Management options for patients with GERD and persistent symptoms on proton pump inhibitors: recommendations from an expert panel

Abstract

Background: The aim of this study was to assess expert gastroenterologists' opinion on treatment for distinct gastroesophageal reflux disease (GERD) profiles characterized by proton pump inhibitor (PPI) unresponsive symptoms.

Methods: Fourteen esophagologists applied the RAND/UCLA Appropriateness Method to hypothetical scenarios with previously demonstrated GERD (positive pH-metry or endoscopy) and persistent symptoms despite double-dose PPI therapy undergoing pH-impedance monitoring on therapy. A priori thresholds included: esophageal acid exposure (EAE) time >6.0%; symptom-reflux association: symptom index >50% and symptom association probability >95%; >80 reflux events; large hiatal hernia: >3 cm. Primary outcomes were appropriateness of four invasive procedures (laparoscopic fundoplication, magnetic sphincter augmentation, transoral incisionless fundoplication, radiofrequency energy delivery) and preference for pharmacologic/behavioral therapy.

Results: Laparoscopic fundoplication was deemed appropriate for elevated EAE, and moderately appropriate for positive symptom-reflux association for regurgitation and a large hiatal hernia with normal EAE. Magnetic sphincter augmentation was deemed moderately appropriate for elevated EAE without a large hiatal hernia. Transoral incisionless fundoplication and radiofrequency energy delivery were not judged appropriate in any scenario. Preference for non-invasive options was as follows: H2RA for elevated EAE, transient lower esophageal sphincter relaxation inhibitors for elevated reflux episodes, and neuromodulation/behavioral therapy for positive symptom-reflux association.

Conclusion: For treatment of PPI unresponsive symptoms in proven GERD, expert esophagologists recommend invasive therapy only in the presence of abnormal reflux burden, with or without hiatal hernia, or regurgitation with positive symptom-reflux association and a large hiatus hernia. Non-invasive pharmacologic or behavioral therapies are preferred for all other scenarios.

Figures

Figure 1.

Personalized decision making flow chart based on pH-impedance monitoring results on PPI therapy. The decision points are ordered as: 1) Is esophageal acid exposure elevated?, 2) Is symptom association positive?, 2) Is there an elevated number of reflux events? Each decision point is further personalized on the basis of hiatal hernia. In the case of positive symptom association, the decision is further personalized on the type of predominant symptom (heartburn versus regurgitation). Proton pump inhibitor (PPI); Gastroesophageal reflux disease (GERD); Laparoscopic fundoplication (LF); Magnetic sphincter augmentation (MSA); Transoral incisionless fundoplication (TIF); Histamine2 receptor antagonist (H2RA); Transient lower esophageal sphincter relaxation (TLESR); Cognitive behavioral therapy (CBT).