augmentation. The technique uses the LINX Reflux Management System, which is a ring of magnetic beads implanted around the distal esophagus. The force of swallowing opens the magnetic ring, and after the food passes through, the magnets help the ring close tightly. In an early pilot study, over 90 percent of participants showed at least a 50 percent increase in quality of life and reduction in PPI usage. “Surgeons on the medical staff at Baylor Dallas have great expertise in this technique,” said Dr. Spechler.
The guidelines also include an important update on the potential side effects of PPIs. According to Dr. Spechler, “PPIs are considered to be a very safe class of drugs. However, over the past ten years, there have been reports of potentially very serious side effects associated with PPI use. In the new guidelines, we discuss how physicians should inform their patients of these possible side effects and what we think is the relative importance of these findings.”
As the authors describe, multiple retrospective studies have identified correlations between PPI use and major side effects such as dementia, heart disease, and bone fractures. However, retrospective studies cannot assess causation, so it is not possible to determine if the PPIs are responsible for these effects. Dr. Spechler adds, “The best studies so far have not found a significant association of PPIs with any of these negative side effects, except for a small increase in the risk of enteric infections. However, there is no way any study, no matter how big it is, can absolutely exclude the possibility of a serious side effect.”
Warning Signs with GERD
The new guidelines still state that heartburn and regurgitation are the cardinal symptoms of GERD. According to Dr. Spechler, “If the patient has these symptoms and no warning signs, we still recommend that primary care providers treat with PPIs. Warning signs would include dysphagia (difficulty swallowing), weight loss, and blood in the stool. These warning signs indicate that there may be more than just GERD driving the symptoms, and a patient with these symptoms should be seen by a gastroenterologist who specializes in esophageal disease.”
The updated ACG guidelines are available here.
Gastroenterology and Gastrointestinal Surgery at Baylor Dallas
The division of gastroenterology at Baylor Dallas is nationally ranked by U.S. News and World Report Best Hospitals for excellence in clinical care. The program’s high-volume clinical practice and multidisciplinary team at Baylor Dallas offer the latest technologies for the diagnosis, treatment, and management of digestive disorders and gastrointestinal disease. The physicians also participate in a robust suite of NIH-funded research projects, through Baylor Scott & White Research Institute, to answer critical clinical questions and drive the field of gastroenterology forward.