13 However, it is necessary to delineate refractory symptoms of GERD (eg, report of heartburn or regurgitation) that may not be GERD-related. Refractory symptoms of GERD are a challenging but important topic with potentially costly diagnosis, treatment, and management. 10 The most common presentation of GERD at an outpatient gastroenterology office visit is unresolved symptoms following failure of PPI therapy. 9 It has been estimated that approximately 30% of patients with a presumed diagnosis of GERD will experience a lack of symptomatic improvement, either partially or fully, despite PPI therapy. 8 Despite the efficacy of PPI therapy, a significant percentage of patients with symptoms of GERD will not respond. 7 Proton pump inhibitors (PPIs) decrease acid production and are the mainstay of treatment for GERD. 4-6Īcid production plays a critical role in the development of heartburn. 2,3 In addition to a significant compromise in quality of life, potential complications of GERD include strictures, dysphagia, esophagitis, Barrett esophagus, and esophageal adenocarcinoma. 1 GERD affects between 18% and 28% of North Americans, with studies suggesting that 20% to 40% of Americans have symptoms of GERD, making it the most prevalent gastrointestinal disorder in the United States. Gastroesophageal reflux disease (GERD) is a chronic condition related to the reflux of gastric contents into the esophagus that leads to troublesome symptoms (classically heartburn and regurgitation). Further therapy, including medical, endoscopic, or surgical, can then be targeted at the etiology. When an alternative cause is not found and index endoscopy is normal, additional testing with either traditional pH or impedance testing can be completed based on prior examination results and response to therapy. Many of these alternatives can be determined on an upper endoscopy or with complementary testing, such as high-resolution esophageal manometry or gastric emptying testing as symptoms dictate. When patients are refractory, alternative etiologies of GERD must be considered. A careful history of symptoms, response to PPI therapy, adherence, compliance, and timing helps elucidate if medication has been helping. This label underestimates the wide differential diagnosis of foregut pathology that can mimic symptoms of GERD. When there is persistence of symptoms despite empiric therapy, patients are labeled as having refractory GERD. However, in some patients, PPI therapy and lifestyle changes are inadequate to control symptoms. An empiric course of PPI therapy is an effective and cost-effective strategy for the management of GERD. Newer endoscopic modalities, including the Stretta and endocinch procedures, are less invasive and have fewer complications than antireflux surgery, but response rates are lower.Abstract: Gastroesophageal reflux disease (GERD) is a common disorder that is treated with lifestyle modification, weight loss, and medications, such as proton pump inhibitors (PPIs). Antireflux surgery, including open and laparoscopic versions of Nissen fundoplication, is an alternative treatment in patients who have chronic reflux with recalcitrant symptoms. Diagnostic testing should be reserved for patients who exhibit warning signs (i.e., weight loss, dysphagia, gastrointestinal bleeding) and patients who are at risk for complications of esophagitis (i.e., esophageal stricture formation, Barrett's esophagus, adenocarcinoma). In patients with erosive esophagitis identified on endoscopy, a PPI is the initial treatment of choice. The preferred empiric approach is step-up therapy (treat initially with an H2RA for eight weeks if symptoms do not improve, change to a PPI) or step-down therapy (treat initially with a PPI then titrate to the lowest effective medication type and dosage). In patients with reflux esophagitis, treatment is directed at acid suppression through the use of lifestyle modifications (e.g., elevating the head of the bed, modifying the size and composition of meals) and pharmacologic agents (a histamine H 2-receptor antagonist taken on demand or a proton pump inhibitor taken 30 to 60 minutes before the first meal of the day). The primary treatment goals in patients with gastroesophageal reflux disease are relief of symptoms, prevention of symptom relapse, healing of erosive esophagitis, and prevention of complications of esophagitis.
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