ASGE Esophagology: Tailoring Management from Testing to Treatment (On-Demand)

Gary Falk_Refractory GERD

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This document discusses the approach to refractory gastroesophageal reflux disease (GERD). Refractory GERD refers to the persistence of symptoms despite being on stable therapy for 8 weeks, in patients with previous objective evidence of GERD. It is more common in females, those with a low body mass index, and those with dyspepsia/IBS symptoms, nocturnal symptoms, and sleep disturbance. Potential causes of refractory GERD include mechanical factors, noncompliance with medication, reflux hypersensitivity, and functional heartburn.<br /><br />The diagnostic approach involves using various tests such as endoscopy, pH monitoring, and impedance monitoring. Endoscopy helps identify the severity of esophagitis, hiatal hernia size, and Hill classification. pH monitoring can be done on or off therapy, and abnormal acid exposure (>6%) confirms GERD. Impedance monitoring can help differentiate between GERD and other conditions like reflux hypersensitivity or functional heartburn.<br /><br />The management of refractory GERD includes lifestyle changes such as weight loss and postural measures like elevating the head of the bed. Optimizing proton pump inhibitor (PPI) dosing is also important, with twice-daily dosing being more effective in controlling acid reflux. Adjunctive pharmacotherapy options include alginates, nocturnal H2RA, baclofen, and prokinetics. For patients with proven GERD, antireflux surgery or procedures like transoral incisionless fundoplication or radiofrequency ablation may be considered. Behavioral approaches like cognitive behavioral therapy and relaxation techniques can help in functional heartburn or reflux hypersensitivity.<br /><br />Newer medications like vonoprazan, a potassium-competitive acid blocker, are showing promise in the treatment of GERD. It has a rapid onset of action and produces prolonged and consistent elevation in intragastric pH compared to PPIs.<br /><br />In summary, refractory GERD is a common problem that requires a comprehensive diagnostic approach to correctly phenotype the patients. This knowledge will guide the optimal therapeutic approach, which may involve lifestyle changes, optimizing PPI dosing, adjunctive pharmacotherapy, or surgical interventions.

Keywords

refractory GERD

gastroesophageal reflux disease

persistent symptoms

stable therapy

objective evidence

endoscopy

pH monitoring

impedance monitoring

lifestyle changes

proton pump inhibitor dosing