Initial Antireflux Management After Endoscopic Diagnosis
Medical management with proton pump inhibitor (PPI) therapy is recommended for symptomatic and confirmed GERD with predominant heartburn, using the lowest possible dose for the shortest possible period of time. [1] At the same time, discussion of long-term management options is recommended. [1]
Medication Selection Algorithm
PPI therapy is recommended as initial medical management for symptomatic and confirmed GERD. [1] Lifestyle interventions should be recommended to reduce GERD symptoms. [1]
Indications for Endoscopic Therapy Escalation
Transoral incisionless fundoplication (TIF) as an alternative to chronic medical management is recommended only in patients with confirmed GERD plus a small hiatal hernia (≤2 cm) and Hill grade I or II who meet guideline criteria. [1] Evaluation for combined hiatal hernia repair and TIF (cTIF) is suggested in a multidisciplinary review for patients with confirmed GERD plus a large hiatal hernia (>2 cm) and Hill grade III or IV. [1]
Indications for Surgical Antireflux Therapy Escalation
In adult patients undergoing repair of a type II, III, or IV hiatal hernia, surgical fundoplication is suggested compared with no fundoplication. [2]
Common Pitfalls to Avoid
TIF monotherapy is not recommended for this endoscopic severity category when Hill grade III or IV is present with a large hiatal hernia, since guideline-directed therapy in that setting is cTIF rather than the Hill I/II small-hiatal-hernia approach. [1]
Target Goals of Therapy
PPI therapy should be titrated to the lowest effective dose and reassessed to limit duration, with parallel planning for long-term management options. [1]