An important consensus statement on the management of gastroesophageal reflux disease for the largest population in the world
Bibliographic record
Abstract
A group of distinguished experts from the Asia–Pacific area have developed an updated consensus on the management of gastroesophageal reflux disease (GERD).1 Although four of the 18 participants also were involved in the global consensus group of the Montreal definition and classification of GERD,2 the definition of Barrett's esophagus is different, as is the extensive focus on the treatment of GERD, accounting for 11 of 38 statements. The level of consensus of the statements is impressive. Even if the level of acceptance of a statement was only “accept completely” or “accept with some reservation”, and not “accept with major reservation”, as defined in the manuscript, acceptance was 85%. After a subgroup discussion of statements and then presentation to the entire consensus group, keypad voting was done to ensure anonymity and avoid the peer pressure of hand or voice voting. One of the unique features of the Asia–Pacific region is the high prevalence of peptic ulcer disease and gastric cancer attributable to the endemic nature of Helicobacter pylori infection. This was especially important in five diagnostic statements considering the role of endoscopy. The role of endoscopy becomes focused on the detection of peptic ulcer and gastric cancer contrasted to the detection of Barrett's esophagus in Western countries. Related to this issue is the recognition of the problem of the overlap of symptoms of different upper gastrointestinal (GI) disorders; that is, the imprecise clinical separation of chronic upper GI symptoms of GERD and peptic ulcer. For example, “heartburn” is a word with no equivalent in any of the Asian languages. Establishing H. pylori status plays a more prominent role in Asia than in Western countries given the prevalence of H. pylori and its resultant peptic ulcer and gastric cancer. The algorithm for the management of reflux symptoms accompanied by alarm features includes H. pylori testing. Compared to the Montreal definition and the British Society of Gastroenterology Guidelines,3 the Asia–Pacific definition of Barrett's esophagus is “the presence of columnar lined epithelium suspected at endoscopy and proven by histology which requires the presence of intestinal metaplasia” with a 94% level of agreement of “accept completely”.1 The Montreal term of “endoscopically suspected esophageal metaplasia” was rejected because of non-sustainability in the Asian context of low prevalence of Barrett's esophagus. Specificity is important for a low prevalence disease in a massive population. Even though GERD is a growing medical problem in Asia, it is less prevalent than in Western countries, and the frequency of esophageal mucosal disease is also less. In fact, non-erosive reflux disease is a larger proportion of GERD in Asia versus Western countries.4 There is agreement on the use of antireflux surgery for GERD patients wanting to stop medical therapy. However, not mentioned is a positive indication for surgery; that is, volume reflux.5 Bothersome regurgitation, even to the point of aspiration pneumonia, may occur even on high-dose proton pump inhibitor therapy. The participants of this Asia–Pacific GERD management consensus are to be congratulated on their complete and thorough consideration of the issues. The prognostic statements can serve as a guide to the practical management of GERD for the region.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.072 | 0.142 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.003 | 0.004 |
| Bibliometrics | 0.004 | 0.002 |
| Science and technology studies | 0.003 | 0.003 |
| Scholarly communication | 0.007 | 0.005 |
| Open science | 0.006 | 0.007 |
| Research integrity | 0.017 | 0.021 |
| Insufficient payload (model declined to judge) | 0.012 | 0.013 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".