Strong recommendation, moderate level of evidence The spectrum of clinical presentations attributed to GERD has expanded from typical esophageal symptoms of heartburn and regurgitation, to an assortment of extraesophageal manifestations including respiratory and laryngeal symptoms. generic viagra Non-responders to a PPI trial should be considered for further diagnostic testing, and are addressed in the refractory GERD section below. generic viagra Strong recommendation, low level of evidence Reflux monitoring should be considered before a PPI trial in patients with extraesophageal symptoms who do not have typical symptoms of GERD. generic viagra Conditional recommendation, low level of evidence Surgery should generally not be performed to treat extraesophageal symptoms of GERD in patients who do not respond to acid suppression with a PPI. generic viagra Strong recommendation, low level of evidence Upper endoscopy is not recommended as a means to establish a diagnosis of GERD-related asthma, chronic cough, or laryngitis.