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首页 > 美国胃肠病协会(AGA)发布可疑胃食管反流病(GERD)处理指南

美国胃肠病协会(AGA)发布可疑胃食管反流病(GERD)处理指南

2011-10-10 14页 pdf 193KB 46阅读

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美国胃肠病协会(AGA)发布可疑胃食管反流病(GERD)处理指南 A A atio th l R Th Med rev D, Bl alua sur Lan gas S. Pr MB Ma PT I str (G the tro AG Co ma in ret be eac du da era ate Ins con abs these conclusions was weighed using US Preventive Services Task Force (USPSTF) grades. Of note, none of the formulated practice reco...
美国胃肠病协会(AGA)发布可疑胃食管反流病(GERD)处理指南
A A atio th l R Th Med rev D, Bl alua sur Lan gas S. Pr MB Ma PT I str (G the tro AG Co ma in ret be eac du da era ate Ins con abs these conclusions was weighed using US Preventive Services Task Force (USPSTF) grades. Of note, none of the formulated practice recommendations were judged to be sufficiently un- equ qu GE log the gra de pa ad up Mo de ble “tr bei tho tis sifi ack to lish tha rat syn fun GE ero ep “tr burn symptoms of insufficient frequency or severity to be perceived as troublesome by the patient (after assurance of their benign nature) do not meet the Montreal definition of A G A IN ST IT U TE GASTROENTEROLOGY 2008;135:1383–1391 ivocal to be proposed as performancemeasures for gauging ality of care. Diagnosis and Initial Therapy 1. What Is an Operational Definition of GERD? What Is the Distinction Between GERD and Episodic Heartburn? There can be no criterion standard definition of RD because the threshold distinction between physio- ic reflux and reflux disease is ultimately arbitrary. Hence, se questions can only be answered by opinion (USPSTF de not applicable). Fortuitously, a recent consensus in fining GERD (the Montreal consensus) emanated from a nel of world experts. The Montreal definition was a symptomatic esophageal GERD syndrome. 2. What Is the Efficacy of Lifestyle Modifications for GERD? Which Elements Should Be Recommended and in Which Circumstances? Grade B: recommended with fair evidence that it improves important outcomes I. Weight loss should be advised for overweight or obese patients with esophageal GERD syndromes. GA INSTITUTE merican Gastroenterological Associ e Management of Gastroesophagea e American Gastroenterological Association (AGA) Institute iew, a community-based gastroenterologist (Stephen W. Hiltz, M ack, MD, Medical Director, Policy Resources Technology Ev geon (Irvin M. Modlin, MD), a patient advocate (Gregory troenterologist with expertise in health services research (Philip actice and Quality Management Committee (John Allen, MD, nagement and Economics Committee and the AGA Institute C n the development of this medical position statement, 12 broad questions pertinent to diagnostic and management ategies for patients with gastroesophageal reflux disease ERD) were developed by interaction among the authors of technical review,1 representatives from the American Gas- enterological Association (AGA) Institute Council, and the A Institute Clinical Practice and Quality Management mmittee. The questions were designed to encapsulate the jormanagement issues encountered in patientswithGERD current clinical practice. The issue of management of Bar- t’s esophagus was intentionally excluded, because this will the focus of a subsequent medical position statement. For h question, a comprehensive literature search was con- cted, pertinent evidence reviewed, and the quality of relevant ta evaluated. The details of development methodology, lit- ture search methodology, and literature search yield associ- d with each of the questions are available on the AGA titute Web site as a separate document.2 The resultant clusions were based on the best available evidence or, in the ence of quality evidence, expert opinion. The strength of opted in the technical review as a suitable framework on which to build management recommendations. The n Medical Position Statement on eflux Disease ical Position Panel consisted of the authors of the technical MBA, AGAF), an insurance provider representative (Edgar tion Center, BlueCross BlueShield Association), a general e), a primary care physician (Steve P. Johnson, MD), a Schoenfeld, MD), the Chair of the AGA Institute Clinical A, AGAF), and the Chair of the AGA Institute Practice Advisor (Joel V. Brill, MD, AGAF). ntreal consensus defined GERD as “a condition which velops when the reflux of stomach contents causes trou- some symptoms and/or complications.” Symptoms are oublesome” if they adversely affect an individual’s well- ng. Esophageal GERD syndromes are categorized as se that are symptom based and those that are defined by sue injury, while the extraesophageal syndromes are clas- ed as of established or proposed association with GERD, nowledging that while the evidence on hand is sufficient link these syndromes to reflux, it is insufficient to estab- causation. A distinguishing feature of the Montreal definition is t it does not use the term “nonerosive reflux disease” but her subdivides esophageal syndromes into symptomatic dromes and syndromes with esophageal injury. Hence, ctional heartburn does not fit theMontreal definition of RD, whereas it is included under the umbrella of non- sive reflux disease. The distinction between GERD and isodic heartburn in theMontreal definition is in the word oublesome.” In the absence of esophageal injury, heart- © 2008 by the AGA Institute 0016-5085/08/$34.00 doi:10.1053/j.gastro.2008.08.045 II G id I. me foo ch ma sp red ces cu the an set su mo rec cifi he tur be pa bu be ov los po G d I. G im I II G is I. ap pli tie dru are are sup the im tw ica da on na He op tw pa sat he the tha pre the com pa PP sid pe a d A G A IN STITU TE 1384 AMERICAN GASTROENTEROLOGICAL ASSOCIATION INSTITUTE GASTROENTEROLOGY Vol. 135, No. 4 . Elevation of the head of the bed for selected patients who are troubled with heartburn or regurgitation when recumbent. Other lifestyle modifications including, but not limited to, avoiding late meals, avoiding specific foods, or avoiding specific activities should be tailored to the circumstances of the individual patient. rade Insuff: no recommendation, insufficient ev- ence to recommend for or against Broadly advocating lifestyle changes for all (as opposed to selected) patients with GERD. Broadly speaking, lifestyle modifications recom- nded for GERD fall into 3 categories: (1) avoidance of ds that may precipitate reflux (eg, coffee, alcohol, ocolate, fatty foods), (2) avoidance of acidic foods that y precipitate heartburn (eg, citrus, carbonated drinks, icy foods), and (3) adoption of behaviors that may uce esophageal acid exposure (weight loss, smoking sation, raising the head of the bed, and avoiding re- mbency for 2–3 hours after meals). The problem with se is that there are simply too many recommendations d each is too narrowly applicable to enforce the whole on every patient. However, it is also clear that there are bsets of patients who may benefit from specific lifestyle difications, and it is good practice to make those ommendations to those patients based on their spe- c history. A patient with symptoms of nighttime artburn or regurgitation of sufficient severity to dis- b his or her sleep despite acid suppressive therapy may nefit from elevation of the head of the bed. Similarly, a tient who consistently experiences troublesome heart- rn after ingestion of alcohol, coffee, or spicy foods will nefit from avoidance of these. Finally, if a patient is erweight or obese, it is reasonable to suggest weight s as an intervention that may prevent, or at least stpone, the need for acid suppression. 3. How Do Antisecretory Therapies Compare in Efficacy and Under What Circumstances Might One Be Preferable to Another? What Is an Acceptable Upper Limit of Empirical Therapy in Patients With Suspected Typical Esophageal GERD Syndromes Before Performing Esophagogastroduodenoscopy? rade A: strongly recommended based on good evi- ence that it improves important health outcomes Antisecretory drugs for the treatment of patients with esophageal GERD syndromes (healing esophagitis and symptomatic relief). In these uses, proton pump inhibi- tors (PPIs) are more effective than histamine2 receptor antagonists (H2RAs), which are more effective than placebo. rap an ing rade B: recommended with fair evidence that it proves important outcomes . Twice-daily PPI therapy for patients with an esophageal syndrome with an inadequate symptom response to once-daily PPI therapy. . A short course or as-needed use of antisecretory drugs in patients with a symptomatic esophageal syndrome without esophagitis when symptom control is the pri- mary objective. For a short course of therapy, PPIs are more effective than H2RAs, which are more effective than placebo. rade D: recommend against, fair evidence that it ineffective or harms outweigh benefits Metoclopramide as monotherapy or adjunctive therapy in patients with esophageal or suspected extraesophageal GERD syndromes. The current consensus is that empirical therapy is propriate initial management for patients with uncom- cated heartburn. Abundant data support treating pa- nts with esophageal GERD syndromes with antisecretory gs, and there is ample evidence that, as a drug class, PPIs more effective in these patients than are H2RAs, which in turn more effective than placebo. However, the data porting the use of PPIs (or H2RAs) in doses higher than standard are weak. Similarly, there is no evidence of proved efficacy by adding a nocturnal dose of an H2RA to ice-daily PPI therapy. A notable disconnect between clin- l trial data and clinical practice is in the use of PPIs twice ily. Almost all efficacy data on these medications are from ce-daily dosing studies, even though the pharmacody- mics of the drugs logically supports twice-daily dosing. nce, guidance on this issue comes primarily from expert inion, which is essentially unanimous in recommending ice-daily dosing of PPIs to improve symptom relief in tients with an esophageal GERD syndrome with an un- isfactory response to once-daily dosing. Patients whose artburn has not adequately responded to twice-daily PPI rapy should be considered treatment failures, making t a reasonable upper limit for empirical therapy. Circumstances in which one antisecretory drug might be ferable to another primarily relate to side effects or when onset of effect is a prime consideration. The most mon side effects of PPIs are headache, diarrhea, consti- tion, and abdominal pain. Switching among alternative I drugs or to a lower dose can usually circumvent these e effects. As for the issue of onset of action, this primarily rtains to on-demand therapy. If a patient intends to take rug only in response to symptoms, then it should be a idly acting drug. The most rapidly acting agents are tacids, the efficacy of which can be sustained by combin- them with an H2RA or a PPI. G im I II IV G id I II is i to eva mi eas tha alt bla ulc agi ala ind ide los ing vea en mu spe is p tha PP tom the no dia Ba tro sho eff on refl tir dis he som tan as or on try the ap for de pe dif ad equ thi tom A G A IN ST IT U TE October 2008 AMERICAN GASTROENTEROLOGICAL ASSOCIATION INSTITUTE 1385 4. What Is the Role and Priority of Diagnostic Tests (Endoscopy With or Without Biopsy, Esophageal Manometry, Ambulatory pH Monitoring, Impedance-pH Monitoring) in the Evaluation of Patients With Suspected Esophageal GERD Syndromes? rade B: recommended with fair evidence that it proves important outcomes I. Endoscopy with biopsy for patients with an esophageal GERD syndrome with troublesome dysphagia. Biopsies should target any areas of suspected metaplasia, dysplasia, or in the absence of visual abnormalities, normal mucosa (at least 5 samples to evaluate for eosinophilic esophagitis). I. Endoscopy to evaluate patients with a suspected esophageal GERD syndrome who have not responded to an empirical trial of twice-daily PPI therapy. Biopsies should target any area of suspected metaplasia, dysplasia, or malignancy. I. Manometry to evaluate patients with a suspected esophageal GERD syndrome who have not responded to an empirical trial of twice-daily PPI therapy and have normal findings on endoscopy.Manometry will serve to localize the lower esoph- ageal sphincter for potential subsequent pH monitoring, to evaluate peristaltic function preoperatively, and to diagnose subtle presentations of the major motor disorders. Evolving information suggests that high-resolution manometry has superior sensitivity to conventional manometry in recogniz- ing atypical cases of achalasia and distal esophageal spasm. . Ambulatory impedance-pH, catheter pH, or wireless pH monitoring (PPI therapy withheld for 7 days) to evaluate patients with a suspected esophageal GERD syndrome who have not responded to an empirical trial of PPI therapy, have normal findings on endoscopy, and have no major abnormality on manometry. Wireless pH monitor- ing has superior sensitivity to catheter studies for detect- ing pathological esophageal acid exposure because of the extended period of recording (48 hours) and has also shown superior recording accuracy compared with some catheter designs. rade Insuff: no recommendation, insufficient ev- ence to recommend for or against I. Using alarm symptoms (other than troublesome dys- phagia) as a screening tool to identify patients with GERD at risk for esophageal adenocarcinoma. I. Combined impedance-pH, catheter pH, or wireless pH monitoring studies to distinguish hypersensitivity syn- dromes from functional syndromes, the distinction being that in hypersensitivity syndromes symptoms are attrib- utable to reflux events, whereas in functional syndromes they are not. I. Combined impedance-pH, catheter pH, or wireless pH esophageal monitoring studies performed while taking PPIs. pe mu gea Diagnostic testing for esophageal GERD syndromes nvoked in 3 broad scenarios: (1) to avert misdiagnosis, (2) identify complications of reflux disease, and (3) in the luation of empirical treatment failures. The discussion of sdiagnosis and identifying complications of reflux dis- e usually revolves around the concept of “alarm features” t are suggestive of an alternative diagnosis. Important ernative diagnoses include coronary artery disease, gall- dder disease, gastric or esophageal malignancy, peptic er disease, and eosinophilic, infectious, or caustic esoph- tis. High-quality evidence supporting the broad utility of rm features as a diagnostic tool is quite limited. However, ividual alarm features with the best performance for ntifying esophageal or gastric malignancies are weight s, dysphagia, and epigastric mass on examination, mak- it appropriate to evaluate these with endoscopy. A ca- t in the endoscopic evaluation of dysphagia is that the doscopist should have a low threshold for obtaining ltiple (preferably at least 5) esophageal mucosal biopsy cimens to evaluate for eosinophilic esophagitis. The other broad scenario under which diagnostic testing erformed is in the evaluation of troublesome symptoms t have not adequately responded to empirical twice-daily I therapy. Did therapy fail because of troublesome symp- s attributable to reflux that did not resolve with PPI rapy or because the symptoms under consideration are t attributable to reflux? Endoscopy is again the first gnostic test to consider because it may demonstrate rrett’s metaplasia, stricture, or an alternative upper gas- intestinal diagnosis. After a normal endoscopy, priority uld be given to identifying conditions for which an ective alternative therapy exists. In the case of GERD, the ly alternative, potentially more effective, therapy is anti- ux surgery. High-quality evidence on the efficacy of an- eflux surgery exists only for esophagitis and/or excessive tal esophageal acid exposure when PPI therapy is with- ld. Another requirement for antireflux surgery is that e peristaltic function be preserved. Finally, it is impor- t to identify alternative diagnoses that may masquerade GERD: functional heartburn, atypical cases of achalasia, distal esophageal spasm. Given these priorities, the sec- d diagnostic evaluation should be esophageal manome- and the third should then be to ascertain whether or not re is excessive esophageal acid exposure when PPI ther- y is withheld. Whether this examination should be per- med with the patient on acid suppressive therapy is bated. The unclear relevance of “normative” data for im- dance-pH studies performed on PPI therapy makes it ficult to interpret such studies. If normal values are not justed, then such an on-PPI study could show an un- ivocal PPI nonresponse. That, however, rarely occurs. At s point in the diagnostic algorithm, troublesome symp- s of heartburn, chest pain, regurgitation, or dysphagia rsist despite normal findings on endoscopy (including cosal biopsy in the case of dysphagia), normal esopha- l acid exposure, and a manometry study that ruled out a ma rem fun of refl the wh ing G id I. dia an su the tio for On ere thi tre GE ses su tri to no im or G im I. G is I. G id I. est ula ast tha the no eso un ing dro dro exi tio of tan ext tor tre are ing elu cri eso sym dia en ica Mo tw mo un sh aci GE do cau the A G A IN STITU TE 1386 AMERICAN GASTROENTEROLOGICAL ASSOCIATION INSTITUTE GASTROENTEROLOGY Vol. 135, No. 4 jor motor disorder. Current thinking is that the major aining possibilities are a hypersensitivity syndrome or a ctional syndrome, the distinction being that in the case a hypersensitivity syndrome symptoms are attributable to ux events, whereas in the case of a functional syndrome y are not. This is a subtle distinction and a domain in ich there is currently no high-quality evidence support- one management approach or another. 5. What Are the Unique Management Considerations in Patients With Suspected Reflux Chest Pain Syndrome? rade A: strongly recommended based on good ev- ence that it improves important health outcomes Twice-daily PPI therapy as an empirical trial for patients with suspected reflux chest pain syndrome after a cardiac etiology has been carefully considered. Chest pain indistinguishable from ischemic car- c pain can be caused by GERD. Because the morbidity d mortality associated with ischemic heart disease is bstantially greater than that of GERD and because of impressive array of available therapeutic interven- ns, this diagnosis must be thoroughly considered be- e accepting a diagnosis of reflux chest pain syndrome. ce ischemic heart disease has been adequately consid- d, the relative rarity of esophageal motor disorders in s group of patients, as well as results from empirical atment trials of acid suppressive therapy, suggest that RD may be the next most likely etiology. Meta-analy- of placebo-controlled treatment trials in patients with spected reflux chest pain suggest benefit from a 4-week al with twice-daily PPI therapy. If a patient continues have chest pain despite this course of therapy, diag- stic testing with esophageal manometry and pH or pedance-pH monitoring can exclude motility disorders refractory reflux symptoms. 6. What Is the Best Initial Management for Patients With Suspected Extraesophageal Reflux Syndromes (Asthma, Laryngitis, Cough)? What Are the Unique Management Considerations With Each? What Is the Appropriate Dose and Course of Antisecretory Therapy in Each? rade B: recommended with fair evidence that it proves important outcomes Acute or maintenance therapy with once- or twice-daily PPIs (or H2RAs) for patients with a suspected extra- esophageal GERD syndrome (laryngitis, asthma) with a concomitant esophageal GERD syndrome. do tra da rade D: recommend against, fair evidence that it ineffective or harms outweigh benefits Once- or twice-daily PPIs (or H2RAs) for acute treat- ment of patients with potential extraesophageal GERD syndromes (laryngitis, asthma) in the absence of a con- comitant esophageal GERD syndrome. rade Insuff: no recommendation, insufficient ev- ence to recommend for or against Once- or twice-daily PPIs for patients with suspected reflux cough syndrome. Chronic cough, laryngitis, and asthma have an ablished association with GERD on the basis of pop- tion-based studies. However, cough, laryngitis, and hma have a multitude of potential etiologies other n GERD, making them nonspecific for GERD. Fur- rmore, the causal relationship of GERD with these nspecific syndromes in the absence of a con
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