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Recent advances in clinical practice
Modern diagnosis of GERD: the Lyon Consensus
  1. C Prakash Gyawali1,
  2. Peter J Kahrilas2,
  3. Edoardo Savarino3,
  4. Frank Zerbib4,
  5. Francois Mion5,6,7,
  6. André J P M Smout8,
  7. Michael Vaezi9,
  8. Daniel Sifrim10,
  9. Mark R Fox11,12,
  10. Marcelo F Vela13,
  11. Radu Tutuian14,
  12. Jan Tack15,
  13. Albert J Bredenoord8,
  14. John Pandolfino2,
  15. Sabine Roman5,6,7
  1. 1 Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
  2. 2 Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
  3. 3 Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
  4. 4 Department of Gastroenterology, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
  5. 5 Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France
  6. 6 Digestive Physiology, Université de Lyon, Lyon I University, Lyon, France
  7. 7 Université de Lyon, Inserm U1032, Lyon, France
  8. 8 Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
  9. 9 Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  10. 10 Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
  11. 11 Gastroenterology, St. Claraspital, Kleinriehenstrasse 30, Basel, Switzerland
  12. 12 Zürich Neurogastroenterology and Motility Research Group, Clinic for Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
  13. 13 Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
  14. 14 Division of Gastroenterology, University Clinics for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
  15. 15 Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
  1. Correspondence to Professor C Prakash Gyawali, Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO 63110, USA; cprakash{at}wustl.edu

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.

  • gastroesophageal reflux disease
  • PH monitoring
  • manometry
  • endoscopy

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/gutjnl-2017-314722

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    Footnotes

    • Contributors All authors contributed to the content of the manuscript, and reviewed, edited and approved the final draft.

    • Funding The consensus process was supported by the Working Group for Gastrointestinal Motility and Function. This group received an educational grant from United European Gastroenterology (UEG).

    • 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.

    • Provenance and peer review Commissioned; externally peer reviewed.

    • Correction notice This article has been corrected since it published Online First. The acknowledgement and funding statements and affiliation for Mark Fox have been updated.