With evolving understanding and technology, clinical guidelines for Gastroesophageal Reflux Disease (GERD) are continually updated worldwide. Professor Xiao Yinglian from The First Affiliated Hospital of Sun Yat-sen University has published an insightful article comparing the 2020 Chinese GERD consensus with the 2021 American College of Gastroenterology (ACG) guideline. This analysis highlights key differences of two countries the win diagnostic approaches, preferred medications, and surgical recommendations, aiming to identify optimal strategies.
Diagnosis of GERD: Different Thresholds and Priorities
Both Chinese and US guidelines recommend a comprehensive diagnosis combining symptoms, trial therapy, endoscopy, and pH monitoring, and endorse a proton pump inhibitor (PPI) trial.
- Role of Endoscopy: The Chinese guideline recommends considering upper endoscopy early, prior to a PPI trial, for disease screening and assessment. In contrast, the US guideline reserves endoscopy for patients with alarm symptoms, risk factors for Barrett's esophagus, or those with refractory symptoms.
- Diagnostic Criteria for pH Monitoring: A key difference lies in the threshold for abnormal acid exposure. The widely-used Lyon Consensus (2018) sets an Acid Exposure Time (AET) threshold of >6%, which is applied in the West. However, recognizing that Chinese patients typically have a lower gastric acid burden, the Chinese guideline defines pathological reflux as an AET >4.2%, making the diagnostic criterion more applicable to the local population.
Pharmacological Treatment: Diverging First-Choice Therapies
- First-Line Medication: The US guideline maintains PPIs as the primary therapy. The Chinese guideline, however, recommends either PPIs or Potassium-Competitive Acid Blockers (P-CABs) as first-choice drugs. Asian multi-center studies led by Chinese researchers indicate that the P-CAB vonoprazan may offer superior mucosal healing rates compared to PPIs like lansoprazole in severe reflux esophagitis.
- Use of Prokinetic Agents: This represents another major divergence. The Chinese guideline suggests that adding prokinetic agents to acid suppressants may help alleviate GERD symptoms, as they are widely used for various functional gastrointestinal disorders in China. The US guideline does not recommend prokinetics for GERD treatment, citing limited efficacy data for agents like metoclopramide and significant potential side effects.
Surgical and Procedural Interventions
- Endoscopic Radiofrequency Ablation (RFA): The Chinese guideline recommends RFA, citing studies showing it can promote mucosal healing and improve symptoms. The US guideline does not recommend RFA, arguing its mechanism may primarily alter esophageal sensitivity rather than strengthen the anti-reflux barrier.
- Minimally Invasive Procedures: The US guideline recommends considering Transoral Incisionless Fundoplication (TIF) for specific patients, a procedure not yet available in China. For surgical treatment, while traditional laparoscopic fundoplication remains the standard anti-reflux surgery in China, the US guideline also recommends Magnetic Sphincter Augmentation (MSA) as an alternative, a device not yet approved in China.
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