According to the Montreal Consensus on the diagnosis of GERD, GERD was defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications [1]. Recently, the modern diagnosis of GERD was revised by the Lyon Consensus. The Lyon Consensus 2.0 provides an updated definition of GERD.

Unlike the Montreal Consensus, which defined GERD based on troublesome symptoms or complications alone, the Lyon Consensus 2.0 requires both symptoms and objective evidence for a conclusive diagnosis [2]. Diagnosis of GERD is based on conclusive evidence from endoscopy or reflux monitoring that goes beyond symptoms alone. According to this new definition, actionable GERD requires conclusive evidence of reflux-related pathology on endoscopy and/or abnormal reflux monitoring in the presence of compatible bothersome symptoms [2]: that evidence from endoscopy and/or abnormal reflux monitoring should support escalation or personalization of GERD management for the symptomatic patient. This personalized approach recognizes that GERD patients present with heterogeneous symptoms, treatment responses and physiological profiles. The proposed stepwise framework for phenotyping GERD, starting with 1) characterization of the symptom profile and response to acid suppression, 2) endoscopic evaluation of mucosal and anatomical integrity, 3) ambulatory reflux monitoring to characterize reflux burden and sensitivity, and 4) esophageal physiological testing to assess gastroesophageal reflux mechanism, effectors of reflux clearance and evaluate for alternative aetiologies [3]. Recently, the American Gastroenterological Association presented a personalized approach to the evaluation and treatment of GERD based on expert consensus [4]. According to this, if troublesome heartburn, regurgitation, and/or non-cardiac chest pain do not respond adequately to a PPI trial or when alarm symptoms exist, clinicians should investigate with endoscopy and, in the absence of erosive reflux disease (Los Angeles B or greater) or long-segment (>3 cm) Barrett’s esophagus, perform prolonged wireless pH monitoring off medication (96-hour preferred if available) to confirm and phenotype or to rule out GERD [3].

In this issue, Alon et al. [5] suggest who to treat when patients present with GERD-like symptoms and who to test. Alon et al. [5] suggested who to treat as those with typical symptoms without alarm features, extraesophageal symptoms and concurrent typical symptoms, typical symptoms without alarm features who have failed once-daily PPIs; these patients are treated with PPIs and other acid-suppressing drugs without the need for diagnostic tests such as endoscopy.

According to the Lyon Consensus 2.0, GERD is defined by symptoms as follows: 1) typical symptoms of GERD are heartburn, oesophageal chest pain and regurgitation. 2) The relationship between regurgitation and reflux disease is variable, but regurgitation may be part of the reflux pathophysiology, 3) chronic cough and wheezing have a low but possible pathophysiological relationship with reflux disease. 4) Hoarseness, globus, nausea, abdominal pain and other dyspeptic symptoms in the absence of typical symptoms have a low likelihood of a pathophysiological relationship with reflux disease [2]. The Lyon Consensus 2.0 emphasizes that not all “bothersome” symptoms can be directly linked to reflux of gastric contents and that symptoms alone are not sufficient to make a definitive diagnosis of GERD. However, the consensus suggests that the presence of typical troublesome symptoms may be sufficient for a trial of antisecretory medications.

Alon et al. [5] suggested that those who should be screened include those who have alarming (e.g., chronic GERD, male, age >50 years), underlying comorbidities (e.g., obesity, scleroderma), refractory GERD, elderly patients with atypical GERD symptoms or comorbidities should undergo diagnostic testing in addition to a PPI trial. Endoscopy is the preferred diagnostic test. The opinions of Alon et al. [5] will help clinicians choose the best approach to approach for patients with reflux symptoms and improve treatment outcomes.