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Gut. 2018 Jul;67(7):1351-1362. doi: 10.1136/gutjnl-2017-314722. Epub 2018 Feb 3.

Modern diagnosis of GERD: the Lyon Consensus.

Author information

1
Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA.
2
Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA.
3
Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy.
4
Department of Gastroenterology, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France.
5
Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France.
6
Digestive Physiology, Université de Lyon, Lyon I University, Lyon, France.
7
Université de Lyon, Inserm U1032, Lyon, France.
8
Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
9
Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
10
Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
11
Gastroenterology, St. Claraspital, Kleinriehenstrasse 30, Basel, Switzerland.
12
Zürich Neurogastroenterology and Motility Research Group, Clinic for Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland.
13
Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA.
14
Division of Gastroenterology, University Clinics for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland.
15
Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium.

Abstract

Clinical history, questionnaire data and response to antisecretory therapy are insufficient to make a conclusive diagnosis of GERD in isolation, but are of value in determining need for further investigation. Conclusive evidence for reflux on oesophageal testing include advanced grade erosive oesophagitis (LA grades C and D), long-segment Barrett's mucosa or peptic strictures on endoscopy or distal oesophageal acid exposure time (AET) >6% on ambulatory pH or pH-impedance monitoring. A normal endoscopy does not exclude GERD, but provides supportive evidence refuting GERD in conjunction with distal AET <4% and <40 reflux episodes on pH-impedance monitoring off proton pump inhibitors. Reflux-symptom association on ambulatory reflux monitoring provides supportive evidence for reflux triggered symptoms, and may predict a better treatment outcome when present. When endoscopy and pH or pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (histopathology scores, dilated intercellular spaces), motor evaluation (hypotensive lower oesophageal sphincter, hiatus hernia and oesophageal body hypomotility on high-resolution manometry) and novel impedance metrics (baseline impedance, postreflux swallow-induced peristaltic wave index) can add confidence for a GERD diagnosis; however, diagnosis cannot be based on these findings alone. An assessment of anatomy, motor function, reflux burden and symptomatic phenotype will therefore help direct management. Future GERD management strategies should focus on defining individual patient phenotypes based on the level of refluxate exposure, mechanism of reflux, efficacy of clearance, underlying anatomy of the oesophagogastric junction and psychometrics defining symptomatic presentations.

KEYWORDS:

PH monitoring; endoscopy; gastroesophageal reflux disease; manometry

PMID:
29437910
PMCID:
PMC6031267
DOI:
10.1136/gutjnl-2017-314722
[Indexed for MEDLINE]
Free PMC Article

Conflict of interest statement

Competing interests: CPG: consulting: Ironwood, Torax, Quintiles; teaching and speaking: Medtronic, Diversatek, Reckitt-Benckiser. ES: consulting: AbbVie, Allergan, MSD, Takeda, Sofar, Janssen; teaching and speaking: Medtronic, Reckitt-Benckiser, Malesci, Zambon. FZ: research support: Medtronic, Sandhill Scientific; consulting: Allergan, Reckitt-Benckiser; speaking and teaching: Ipsen Pharma, Biocodex, Coloplast, Takeda, Vifor Pharma, Mayoly Spindler. PJK: consulting: Ironwood. FM: teaching and speaking: Laborie, Medtronic; consulting: Allergan, Endostim. AJPMS: none. MV: Vanderbilt University and Diversatek co-own patent on mucosal impedance technology. DS: research support: Diversatek, Reckitt-Benckiser; OMOM, Jinshan Science & Technology (Group) Co. Ltd., Chongqing, China. MRF: research support: Given Imaging/Covidien, Reckitt Benckiser, Mui Scientific. Educational events: Given Imaging/Covidien, MMS, Sandhill Scientific Instruments. Speaking and teaching: Given Imaging/Covidien, Reckitt Benckiser, Shire, Almirall. MV: consulting: Torax. RT: teaching: Laborie. JT: consulting: Ironwood. AJB: research support: Danone, Bayer; speaking and/or consulting: MMS, Astellas, AstraZeneca, Bayer, Almirall and Allergan. JP: research support: Impleo; speaking and/or consulting: Medtronic, Diversatek, Torax, Ironwood, Takeda, AstraZeneca; stock options: Crospon. SR: research support: Sandhill Scientific, Crospon; teaching: Medtronic; speaker: Mayoly Spindler.

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