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  • Review Article
  • Published:

Adult and paediatric GERD: diagnosis, phenotypes and avoidance of excess treatments

Key Points

  • Diagnosis of GERD is particularly challenging in adults who do not respond to PPI therapy and in children; careful assessment and phenotyping of patients presenting with reflux symptoms can reduce unnecessary treatment with PPIs and surgery

  • Several methods are available for the diagnosis of GERD; however, their sensitivity, specificity and ability to predict outcomes of medical or surgical antireflux therapy is often limited

  • Wireless pH-metry and pH–impedance monitoring are currently the most sensitive methods to assess patients presenting with symptoms attributed to gastro-oesophageal reflux

  • More research and better techniques are needed to identify which patients with extraoesophageal reflux symptoms will respond to antireflux treatment

  • Infants with GERD should only be treated with PPIs when there is confirmation of increased oesophageal acid exposure

  • Further research is required in paediatric GERD to achieve better understanding of the disease process, detailed patient phenotyping and improved treatment outcomes

Abstract

Detailed investigations and objective measurements in patients with symptoms of gastro-oesophageal reflux should be performed with the intent of making the correct diagnosis, thus enabling choice of appropriate therapy. Establishing the most effective therapy is particularly important in adults who do not respond to standard treatment and in children. The use of PPIs for suspected GERD has increased substantially over the past decade, providing great relief in patients with acid-related symptoms, but also leading to adverse effects and a considerable economic burden. Adults with functional heartburn do not benefit from PPIs, while prolonged PPI use in patients with extraoesophageal symptoms remains a controversial area. Moreover, PPIs are not indicated in infants with GERD unless symptoms are proven to be acid-related. With regard to antireflux surgery, patients must be carefully selected to avoid the need for ongoing PPI treatment postoperatively. Correct diagnosis and phenotyping of patients with symptoms attributed to gastro-oesophageal reflux through detailed investigations is therefore imperative, leading to improved patient outcomes and rationalized use of available treatment options. In this Review, we outline currently available diagnostic tests and discuss approaches to limit any unnecessary medical or surgical interventions.

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Figure 1: Supragastric belching episodes followed by acid reflux.
Figure 2: Example impedance phenotypes of patients with GERD symptoms and normal endoscopy.
Figure 3: Proposed treatment algorithm for adult GERD.
Figure 4: Proposed treatment algorithm for infant GERD (aged 0–2 years).
Figure 5: Proposed treatment algorithm for GERD in older children (aged 2–12 years).

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All authors contributed equally to discussion of content, K.N. researched data for the article, K.N. and D.S wrote the article, and P.W. and D.S. reviewed and edited the manuscript before submission.

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Correspondence to Daniel Sifrim.

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P.W. has received a research grant from Reckitt Benckiser. D.S. has received research grants from Reckitt Benckiser and Sandhill Scientific. K.N. declares no competing interests.

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Nikaki, K., Woodland, P. & Sifrim, D. Adult and paediatric GERD: diagnosis, phenotypes and avoidance of excess treatments. Nat Rev Gastroenterol Hepatol 13, 529–542 (2016). https://doi.org/10.1038/nrgastro.2016.109

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