Refractory Gastroesophageal Reflux Disease: A Management Update
Opening Hours: Sun - Thur 09:00 - 17:00
Refractory Gastroesophageal Reflux
Disease: A Management Update
Gastroesophageal reflux disease (GERD) is one of the most frequent gastrointestinal disorders. Proton pump inhibitors (PPIs) are effective in healing lesions and improving symptoms in most cases, although up to 40% of GERD patients do not respond adequately to PPI therapy. Refractory GERD (rGERD) is one of the most challenging problems, given its impact on the quality of life and consumption of health care resources. The definition of rGERD is a controversial topic as it has not been unequivocally established. Indeed, some patients unresponsive to PPIs who experience symptoms potentially related to GERD may not have GERD; in this case the definition could be replaced with “reflux-like PPI-refractory symptoms.” Patients with persistent reflux-like symptoms should undergo a diagnostic workup aimed at finding objective evidence of GERD through endoscopic and pH-impedance investigations. The management strategies regarding rGERD, apart from a careful check of patient’s compliance with PPIs, a possible change in the timing of their administration and the choice of a PPI with a different metabolic pathway, include other pharmacologic treatments. These include histamine-2 receptor antagonists (H2RAs), alginates, antacids and mucosal protective agents, potassium competitive acid blockers (PCABs), prokinetics, gamma aminobutyric acid-B (GABA-B) receptor agonists and metabotropic glutamate receptor-5 (mGluR5) antagonists, and pain modulators. If there is no benefit from medical therapy, but there is objective evidence of GERD, invasive antireflux options should be evaluated after having carefully explained the risks and benefits to the patient. The most widely performed invasive antireflux option remains laparoscopic antireflux surgery (LARS), even if other, less invasive, interventions have been suggested in the last few decades, including endoscopic transoral incisionless fundoplication (TIF), magnetic sphincter augmentation (LINX) or radiofrequency therapy (Stretta). Due to the different mechanisms underlying rGERD, the most effective strategy can vary, and it should be tailored to each patient. The aim of this paper is to review the different management options available to successfully deal with rGERD.
introduction
Gastroesophageal reflux disease (GERD) is one of the most frequent gastrointestinal diseases (1). It is defined on the basis of both esophageal and extra-esophageal symptoms, and/or lesions resulting from the reflux of gastric contents into the esophagus. GERD symptoms can be typical, such as heartburn and regurgitation, and atypical, such as chest pain, chronic cough, laryngeal burn, globus, and hoarseness. Therapy is commonly based on proton pump inhibitors (PPIs) and alginates as an add- on therapy. PPIs are effective in healing lesions and improving symptoms in most cases (2). However, there is a significant proportion of patients, ranging from 10 to 40%, whose symptoms do not adequately respond to PPI therapy (3–6). This condition, commonly known as “refractory GERD” (rGERD), represents a major health problem, given its impact on quality of life and consumption of health care resources (7). The definition of rGERD is controversial as it has never been clearly established (8). The most commonly used definition is: symptoms (retrosternal heartburn and/or regurgitation) present at least 3 times per week not responding to a double dose of PPIs for 8–12 weeks (4, 7–10). It must be emphasized that this definition is only clinical, and it does not take into account the need to have objective evidence of GERD based on endoscopic findings and pH-impedance monitoring. Indeed, many patients who experience symptoms potentially related to GERD and not responding to PPI are not really affected by GERD (7, 9). In this case the definition could be changed to “reflux-like PPI-refractory symptoms.” The latest ESNM/ANMS consensus paper (11), in accordance with recent recommendations (12–14), defined “refractory GERD symptoms” as the persistence of symptoms on therapy, in patients with prior objective evidence of GERD (erosive esophagitis, peptic stricture, long segment Barrett’s esophagus, or abnormal esophageal acid exposure on reflux monitoring performed off therapy) and rGERD as “persistence of GERD symptoms with objective evidence of GERD (through endoscopic and pH- impedance findings) despite optimized PPI therapy over at least 8 weeks.” The complex pathogenetic mechanisms underlying rGERD represent a major challenge in gastroenterological clinical practice and need to be further investigated in order to guide effective therapeutic interventions (15). The present paper was aimed at reviewing the treatment of rGERD in light of the most recent research.
© Copyright 2022. All Rights Reserved.