Agency for Healthcare Research and Quality
Managing Chronic Gastroesophageal Reflux Disease
Clinician Summary Guide published 23 September 2011
Clinical Bottom Line
Treatment With Medication
- PPIs were superior to H2RAs for esophagitis healing, patient satisfaction and compliance, and symptom remission. [Evidence Scale: Moderate]
- All of the commercially available PPIs appeared to be similarly effective for relieving symptoms and healing esophagitis for up to 1 year, although continuous therapy with a PPI appeared to be more effective than on-demand therapy for symptom control. [Evidence Scale: Moderate]
- Obesity, baseline symptoms, and severe baseline esophagitis were significantly associated with worse outcomes. Older age was associated with improved symptom control at 6 months. [Evidence Scale: Moderate]
- PPIs demonstrated no difference from placebo in resolving hoarseness but did demonstrate some improvement inconsistently in resolving cough. [Evidence Scale: Low]
- Findings concerning the effectiveness of GERD treatment on asthma symptoms were inconsistent. [Evidence Scale: Insufficient]
- Potential adverse effects from PPI treatment included diarrhea, nausea or vomiting, abdominal pain, dyspepsia, headache, intestinal infection, pneumonia, and increased risk of bone fracture. [Evidence Scale: Low]
- There was no significant difference in effectiveness between laparoscopic total and partial fundoplication, between laparoscopic fundoplication with and without division of short gastric vessels, or between open total and partial fundoplication. [Evidence Scale: Moderate]
- Older age, morbid obesity, female sex, presence of baseline symptoms or esophagitis, and hiatal hernia more than 3 centimeters at baseline were inconsistently associated with worse surgical outcomes. [Evidence Scale: Low]
- Evidence was inconclusive regarding the effectiveness of surgical treatment on extraesophageal manifestations of GERD.* [Evidence Scale: Insufficient]
- Serious adverse effects included bloating and dysphagia. Fundoplication was also associated with procedural complications such as postoperative infection and incisional hernia. [Evidence Scale: Low]
- Evidence regarding the effectiveness of the endoscopic treatment EndoCinch ¢ was mixed regarding improvement in symptoms, quality of life, and healing of esophagitis ([Evidence Scale: Low]), and there was insufficient evidence to evaluate other endoscopic procedures (e.g., Stretta ® and EsophyX ¢). [Evidence Scale: Insufficient]
- With regard to how patient characteristics influenced treatment outcomes, lesser degrees of esophagitis were associated with a reduction in the need for PPIs after treatment. Sex did not appear to influence outcomes. [Evidence Scale: Low]
- Common adverse effects from endoscopic suturing included chest or abdominal pain, bleeding, dysphagia, and bloating. [Evidence Scale: Low]
Medical-Surgical-Endoscopic Treatment Comparisons
- Fundoplication is as effective as continued medical treatment in controlling GERD-related symptoms. In some studies, fundoplication was superior to medication. [Evidence Scale: Moderate]
- Out of 7 evaluated studies, 5 included only patients whose symptoms were already well controlled by medication.
- Serious adverse effects could be more common for surgery than for medical treatment. [Evidence Scale: Low]
- Evidence was insufficient to determine whether prevention of long-term complications (such as Barrett s esophagus and esophageal adenocarcinoma) is equivalent between medical and surgical treatments. [Evidence Scale: Insufficient]
- Evidence was insufficient to compare endoscopic treatments to medication or surgery. [Evidence Scale: Insufficient]
*Extraesophageal manifestations of GERD include asthma, cough, and laryngeal symptoms.
H2RA = histamine type 2 receptor antagonists; PPI = proton pump inhibitors
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