Updates to the modern diagnosis of GERD: Lyon consensus 2.0

The Lyon Consensus 2.0 serves as an updated international guideline for the diagnosis of gastro-oesophageal reflux disease (GERD). Building upon the original 2018 framework, this revision incorporates new research to refine how clinicians differentiate between unproven and proven GERD, ultimately aiming to increase diagnostic specificity and personalize treatment strategies.

A central shift in this update is the status of Los Angeles (LA) grade B oesophagitis. Whereas previously it was considered less definitive, the new consensus establishes LA grades B, C, and D as conclusive evidence of GERD, eliminating the need for further reflux monitoring to confirm the diagnosis in these patients. The guidelines also introduce specific metrics and thresholds for prolonged wireless pH monitoring, suggesting that 96-hour monitoring provides a superior diagnostic yield for patients without prior evidence of GERD.

The consensus categorizes patients into two pathways based on their diagnostic history:

• Unproven GERD: For patients without prior objective evidence, testing is conducted off antisecretory medication. The goal is to establish or refute the presence of GERD using wireless pH monitoring or catheter-based systems.
• Proven GERD with Persisting Symptoms: For patients who have already been diagnosed with GERD but remain symptomatic while on treatment, the guidelines recommend pH-impedance monitoring on optimized therapy. This approach helps clinicians identify refractory reflux that may require escalation to interventional or surgical management.

Misdiagnosis of GERD leads to unnecessary long-term use of proton pump inhibitors (PPIs), high costs, and ineffective treatment of other conditions like disorders of gut-brain interaction (DGBI). By clarifying which symptoms (e.g., heartburn vs. hoarseness) are likely linked to reflux and providing clearer thresholds for objective testing, the Lyon Consensus 2.0 aims to minimize the over-reliance on empiric treatment and ensure that invasive interventions are reserved for patients with verified pathological reflux.