Refractory gastroesophageal reflux disease

Charumathi Raghu Subramanian, George Triadafilopoulos, Charumathi Raghu Subramanian, George Triadafilopoulos

Abstract

Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of stomach contents into the esophagus causes troublesome symptoms, esophageal injury, and/or complications. Use of proton pump inhibitors (PPI) remains the standard therapy for GERD and is effective in most patients. Those whose symptoms are refractory to PPIs should be evaluated further and other treatment options should be considered, according to individual patient characteristics. Response to PPIs could be total (no symptoms), partial (residual breakthrough symptoms), or absent (no change in symptoms). Patients experiencing complete response do not usually need further management. Patients with partial response can be treated surgically or by using emerging endoscopic therapies. Patients who exhibit no response to PPI need further evaluation to rule out other causes.

Keywords: acid-related diseases; endoscopy; gastroesophageal reflux disease; pH monitoring.

© The Author(s) 2014. Published by Oxford University Press and the Digestive Science Publishing Co. Limited.

Figures

Figure 1.
Figure 1.
Refractory gastroesophageal reflux disease may be distinguished by the magnitude of esophageal acid exposure.
Figure 2.
Figure 2.
Non- gastroesophageal reflux disease causes of refractory gastroesophageal reflux symptoms.

  1. - Achalasia & dysmotility: defined manometrically.

  2. - EoE (Eosinophilic Esophagitis): >15 eosinophils / HPF (high-power field).

  3. - RD (reflux-like dyspepsia): normal endoscopy, biopsies and pH monitoring.

  4. - Gastroparesis: normal endoscopy, abnormal gastric emptying scintigraphy.

Figure 3.
Figure 3.
Structural and functional assessment of patients with refractory gastroesophageal reflux disease.
Figure 4.
Figure 4.
Potential outcomes of proton pump inhibitor (PPI) therapy in patients with gastroesophageal reflux symptoms.
Figure 5.
Figure 5.
The treatment gap in patients with refractory gastroesophageal reflux symptoms. 'Gap’ is the percentage of patients refractory to proton pump inhibitor (PPI) not interested in undergoing anti-reflux surgery (ARS).
Figure 6.
Figure 6.
Available endoscopic and surgical therapies for refractory gastroesophageal reflux disease. TIF = transoral incisionless fundoplication.

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