ASGE Esophagology: Tailoring Management from Testing to Treatment (Live and Virtual)

Gary Falk_Refractory GERD
Pdf Summary
Refractory gastroesophageal reflux disease (GERD) refers to the persistence of symptoms in patients who have previously shown objective evidence of GERD despite being on stable therapy for 8 weeks. This can include erosive esophagitis, peptic stricture, long-segment Barrett's esophagus, or abnormal acid exposure on pH testing. Refractory GERD is relatively common and is more prevalent in females, those with a low body mass index, individuals with dyspepsia or irritable bowel syndrome symptoms, and those with nocturnal symptoms and sleep disturbances.<br /><br />Potential causes of refractory GERD include mechanical factors at the esophagogastric junction (such as hiatal hernia, obesity, and transient lower esophageal sphincter relaxations), noncompliance with medication, reflux hypersensitivity, and functional heartburn. It is important to distinguish refractory GERD from other conditions such as major motility disorders, eosinophilic esophagitis, rumination, and supragastric belching.<br /><br />The diagnostic approach for refractory GERD involves various tests such as esophagogastroduodenoscopy (EGD) to assess the severity of esophagitis, hiatal hernia size, and the Hill classification. pH testing off therapy can help determine the extent of acid exposure, and multichannel intraluminal impedance/pH monitoring can provide additional information about reflux events and rumination episodes.<br /><br />Management strategies for refractory GERD include weight loss, postural measures (such as avoiding meals close to bedtime and elevating the head of the bed), optimizing proton pump inhibitor (PPI) dosing (preferably twice daily), and personalized adjunctive pharmacotherapy based on the GERD phenotype (such as alginates for breakthrough symptoms, nocturnal histamine-2 receptor antagonist for nocturnal symptoms, and baclofen or prokinetics for specific symptoms).<br /><br />Surgical interventions such as fundoplication or the LINX device may be considered for patients with proven GERD, while pharmacologic neuromodulation, cognitive-behavioral therapy, hypnotherapy, diaphragmatic breathing, and relaxation techniques may be helpful for patients with functional heartburn, reflux hypersensitivity, or behavioral disorders.<br /><br />Newer agents such as vonoprazan, a potassium competitive acid blocker, show promise in treating GERD and may provide an alternative to standard PPI therapy.<br /><br />In summary, refractory GERD is a common problem that requires careful evaluation and personalized management based on the patient's phenotype. Diagnosis involves various tests, and treatment strategies include lifestyle modifications, optimization of PPI dosing, and potential surgical interventions or personalized pharmacotherapy. Newer agents may offer additional options for refractory GERD management.
Keywords
refractory GERD
symptoms
acid exposure
pH testing
hiatal hernia
reflux hypersensitivity
functional heartburn
surgical interventions
proton pump inhibitor
newer agents