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Refractory GERD

Refractory gastroesophageal reflux disease (refractory GERD) is also aptly called “gastroesophageal reflux disease (GERD) despite therapy” which describes when a GERD patient continues to experience symptoms despite receiving the standard treatment of proton pump inhibitor medication (PPIs).

Refractory GERD is very common and may affect up to 40% of patients who use a proton pump inhibitor (PPI) once daily. Patients show a wide range of symptom severity and frequency while on PPI treatment. Poor compliance and improper timing of PPI consumption always needs be ruled out before further evaluation is done. Many doctors will increase dosage of PPIs to a twice daily regimen with a follow up several weeks later to see if there is improvement. Despite twice-daily dosing of PPIs, reflux symptoms can persist, new symptoms can occur or be unmasked, and esophagitis can fail to heal.

Refractory GERD patients are usually referred for testing to confirm they actually have GERD or to identify other possible causes of the symptoms. The first test to perform is upper endoscopy, primarily to assess the presence or absence of esophagitis and other gastric pathology. Those patients who do not have esophagitis are more difficult to manage and need to undergo further tests, including prolonged pH monitoring, impedance testing for nonacid gastroesophageal reflux (GER), esophageal manometry or gastric function testing. New diagnostic techniques that may be useful with refractory GERD include impedance-pH monitoring, which is very sensitive in detecting persistent acidic reflux, and bilirubin monitoring, which detects increased esophageal exposure to bile. Gastric pH monitoring is used for patients in whom PPI resistance is suspected.

Patients who have esophagitis often have a pill-induced injury, autoimmune skin disease associated with the esophagus, or eosinophilic esophagitis (an allergic inflammatory condition of the esophagus) or possibly an inability to metabolize PPIs. .

People with refractory GERD without esophagitis might have nocturnal acid breakthrough (acid reflux), nonacid GER or another disease such as achalasia or gastroparesis.

Patients may be asked to take an H2 blocker (H2-receptor antagonist) before bedtime. Histamine2, a common chemical in the body, signals the stomach to make acid. H2 Blockers oppose histamine’s action and reduce the amount of acid the stomach produces. H2 blockers include: Pepcid (famotidine), Axid (nizatidine) and Zantac (ranitidine). Physicians may also prescribe the use of a promotility agent, such as Reglan, before meals and before bedtime to help decrease the risk of acid reflux. Surgery may be another option.

A new clinical tool may help both investigation and management. With multichannel impedance manometry (MIM), an impedance catheter is passed through the nostril into the esophagus. It detects the presence of gas and fluid in the esophagus, and the direction of travel (i.e., towards the stomach with a swallow, towards the mouth with gastroesophageal reflux). With MIM and pH monitoring, reflux episodes can be counted and separated into acidic and non-acidic events. If further combined with a patient symptoms diary, a doctor can determine the relationship of GERD-like symptoms to reflux events.

Using MIM, researchers have shown that patients with GERD who are treated with PPIs do not have fewer reflux events, but the refluxate composition changes from primarily acidic to primarily non-acidic Baclofen, which decreases LES relaxation frequency. Unfortunately, due to its side-effect profile, baclofen will likely not be widely used for refractory GERD symptoms. However, there may be other medications that improve LES function and have similar effects. It is also possible that surgery may be useful for patients with refractory GERD symptoms who have ongoing non-acidic reflux. Hopefully, the development of MIM will foster further research into the causes of refractory GERD, allowing pharmaceutical developers to better identify potential treatments.

 

Refractory GERD - References

By Mortin - Copyright 2010
Last modification 05/02/2010