World Gastroenterology Organisation Global Guidelines

This is the second WGO guideline published to complement World Digestive Health Day themes. WGO guidelines are intended to highlight appropriate, context-sensitive and resource-sensitive management options for all geographical regions, regardless of whether they are considered to be “developing,” “semi-developed,” or “developed.” There is a concern that guidelines from developed countries, by emphasizing high-tech investigations and Barrett esophagus (BE) surveillance, for example, may divert research and clinical resources from more urgent problems in developing and semideveloped countries. However, one could argue that there are similar problems in developed countries and that an overemphasis on complications or “proposed GERD associations” (as in the Montreal Consensus1) is leading to inappropriate investigations and resource utilization even in developed regions. It is also important to emphasize to health care insurers and funding bodies that appropriate, effective therapy is both therapeutic and diagnostic and that conducting mandatory investigations [eg, esophagogastroduodenoscopy (EGD) to permit proton-pump inhibitor (PPI) therapy is not patient-centered and, more importantly, is likely not to be cost-effective. WGO Cascades are thus context-sensitive, and the context is not necessarily defined solely by resource availability. Neither the epidemiology of the condition, nor the availability of resources for the diagnosis and management of gastroesophageal reflux disease (GERD), is sufficiently uniform throughout the world to support the provision of a single, gold-standard approach. WGO Cascades: a hierarchical set of diagnostic, therapeutic, and management options for dealing with risk and disease, ranked by the resources available. GERD is now widely prevalent around the world (Table 1), with clear evidence of increasing prevalence in many developing countries. Prevalence estimates show considerable geographic variation, but it is only in East Asia that they are currently consistently lower than 10%.2 The high prevalence of GERD, and hence of troublesome symptoms, has significant societal consequences, impacting adversely on work productivity3 and many other quality-of-life aspects for individual patients.4,5TABLE 1: GERD Symptoms: Range of IncidencePractice recommendations should be sensitive to context, with the goal of optimizing care in relation to local resources and the availability of health care support systems. The expression of the disease is considered to be similar across regions, with heartburn and regurgitation as the main symptoms. For initial management, the patient may purchase over-the-counter (OTC) medication for heartburn relief or seek further advice from a pharmacist. When patients perceive that their symptoms are more troublesome, they may seek a doctor’s advice; depending on the patient’s circumstances and the structure of the local health care system, patients may seek advice at the primary care level or they may consult a gastroenterology specialist or surgeon, directly or by referral. The WGO Cascade approach aims to optimize the use of available health care resources for individual patients, based on their location and access to various health care providers. CLINICAL FEATURES Predisposing and Risk Factors GERD is a sensorimotor disorder associated with impairment of the normal antireflux mechanisms (eg, lower esophageal sphincter function, phrenicoesophageal ligament), with changes in normal physiology (eg, impaired esophageal peristalsis, increased intragastric pressure, increased abdominothoracic pressure gradient) or, very rarely, excess gastric acid secretion (Zollinger-Ellison syndrome). Eating and Lifestyle An increase in GERD symptoms occurs in individuals who gain weight.6 A high body mass index (BMI) is associated with an increased risk of GERD.7 High dietary fat intake is linked to a higher risk of GERD and erosive esophagitis (EE).8 Carbonated drinks are a risk factor for heartburn during sleep in patients with GERD.9 The role of coffee as a risk factor for GERD is unclear; coffee may increase heartburn in some GERD patients,10 but the mechanism is unknown and it may be due to caffeine, rather than coffee per se. Coffee is not a dominant risk factor. The role of alcohol consumption as a risk factor for GERD is unclear. Excessive, long-term use may be associated with progression to esophageal malignancy, but this may be independent of an effect of alcohol on GERD.11,12 The role of smoking as a risk factor for GERD is unclear, although like alcohol, it is associated with an increased risk of malignancy.13,14 Medication—Certain Medications May Affect GERD See the Patient history and physical examination section. The treatment of comorbidities (eg, with calcium channel blockers, anticholinergics, and nonsteroidal anti-inflammatory drugs (NSAIDs) may negatively affect GERD and its treatment.15 Some medications (eg, potassium supplements, tetracycline, bisphosphonates) may cause upper gastrointestinal (GI) tract injury and exacerbate reflux-like symptoms or reflux-induced injury. Pregnancy Heartburn during pregnancy usually does not differ from the classic presentation in the adult population, but it worsens as pregnancy advances. Regurgitation occurs with approximately the same frequency as heartburn, and GERD in the first trimester is associated with a number of altered physiological responses.16,17 Factors that increase the risk of heartburn18 are: heartburn before pregnancy, parity, and duration of pregnancy. Maternal age is inversely correlated with the occurrence of pregnancy-related heartburn.19 Symptomatology GERD has a wide spectrum of clinical symptom-based and injury-based presentations, which may manifest either separately or in combination. Symptom evaluation is key to the diagnosis of GERD, particularly in the evaluation of the effectiveness of therapy. Heartburn and regurgitation are the most common symptoms, but atypical symptoms of GERD may occur, with or without the common symptoms. Atypical symptoms may include epigastric pain20 or chest pain,1,21 which may mimic ischemic cardiac pain, as well as cough and other respiratory symptoms that may mimic asthma or other respiratory or laryngeal disorders. Dysphagia may also occur. A minority of GERD patients have multiple unexplained symptoms, which may be associated with psychological distress22 (Table 2).TABLE 2: GERD Symptoms23,24Natural History Most cases of GERD are mild and are not associated with a significant increase in morbidity or mortality in comparison with the general population. In most GERD patients, the severity of the condition remains stable or improves over a 5-year observation period during current routine clinical care.26 There is a relationship between GERD and obesity: a higher BMI or larger waist circumference and weight gain are associated with the presence of symptoms and complications of GERD, including BE.27 Complicated GERD is characterized by stricture, BE, and esophageal adenocarcinoma. The Montreal consensus includes EE as a complication of GERD (recognizing that the definition of “mucosal breaks” used in the Los Angeles classification includes esophageal ulceration in the range of reflux esophagitis).28 Nonerosive reflux disease (NERD) may progress to EE in approximately 10% of GERD patients,29 and EE may therefore be considered as a manifestation of more severe reflux disease. EE is associated with BE and is a major risk factor for BE. In comparison with patients who were free of GERD at follow-up, those with EE had a 5-fold increased risk of BE after 5 years, in a cohort of the general population in Sweden.30 Globally, BE is rare in patients with GERD. It is more common in western populations. It is not known when BE develops relative to the onset of GERD; however, it appears to be more prevalent in older individuals and is strongly associated with an increased risk of esophageal adenocarcinoma.31 There is a well-documented association between BMI and adenocarcinoma of the esophagus and gastric cardia, although the risk of malignancy in a given individual with GERD is very low.32 Alarm Features Most alarm features are not specific for GERD; many are associated with alternative diagnoses that are unrelated to GERD. In most countries, many of these features relate to gastric cancer, complicated ulcer disease, or other serious illnesses. Dysphagia.33 Odynophagia (painful swallowing). Recurrent bronchial symptoms, aspiration pneumonia. Dysphonia. Recurrent or persistent cough. GI tract bleeding. Frequent nausea and/or vomiting. Persistent pain. Iron-deficiency anemia. Progressive unintentional weight loss. Lymphadenopathy. Epigastric mass. New-onset atypical symptoms at age 45 to 55 years (a lower age threshold may be appropriate, depending on local recommendations). Family history of either esophageal or gastric adenocarcinoma.34 The WGO Global Guideline on common GI symptoms may also be consulted: http://www.worldgastroenterology.org/guidelines/global-guidelines/common-gi-symptoms and http://journals.lww.com/jcge/Fulltext/2014/08000/Coping_With_Common_Gastrointestinal_Symptoms_in.4.aspx. DIAGNOSIS Diagnostic Considerations The presence of heartburn and/or regurgitation symptoms 2 or more times a week is suggestive of GERD.35 Clinical, endoscopic, and pH-metric criteria provide a comprehensive characterization of the disease, although investigations are usually not required to establish a diagnosis of GERD—with the caveat that the pretest probability of GERD varies markedly between geographical regions. The initial evaluation should document the presence, severity, and frequency of heartburn, regurgitation (acid or otherwise), and alarm features; atypical esophageal, pulmonary, otorhinolaryngological, and oral symptoms should also be sought. It may be helpful to evaluate precipitating factors such as eating, diet (fat), activity (stooping), and recumbence; and relieving factors (bicarbonate, antacids, milk, OTC medications). At this point, it is important to rule out other GI diagnoses, particularly upper GI cancer and ulcer disease, especially in areas in which these are more prevalent. It is also important to consider other, non-GI diagnoses, especially ischemic heart disease. Diagnostic questionnaire tools for GERD (reflux disease questionnaires, RDQs) have been developed for epidemiological studies. However, RDQs did not perform particularly well in the Diamond study.36 In fact, diagnosis by a physician such as the family practitioner or GI specialist showed better sensitivity and specificity for the diagnosis of GERD than did the RDQ. Questionnaires are generally difficult to use in clinical practice. A careful history is the basis for symptomatic diagnosis, with EGD being reserved for identifying or excluding significant structural lesions in selected cases. A region-based assessment of the local “pretest probability” may provide some guidance with regard to the choices and sequence of diagnostic tests needed, given the relatively poor predictive value of most symptoms. as an to It is to an to 2 of treatment to whether or not the patient’s symptoms are acid this is sensitive nor this is in practice. A of of duration is required to the treatment in GERD reflux may be a of all reflux this is the such patients may not well to therapy to of GERD patients may not to In reflux may to of all reflux In a of reflux-like symptoms may be due to heartburn, rather than diagnoses, including ulcer disease, upper GI malignancy, of the cardia, and disease should also be In patients with cases that are to esophageal with the patient may be considered to there has been to to the should be at week before is may be when to for acid the reflux symptoms have or without esophageal should be with being to for acid reflux that is persistent with esophageal may be with the patient both on and In many countries with a high prevalence of ulcer and gastric cancer to be more common than GERD and cause higher morbidity and In this approach to the diagnosis and management of upper symptoms include an assessment of the of with and an of the and of symptoms of GERD, ulcer disease, and a the relative of a approach in comparison with EGD to for and before antireflux therapy. epidemiological show a association between the prevalence of and the presence and severity of GERD, this is not of should be and therapy given when in with or local there may be an between and GERD prevalence and severity, this may well of a factor or factors on the 2 rather than a relationship between and GERD. have that esophageal acid which is the of esophageal is not by the presence or of In most patients, has effect on severity, or treatment in GERD. does not exacerbate GERD or affect treatment in patients with therapy is associated with a lower prevalence of reflux-like symptoms than therapy A of patients with more of factors and may be likely to have severe esophagitis or BE. This may be in these patients more severe with in acid However, these patients are at risk of developing gastric therapy in these patients has the to the risk of gastric and are associated with a of the of in patients, by an increased prevalence of gastric and that occurs as well as more than in patients who not gastric and are known to be the major risk factors for the of gastric most guidelines and for before long-term particularly in EGD is usually for upper GI symptoms, of in it is available and and both the frequency of ulcer disease and the concern malignancy are as in most of The Cascades given the availability of in areas by the use of therapy as a EGD is in the prevalence of GERD is the of GERD patients have in these the sensitivity of EGD for the diagnosis of GERD be and the main therefore be the of other upper GI is particularly for patients with alarm features suggestive of GERD with complications or of other significant upper GI disease such as or weight loss. with should for a complication or for an stricture, or In countries, the for EGD is by the risk of malignancy at an age and by the availability of approach. investigations other than EGD are they have and are Patient History and The of patient evaluation include the assessment of symptoms and risk factors for the diagnosis of GERD and the of long-term In this it is important to consider the epidemiology of upper GI disease and the pretest probability of GERD relative to other In for BE is and it is not therefore an important risk for esophageal which is The prevalence of ulcer and gastric cancer are the of in Asia in the esophageal adenocarcinoma is and Family History Features The features may be helpful in a diagnosis and the severity of Predisposing factors and risk including family of symptoms. symptoms, including of and relationship to symptoms, including on sleep and the of a and and including symptomatic to with medications including a diagnosis of GERD. or may esophageal or malignancy, as well as esophagitis or esophageal History The patient should be medications that may to upper symptoms necessarily tetracycline, calcium channel blockers, History In some patients, or may be associated with an increased risk of GERD or gastroesophageal reflux symptoms that smoking and some physical as well as of and be but there is evidence for the of alcohol and dietary including caffeine, and In those who are weight may be associated with in GERD or may increase the for There are usually physical of GERD. and BMI are to of rarely, be and to other problems such as cardiac disease, and Diagnostic for GERD A diagnosis of GERD be in the of heartburn and In pregnancy, GERD be on the basis of symptoms the dominant or most troublesome symptoms are atypical for GERD, other diagnoses should be including and disease. In with a high prevalence of an initial or should be are or and esophageal be but are required to structural (eg, in patients with symptoms. reflux symptoms or GERD complications be (Table Diagnostic for ulcer disease. and heartburn on the basis of a clinical to therapeutic acid or of the body esophageal heart disease, disease. chest Cascades for the of GERD For perform esophageal in or for selected patients in with features For consider this only there is a high prevalence of BE in the local population and there are For most EGD not the management, in the of alarm features or access to antireflux There is role for upper GI in the of routine upper GI symptoms (Table Cascades for the of the severity and frequency of symptoms between GERD patients, reflux symptoms not the criteria for a diagnosis of GERD and are with and as or severe symptoms with of and therapy to their of the management of GERD a both with to the and to the health care who or provide therapy. The of GERD management are and of esophageal acid either by local acid or by of gastric acid secretion or, rarely, antireflux The primary of treatment are to symptoms, the patient’s of and or complications in the most heartburn than per week to with an or a week or medications are very to have are and are to in this of patients, of or that symptoms and of at may be in those who are may also the frequency of symptoms. who have more symptoms should be for therapy. A diagnosis of troublesome symptoms 2 or more times per therapy with an acid inhibitor or, may also be used or are or for relief in patients a OTC or patients to a or primary care The definition of treatment to a on the treatment being In treatment may the patient does not have GERD; in it may be that the treatment is to the severity of the GERD. In the there may be a to and management be by the availability and of more may to care initial management to reflux should on clinical with treatment of the symptoms being the It is to the effective of For patients with mild symptoms, and some patients with therapy is a management in many cases. 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Dysphagia or or of GI and anemia. or of or weight loss. and/or suggestive of chest to or of In or years of age for or years for The of are that the patient should and to an of with the most therapy. and relief is not patients should be to a health care for diagnostic who gastric acid should have an for long-term the long-term for should be which should be based on and diagnosis and the treatment does not medication should be is for Family OTC medications and as available from of in EE all may be available in all countries, and the of may differ in some May gastroesophageal but are available for clinical use and their in clinical has been at should be of and is not of around of the on availability and Alarm features the Alarm features medication other medications). for the range of symptoms should be in to or other than heartburn may to Regurgitation may not to treatment as well as treatment may to in a minority of treatment may be common with patients with GERD may show poor to the and this may an important role in treatment most are more effective to before a acid gastric gastric are effective for acid in or but long-term There is evidence to support the use of or in with acid have to in many and be or of acid most of these are based on of and therefore show that may not be and at a from that with GI a increased risk of and an association with increased risk of with tract a increased risk of with use the of the the of a clear and the for not but with studies. evidence of increased risk associated with use per se. likely or Alarm features the Alarm features medication other medications). on the of further and GERD in Pregnancy (Table for GERD in in GERD patients is but may be considered there is a reflux symptoms and there is evidence of aspiration or may include with associated with esophagitis to or persistent symptoms as being by The to acid in patients with heartburn is by definition or at and patients are at risk of being for treatment for GERD. all patients with symptoms of GERD who are for should to rule out should also esophageal a and EGD to rule out other antireflux have been but have due to There is a of long-term for some and and these options should only be in the context of clinical of GERD the for patients with GERD is with to with complications may BE, and malignancy (Table for in for the of GERD A diagnostic evaluation of the patient’s history and a physical examination the Diagnostic and Patient history and physical examination including when symptoms the or and in relation to and the or to antacids, or is for the guidance in to diagnostic The Cascade in that there are alarm features and non-GI of the symptoms, that has been and and that use has been as a cause of Cascades: in the of and (Table of and on GERD of guidelines for diagnosis and for the diagnosis and management of gastroesophageal reflux disease. Guideline of of the of for gastroesophageal reflux advice from the clinical guidelines of the of on the management of on the management of Guideline GERD consensus for the diagnosis and management of gastroesophageal reflux an consensus consensus on the management of gastroesophageal reflux for of in the management of of of in the management of GERD. on therapy in gastroesophageal reflux on the use of therapy for gastroesophageal reflux disease. of GERD on the management of gastroesophageal reflux disease in of guidelines for reflux disease in guidelines for Los Angeles of EE (Table Los Angeles of for BE The criteria for BE provide a classification that has and by The criteria a for the of BE, based on the of the esophagus and by Barrett relative to the gastroesophageal characterized by the of the gastric and/or the lower esophageal sphincter criteria are and by The location of gastroesophageal is to this classification and also be and by This classification the of to the of for BE in individual patients and the classification of patients with BE in clinical

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.